myocardial ischaemia national audit project [minap] - UCL

How the NHS cares for patients with heart attack

NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH

Myocardial Ischaemia National Audit Project


myocardial ischaemia national audit project [minap] MINAP Tenth Public Report 2011

MINAP 2011 Cover 5mm spine.indd 1

How the NHS cares for patients with heart attack Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group

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This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11. Report prepared by: Lucia Gavalova, Project co-ordinator MINAP With assistance from: Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinator Lynne Walker, MINAP Programme manager Professor Tom Quinn, MINAP Steering Group member Professor Adam Timmis, Chairman MINAP Academic Group Mrs Sirkka Thomas, MINAP Patient/carer representative Mr David Geldard, MINAP Patient representative Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap For further information about this report, contact: Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes Research Institute of Cardiovascular Science University College London 175 Tottenham Court Road London W1T 7NU Tel: 0203 108 3931 Email: [email protected] University College London (media enquiries) Media Relations Manager Ruth Howells Tel: 020 3108 3845 Email: [email protected]

Department of Health Enquiries to the Department should be directed to the Customer Service Centre Tel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform

heart attacks recorded in minap in 2010/11

In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS Welsh Assembly Government Ms Cathy White Head of Adult & Children’s Health Medical Directorate Department for Health, Social Services & Children Welsh Government Cathays Park, Cardiff CF10 3NQ Tel: 029 20826108 Email: [email protected] Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/ HomePage.aspx

Acknowledgements The MINAP team would like to thank all the hospitals and ambulance services that have collected data. This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.

MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk. This report may not be published or used commercially without permission.

The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.

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contents foreword

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By the National Director for Heart Disease and Stroke

11. Results by hospitals, ambulance services and cardiac networks

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executive summary

Table 1 Primary angioplasty in hospitals in England, Wales & Belfast

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part one: introduction

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Table 2 Thrombolytic treatment in hospitals in England

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1. Background to heart attacks

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Table 3 Thrombolytic treatment in hospitals in Wales & Belfast

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1.1 ST elevation myocardial infarction and non ST elevation myocardial infarction

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1.2 Aims of management

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1.3 Reperfusion therapy

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Table 4 Ambulance services in England & Wales 37 Table 5 Secondary prevention medication in England

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Table 6 Secondary prevention medication in Wales & Belfast

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2. Background to MINAP 2.1 A look back

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Table 7 Cardiac networks in England & Wales

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2.2 Organisation of MINAP

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2.3 How the data are collected

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Table 8 Care of patients with non ST elevation infarction in England

2.4 Security and patient confidentiality

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Table 9 Care of patients with non ST elevation infarction in Wales & Belfast

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2.5 Case ascertainment

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2.6 Data quality

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3. Improving quality, improving outcomes

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3.1 Use of MINAP data to inform the British Cardiovascular Society working group on the use of the cardiac care unit

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3.2 Use of primary angioplasty

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3.3 Access to coronary angiography for patients with non ST elevation myocardial infarction

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3.4 International comparisons

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4. MINAP: a patient’s perspective

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part two: results

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1. Characteristics of patients with heart attack in 2010/11

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2. Hospitals that perform primary angioplasty

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3. Hospitals using thrombolytic treatment

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4. Angiography for ST elevation infarction patients not having primary angioplasty

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5. Reperfusion treatment by hospital

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6. Ambulance service performance

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7. Use of secondary prevention medication

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8. Cardiac networks

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9. Care for patients with non ST elevation infarction

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10. Change in mortality of heart attack patients

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12. Difference in performance in England and Wales

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part three: case studies

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Implementing a Primary PCI service in Oxford

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MINAP, promoting prevention

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Establishing a primary angioplasty service in Lincolnshire

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Improvement in call-to-balloon times at London Chest Hospital, Barts & the London NHS Trust

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Using data from MINAP to model a PPCI Service in the Chesire & Merseyside network area

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Use of MINAP data to analyse and improve the PPCI service

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part four: research use of minap data

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1. MINAP Academic Group - 5 year overview

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2. Use of MINAP data to evaluate the impact of acute coronary syndrome care by patient age

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3. Enriching MINAP through linkage to primary care & investigator led cohorts

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4. Management of hyperglycaemia in acute coronary syndromes

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part five: appendices

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MINAP Tenth Public Report 2011

MINAP Public Report Part 1 and 2 blue.indd 3

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title foreword This year we celebrate the 11th anniversary of the initial roll out of MINAP in October 2000. During this time, we have witnessed a series of transformations in the management of heart attack which have long-term benefits for individual patients and the NHS as a whole. In the first few years we saw thrombolytic treatment provided with high levels of expertise, timeliness and efficiency by hospitals and by ambulance services. Over the last four years primary angioplasty has rapidly replaced thrombolytic treatment as the preferred treatment for heart attack, centralising acute care in specialist heart attack centres. At present, over 80% of heart attack patients receive primary angioplasty which is associated with shorter hospital stays, is safer and provides better outcomes. The chances of survival after heart attack have improved year on year despite an ageing population so that the outcomes in this country match the best in the world. Data show that death rates after heart attack have fallen faster in the UK than in any other European country.

This is quite an achievement and reflects on the hard work of staff across the NHS both in the ambulance services and in hospitals supported by the improvement programmes led by NHS Improvement and implemented locally by cardiac networks. As more patients with heart attack have primary angioplasty these reports increasingly will also rely on information from the British Cardiovascular Intervention Society’s (BCIS) database, and future reports are likely to include analyses from this source. We would like to thank all those that have been involved.

Professor Sir Roger Boyle, CBE, FRCP National Director for Heart Disease and Stroke [to August 2011]

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MINAP How the NHS cares for patients with heart attack


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executive title summary The Myocardial Ischaemia National Audit Project (MINAP) is a national clinical audit of the management of heart attack. It supplies participating hospitals, ambulance services and commissioners with a record of their management and compares this with nationally and internationally agreed standards. MINAP provides comparative data to help clinicians and managers monitor and improve the quality and outcomes of their local services.

This is the tenth annual MINAP Public Report. It presents analyses from all hospitals and ambulance services in England and Wales that provided care for patients with suspected heart attack between April 2010 and March 2011 (2010/11). For the first time we present data from hospitals in Belfast. The report also presents some data from previous years. Its purpose is to inform the public about the quality of local care for heart attack patients. Heart attack is common and remains a major cause of death and ill health. Importantly, prompt and appropriate treatment reduces the likelihood of death and recurrent heart attack. Good treatment coupled with cardiac rehabilitation promotes optimal recovery. Heart attack, or myocardial infarction, is part of the spectrum of conditions known as acute coronary syndromes (ACS). This term includes both ST elevation myocardial infarction (STEMI), for which emergency reperfusion treatment with primary angioplasty or thrombolytic drugs is beneficial, and non ST elevation myocardial infarction (nSTEMI), which represent the majority and for which a different approach is required.

This year, in England, 82% of patients who received any reperfusion treatment received primary angioplasty compared to 63% in 2009/10. In Wales the increase was from 22% to 30%. In the Belfast hospitals 99% of patients who received any reperfusion treatment received primary angioplasty compared to 59% in 2009/10. This year 90% of eligible patients in England, 68% in Wales and 87% in Belfast were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre. 81% of eligible patients in England, 75% in Wales and 90% in Belfast were treated with primary angioplasty within 150 minutes of calling for professional help. Access to primary angioplasty is variable. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5% and 93%; in 6 cardiac networks fewer than 50% of patients received primary angioplasty. 75% of patients that were treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in the Belfast hospitals.

Initial treatment of patients with ST elevation myocardial infarction High quality care for STEMI includes early diagnosis and rapid treatment to re-open the blocked coronary artery responsible for the heart attack. Two forms of treatment are available; primary angioplasty, where the artery is re-opened mechanically using a balloon catheter inserted into the blocked artery, and thrombolytic treatment, where the clot is dissolved by a drug given by ambulance or hospital staff. Delay to providing either treatment is associated with poorer outcomes.

Patients who received primary angioplasty for ST elevation myocardial infarction Primary angioplasty is the preferred treatment if it can be provided promptly. Once a patient is recognised as having a heart attack, ambulance staff take the patient directly to the catheter laboratory of the nearest heart attack centre, often bypassing smaller hospitals and the Accident and Emergency (A&E) department.



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Patients who received thrombolytic treatment for ST elevation myocardial infarction As the number of patients having primary angioplasty has increased, the number having thrombolytic treatment, either before or on arrival at hospital, has fallen. 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help in England; 53% in Wales. Thrombolytic treatment is not used in the Belfast hospitals. 69% of patients who received thrombolytic treatment or who had no reperfusion treatment had, or were later referred for, coronary angiography in England; 83% in Wales and 50% in Belfast.

Thrombolytic treatment given by paramedics before the patient reaches hospital For many ambulance services, the focus has shifted from provision of early pre-hospital thrombolytic treatment to identifying those patients with a heart attack who might benefit from primary angioplasty, and transferring these patients rapidly to a heart attack centre. This means that for many ambulance services the number of patients receiving pre-hospital thrombolytic treatment has declined.

important facet of treatment for the majority of these patients. Ideally, admission should be to a cardiac facility where nursing staff have cardiac expertise and there is easy access to cardiological advice. This year: 50% of nSTEMI patients were admitted to a cardiac unit or ward in England, 59% in Wales and 81% in Belfast. 91% of nSTEMI patients were seen by a cardiologist or member of their team in England, 84% in Wales and 99% in Belfast. However the Welsh data are incomplete as 4/18 hospital did not enter data on their nSTEMI patients.

Prescription of secondary prevention medication Taking secondary prevention drugs after the acute event (for both STEMI and nSTEMI patients) reduces the risk of death and further heart attack. The proportion of patients in England, Wales and Belfast who are suitable for treatment and in whom secondary prevention medication is prescribed on discharge from hospital continues at over 90% for each of the 5 drug classes monitored.

824 patients received pre-hospital thrombolytic treatment in England in 2010/11 compared to 1633 in 2009/10, a decrease of 50%. In Wales 219 patients received prehospital thrombolytic treatment compared to 250 in 2009/10. Pre-hospital thrombolytic treatment is not used in Belfast.

Care of patients with non ST elevation myocardial infarction Patients with nSTEMI have a lower early risk of death (within the first month), but appear to be at similar or even greater long-term risk than patients with STEMI. Perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to cardiac care units and are not always cared for by cardiologists. However, specialist involvement has been shown to lead to better outcomes. The performance of angiography and coronary intervention soon, within the first 2-4 days, is an

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Falling mortality There has been a year on year fall in the percentage of patients with STEMI and nSTEMI who die within 30 days of admission to hospital.



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part titleone: introduction 1. Background to heart attacks The term ‘heart attack’, while used widely in discussions between clinicians and their patients, and therefore in this public report, is too imprecise to define the clinical condition that is the subject of this national audit. The preferred term is acute coronary syndrome. This covers the symptoms and clinical features that occur when there is an abrupt reduction in the blood supply to a segment of heart muscle. Usually this is a consequence of a gradual build-up of fibro-fatty material (atheroma) within the wall of the coronary artery, which may have happened over years and often without symptoms, followed by sudden disruption of the internal artery wall at this site. This causes blood to clot within the artery – a coronary thrombosis – and leads to a state of myocardial ischaemia, in which the demands of the effected heart muscle for oxygen-rich blood exceed the supply of such blood down the clot-containing artery.

If ischaemia is sufficiently prolonged or complete, death of heart muscle results. This is myocardial infarction and is confirmed if evidence of heart muscle cell death is found on blood testing. Such evidence may take some hours to appear and, to be most effective, treatment must start before the results of such tests are available. Ischaemia is suggested by characteristic symptoms (for example central chest discomfort, sweating, breathlessness) and abrupt changes in blood pressure, heart rate and heart rhythm (sometimes leading to collapse or sudden death). Features of ischaemia often can be seen as electrical alterations on the electrocardiogram (ECG). At the onset of symptoms it is uncertain whether the ischaemia will be transient and of no long-term consequence, or whether it will progress to infarction and consequent failure of the heart to pump strongly. So all patients require urgent treatment to reverse ischaemia and prevent infarction.

Although those with STEMI are at greater early risk, the medium to long-term outcome (in terms of recurrent heart attack or death) is similar, if not worse, for those with nSTEMI. Within the last two years the National Institute for Health and Clinical Excellence (NICE)1 has published guidelines for the management of patients with nSTEMI. NICE have a STEMI guideline and Quality Standard in development.2

1.2 Aims of management The aims of management of acute coronary syndrome are presented in Figure 1 together with examples of some interventions that have been shown to be associated with better outcomes for patients and have therefore been included in various guidelines. Not all patients require all the interventions and some interventions are unsuitable – contraindicated – in some patients. Therefore, clinicians involved in providing care do not blindly follow protocols of treatment but must use their clinical judgement to determine when particular treatments should be used, and when best avoided, in individual patients. Aims

Examples of interventions

Prompt recognition of symptoms

Public education

Provision of heart monitoring & resuscitation

Ambulance ‘999’ response

Restoration of coronary blood flow

Reperfusion treatment

Education of professionals Hospital Cardiac Care Units Primary angioplasty Thrombolytic therapy Nitrates Elective angioplasty/surgery

Prevention of further coronary thrombosis

Anticoagulants

Reduction & reversal of ischaemia

Reperfusion treatment

Antiplatelet agents Anti-anginal drugs e.g. beta blockers, nitrates

1.1 ST elevation myocardial infarction and non ST elevation myocardial infarction Based upon the ECG, patients are categorised into those with, and those without, ST segment elevation – leading to the final diagnosis of those with ST elevation myocardial infarction (STEMI) and those with non ST elevation myocardial infarction (nSTEMI). ST elevation usually indicates complete blockage of a coronary artery and warrants specific immediate treatment to re-open the artery – see Section 1.3 Reperfusion therapy. The absence of ST elevation usually indicates that any coronary thrombosis is only partially occluding the artery.

Stabilisation of coronary artery

Statins

Optimise healing

ACE inhibitors

Prevention of future myocardial infarction

Secondary prevention drugs

Education & support, promotion of healthy lifestyles

Hospital cardiac nurse specialists

Lifestyle changes

Cardiac Rehabilitation classes Patient support groups

Fig 1. Aims of management of acute coronary syndrome

1. www.nice.org.uk/guidance/CG94 2. http://guidance.nice.org.uk/CG/WAVE25/8 MINAP Tenth Public Report 2011


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1.3 Reperfusion therapy

2. Background to MINAP

These are treatments that re-open the blocked coronary artery that is causing the ACS; thereby reducing the amount of heart damage. If re-opening the artery is to be of benefit it needs to happen as quickly as possible, before all the heart muscle at risk has been damaged. These therapies are therefore used in the immediate management of those with STEMI (see above). If patients delay too long after the start of their symptoms reperfusion therapy may be of no value and would not then be advised.

2.1 A look back

Two forms of treatment exist, primary angioplasty (percutaneous coronary intervention (PCI) – where the artery is opened mechanically using a balloon catheter and a stent is then left in the artery to prevent re-occlusion – and thrombolytic therapy – where the clot is dissolved by a drug. Thrombolytic therapy is given by intravenous injection and can therefore be delivered rapidly, preferably even before arriving at hospital. While the drug can be given quickly its effect on the blood clot is not immediate and varies from person to person – in some failing to re-open the artery at all. Primary angioplasty requires specialised equipment and highly-trained clinical staff within the hospital. Patients tend to wait longer for primary angioplasty than they would for thrombolytic treatment, but the final results are more reliable in terms of complete restoration of coronary blood flow, see Fig 2.

Thrombolytic drugs

Advantages

Disadvantages

Established treatment

Fails in at least 20%

Simple administration (intravenously)

Risk of bleeding and stroke

Potentially available in all hospitals Pre-hospital use by ambulance paramedics Primary angioplasty

Successful in at least 95%

Not available in all centres

Lower stroke risk

Treatment must be Allows visualisation of delayed until arrival at hospital all coronary arteries Risk of bleeding Cardiologist necessarily involved in care of all patients Randomised trials suggest primary angioplasty more effective than thrombolytic therapy

Fig 2. Reperfusion therapy in ST elevation myocardial infarction 3. Tunstall Pedoe H. Uses of coronary heart attack registers. Br Heart J 1978;40:510-5. 4. Rowley JM, Mounser P, Harrison EH, et al. Management of myocardial infarction: implications for current policy derived from the Nottingham Heart Attack Register. Br Heart J 1992;67:255-62.

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It is only by collecting data and using them that you get sense William Osler, 1928 The publication of the tenth annual report of MINAP provides an opportunity to reflect on the development of the audit project, and to consider its future role in supporting and assuring good quality care for patients with ACS. The concept of collecting a common dataset of information on geographically distinct groups of people with heart attack was proposed by the European Regional Office of the World Health Organisation in 1968, and led to the promotion of Myocardial Infarction Community Registers, (and later to the WHO MONICA research project). In Britain, early community registers were developed in Oxford, Edinburgh and Tower Hamlets. The primary purpose of such registers was ‘educational’ – to more precisely report the incidence of coronary events in a community; both within and without hospital, to describe the manifestations of heart attacks and to allow a comparison of fatality rates between localities. Little information was collected about the care provided within hospital. To be of more practical use to clinicians and the general population a change of emphasis was needed. As Hugh Tunstall Pedoe commented in 1978.

“The collection of information for its own sake is of doubtful value unless it is acted upon. Community registers should not become the equivalent of village war memorials.” 3 He also recognised that such information could be used in “monitoring the effects of treatment” and ensuring that it was “reaching those who needed it”. Here was recognition that data collection could be used to assure appropriate treatment; to go beyond a register toward an audit function. Clinicians have for many years maintained hospital-based cardiac care unit registers. Perhaps the most enduring is the Nottingham Heart Attack Register, which began in simple form in 1972, and has collected more definitive data since 1982 4.



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Such registers have been of great value in showing variation over time in the presentation and outcome of patients with heart attacks. Being unique to each hospital, they are of limited value in revealing and quantifying variation between hospitals. By the end of the 1980s large randomised trials, in carefully selected groups of patients, confirmed the effectiveness of clinical treatments of heart attack, and provided robust evidence upon which to base recommendations for best management. In particular, the recognition that thombolytic drugs had substantial benefits when given early after the onset of symptoms led to the realisation that it also mattered how and when a treatment was given as well as whether it was given. Measurable standards for treatment, such as doorto-needle time and call-to-needle time appeared in national guidelines, together with advice that hospitals “should provide audit data of delays to treatment” (against agreed standards)5. Some cardiologists actively lobbied for a common audit in which all hospitals would participate. They believed that a truly national audit would lead to a more rapid implementation of evidence-based clinical practice and thus to improved outcomes for patients with heart attack. Beginning with paper records and later using portable pre-programmed Psion organisers, these cardiologists formed the Myocardial Infarction Audit Group and began, from 1992, to share their (anonymised) data, providing evidence of significant variation in practice6. A regionwide comparative audit conceived by Dr John Birkhead and Professor Rod Griffiths, the West Midlands Thrombolysis Project, reported significant improvement in call-to-needle time as a result of this approach7 . Around this time certain significant advances facilitated the aspiration of the group. Anthony Rickards and David Cunningham conceived and developed the Central Cardiac Audit Database (CCAD) to which data from all participating hospitals could be sent electronically, with automatic encryption8. Government policy emphasised the potential gain to health from the optimum management of heart attack. Setting, delivering and monitoring standards became an imperative, resulting in much professional and public engagement in describing both potential health outcome indicators9 and the standards of care expected by patients with coronary disease10. This latter document, a National Service Framework (NSF), mandated every acute hospital to have available clinical audit data that was no more than 12 months old and suggested that “where relevant” these should be “derived from participation in national audits”.

The Myocardial Infarction (later, Ischaemia) National Audit Project (MINAP) was established in 1999. It was founded on the following propositions: The audit should be a complete record of care rather than a snapshot – all (rather than a sample of) patients being included The audit should be prospective – information being collected as soon after treatment as possible Participating hospitals should agree both common definitions of clinically important variables and common standards of good quality care against which to audit their practice Standards of care should be chosen that have a proven link to improved outcome – i.e. those aspects of care being audited, whilst capable of being expressed as measures of process or performance, should link directly to better patient outcomes The practices of individual hospitals should be aggregated into a national figure – a hospital could audit against agreed standards and compare against the national aggregate Sufficient data should be recorded to allow for casemix adjustment and other techniques for investigating differences in outcomes between hospitals, The dataset should be revised periodically to account for the introduction of newer treatments The audit should maintain its credibility and validity by being guided and supported by relevant professional and patient groups and be managed by a small project team A publicly accessible report should be published annually. The standards presented in the NSF became the standards against which care was compared and a core dataset was prepared for participating hospitals11. Data collection began in October 2000 and by mid-2002 all acute hospitals in England and Wales were participating in the audit.

5. Weston CFM, Penny WJ, Julian DG. Guidelines for the early management of patients with myocardial infarction. BMJ 1994;308:767-71. 6. Birkhead JS. Thrombolytic treatment for myocardial inraction: an examination of practice in 39 United Kingdom hospitals. Myocardial Infarction Audit Group. Heart 1997;78:28-33 7. Quinn T, Allan TF, Birkhead J et al. Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project. Eur J Cardiovasc Nurs 2003 Jul;2(2):131-9. 8. Rickards A, Cunningham D. From quantity to quality: the Central Cardiac Audit Database Project. Heart 1999;82:II18-II22. 9. Birkhead J, Goldacre M, Mason A, et al. Health Outcome Indicators: Myocardial Infarction. Oxford, Centre for Health Outcomes Development, 1999. 10. National Service Framework for Coronary Heart Disease. Modern standards and service models. Accessed on 25 June 2011 at http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf 11. Birkhead JS. Responding to the requirements of the National Service Framework for coronary disease: a core data set for myocardial infarction. Heart 2000;84:116-7. MINAP Tenth Public Report 2011


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2.2 Organisation of MINAP MINAP is one of 7 national cardiac clinical audits that are now managed by the National Institute for Cardiovascular Outcomes Research (NICOR) which is part of the Institute for Cardiovascular Science at University College London (UCL). MINAP is overseen by a Steering Group that represents key stakeholders including professional bodies, national government and patient representation, in conjunction with the British Cardiovascular Society (Appendix 1). MINAP is commissioned by the Healthcare Quality Improvement Partnership (HQIP) who hold commissioning and funding responsibility for MINAP and other national clinical audits. An academic group, which reports to the Steering Group, has been established to facilitate research use of the data, see part 4. 2.3 How the data are collected The current dataset v9.1 contains 122 fields and includes information on pre- and in- hospital treatment, patient demographics and previous medical history. The dataset is revised every 2 years to meet the requirements of users and to respond to developments in the management of ACS. The dataset is available on the MINAP web pages12. Data are collected by nurses and clinical audit staff and entered in a dedicated data application (either on-line or web based). Alternatively hospitals can also use commercial software that is able to collect the data. The project uses a highly secure electronic system of data entry, transmission and analysis developed by the CCAD team that is now part of NICOR. The audit has been running continuously since 2000 and all hospitals in England and Wales that admit patients with ACS contribute data. Participating hospitals are requested to enter all patients with suspected myocardial infarction. About 90,000 records are created annually and in June 2011 the database contained over 873,000 records. 2.4 Security and patient confidentiality All data uploaded by hospitals are encrypted on transmission and stored encrypted on the CCAD servers. CCAD manages access control to the servers via user IDs and passwords. All patient identifiable data are pseudonymised by CCAD before release to NICOR via a secure drop box on the CCAD server. Data held within NICOR are managed within a secure environment for storage and processing provided by the UCL network and within the UCL information governance and security policy. The national cardiac audit data held by CCAD are registered under the Data Protection Act. NICOR has support under section 251 of the National Health Service (NHS) Act 2006. (Ref: NIGB: ECC 1-06 (d)/2011).

In addition, NICOR staff recognise that confidentiality is an obligation and regularly undergo information governance training to ensure understanding of the duty of confidentiality and how it relates to patient data. 2.5 Case ascertainment In practice MINAP records the great majority of patients having STEMI in England and Wales. However it is accepted that a number of hospitals do not enter all their nSTEMI patients mainly due to lack of resources. The true number is difficult to establish as it is not possible to compare MINAP data with Hospital Episode Statistics (HES), the only possible comparator, except in aggregate. Although HES reports approximately 105,000 hospital admissions annually with myocardial infarction, it is not possible to separate this number into the clinical categories used within MINAP. MINAP records about 30,000 STEMIs, but only about 50,000 nSTEMIs annually. From internal data we consider that approximately 80,000 nSTEMIs per year would be an appropriate number. Where all patients with ACS are admitted to the same ward or area it is easy to identify patients. It is much harder where patients are not all cared for in one area, and are looked after in several wards. Under-reporting of nSTEMIs varies between hospitals and reflects variation in resources allocated to data collection. Many hospitals do not have the resource to identify and record all nSTEMIs as these may not be admitted to a cardiac facility. Instead, patients with nSTEMI may be cared for in many areas in a hospital, and identification is difficult. 2.6 Data quality Assessment of data completion and validation is presently based on patients with nSTEMI. The completeness of 20 key fields is continually monitored and is available to hospitals in an online view. Currently these fields are 99% complete. MINAP performs an annual data validation study to assess the agreement of data held on the CCAD servers with data re-entered from the case notes. Hospitals are required to re-enter data from case notes in 20 key fields in 20 randomly selected nSTEMI records using an online data validation tool. Agreement between the original and the re-entered data is assessed for each variable and for each record. Reports

12. www.ucl.ac.uk/nicor/audits/minap

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showing the agreement of each variable compared to national aggregate data are sent to hospitals to allow them to identify and act on areas of weakness with respect to data collection and entry. 97.5% of eligible hospitals in England and Wales participated in this year’s data validation study. The median score for 2009/10 was 94.8% (IQR 90.097.8). However the data are only as good as the data provided by hospitals and there is no independent validation. The MINAP data application contains error checking routines, including range and consistency checks, designed to minimise common errors and online help. MINAP provides detailed guidelines for data entry and provides a dedicated helpdesk to support problems regarding data entry and clinical definitions.

3. Improving quality, improving outcomes 3.1 Use of MINAP data to inform the British Cardiovascular Society working group on the use of the cardiac care unit. MINAP data continue to be used at local level and nationally to inform the development of cardiac services. MINAP data have recently been used to provide a report to the British Cardiovascular Society’s (BCS) working group on the future of the cardiac care unit (CCU). Cardiac or coronary care units have been in existence since the early 1960s –almost 50 years – and in that time the management for heart attack has evolved in a fashion that would be unrecognisable to those working at that time. Coronary care units, to use the term originally applied, were primarily for the care of STEMI, a group of infarctions with a high early mortality. Death was, in the main, due to primary ventricular fibrillation (VF), a lethal condition treatable by immediate electrical cardioversion. It made sense therefore to admit all patients with STEMI, at high risk of VF, to a CCU. For other ACS, the majority, who were at lesser risk of early sudden death it was not thought necessary to admit to a CCU. CCUs were expensive to staff, and tended to be small in size, with 4 - 8 beds being typical. Units changed little over the next 40 years, and continued to provide excellent care for the limited number of patients that could be managed there.

Pressure for change has recently come from a number of directions. The first has been the rapid development of primary angioplasty performed in a limited number of hospitals for a number of surrounding hospitals. CCUs are no longer admitting the patients with STEMI that they had cared for over more than 40 years. At the same time there has been increased awareness of the opportunities for care for nSTEMI, previously often cared for in general medical facilities and by non-specialist physicians. In addition the value of specialised nursing and medical management for cardiac arrhythmias and severe forms of heart failure has long been apparent. However, a short term financially driven view of a CCU that no longer admits the patients for which it was designed almost 50 years ago is to close it, and deploy nursing staff elsewhere. This disturbing approach has been noted in a number of parts of the country. It was in the light of reports of pressures to close CCUs, and an awareness that the facilities of existing CCUs might potentially be put to very good use that led to the setting up of the working group of the BCS. MINAP was invited to comment to the working group, and produced a report based on MINAP data for the care of patients with nSTEMI. This report, the contents of which will inform part of the report of the working group, indicated very clearly the benefits of admission of patients with nSTEMI to a CCU in terms of more appropriate care, the economic benefit of a shortened length of stay, and improvement in early mortality. 3.2 Use of primary angioplasty The number of patients having STEMI who receive reperfusion treatment has declined slightly in the last few years. This decline appears to be associated with the increased use of primary angioplasty and, on reflection, might have been expected as primary angioplasty is preceded by a detailed radiographic examination of the coronary arteries. When thrombolytic treatment was the reperfusion treatment of choice for STEMI the decision to use thrombolytic treatment was based on clinical findings and crucially on the appearances of the ECG. The appearances of the ECG do not always allow for a clear cut treatment decision; sometimes the appearances on which thrombolytic treatment is based are borderline and the clinician must make a judgement on the available evidence. This approach can potentially result in a small number of patients receiving thrombolytic treatment where clinical benefit is unlikely. By contrast all patients having primary angioplasty undergo a coronary angiogram as part of the procedure, and this provides detailed information on the presence of a coronary artery occlusion, it’s site, and likely impact on outcome. An additional benefit to patients admitted for primary angioplasty is that they come under the care of a consultant cardiologist almost immediately.



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Coronary angiogram of blocked left anterior descending artery before PCI

Coronary angiogram of left anterior descending artery after PCI

MINAP data allow an analysis of what procedure was ultimately performed for patients who present with ECG appearances of STEMI and who are therefore considered suitable candidates for primary angioplasty.

on testing (evidence of persisting narrowing of a coronary artery) should have a coronary angiogram within 96 hours of admission, in order to determine the need for further treatment, typically coronary angioplasty or in a minority of cases, coronary artery bypass grafting.

In 2010/11 MINAP data show that 8.6% of patients for whom it was intended to perform primary angioplasty did not receive it. Of those, 6.4% received an angiogram after which it was decided not to proceed to angioplasty. The commonest reasons for this was that the infarct related vessel had re-opened spontaneously or, that the coronary disease was too severe for angioplasty and that coronary artery bypass grafting was a more suitable treatment option. Another 1.8% of patients were not thought to require an angiogram. Thus, the adoption of primary angioplasty, now provided for more than 80% of the population of England has resulted in reperfusion treatment for STEMI being more accurately tailored to those who might benefit most. 3.3 Access to coronary angiography for patients with non ST elevation myocardial infarction In 2010 NICE published a guideline on the management of patients with nSTEMI13. A significant part of this report was written based on data from MINAP. One of the recommendations was that patients having infarctions of moderate severity, and those in whom it is possible to demonstrate residual ischaemia

During the last 10 years there has been a very substantial expansion of the number of catheterisation laboratories, with 141 hospitals in England (133) and Wales (8) having catheter laboratories compared with 86 in England and 2 in Wales 10 years ago.14 Since 2004, the percentage of patients with a final diagnosis of nSTEMI (broadly reflecting the NICE classification of moderate or greater severity) who have angiography during the admission has increased from just under 45% in 2004 to 71% in 2010. It should be recognised that angiography is not appropriate for all patients with nSTEMI. The average age of patients having a first nSTEMI is 70 years, and where performance of angiography is unlikely to alter longer term outlook because of co-morbidity, it may not be appropriate to perform it. The improved access to angiography for patients with nSTEMI has resulted in a significant fall in the median length of stay for patients having angiography from 7.4 days in 2004/5 to 5.5 days in 2010/11. Over the same time the length of stay of patients not having angiography has fallen from 7.1 to 6.6 days.

13. The early management of unstable angina and non-ST-segment-elevation myocardial infarction. CG 94. National Institue for Health and Clinical Excellence. London 2010. 14. Birkhead J, Pearson J and Walker L. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians 2007. ISBN 978-1-86016-314-2.

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3.4 International comparisons Outcomes from heart attack have been a source of controversy in the ongoing debate about proposals for NHS reform in England. The Prime Minister has stated that “Someone [in this country] is twice as likely to die from a heart attack as someone in France”15. Statements from other Ministers have subsequently given a similar message. The comparison with France appears to have been based on an Organisation for Economic Co-operation and Development (OECD) report using data from 200616 and includes the whole of the UK, rather focusing on than the NHS in England. MINAP has demonstrated in this and previous reports that mortality for both main types of heart attack –STEMI and nSTEMI- has fallen significantly in recent years in England and Wales, not least because of the success of the NSF for coronary heart disease17, the rapid introduction of primary angioplasty services with around 80% of the population of England now having access to this ‘gold standard’ treatment, and better uptake of evidence-based therapies for secondary prevention. Others, including the highly respected Kings’ Fund have suggested that the rate of improvement in outcomes from heart attack has been the fastest in Europe18.

Comparing outcomes between different countries is a complex undertaking, with evidence of miscoding and misclassification of the cause of death, variation in the entry criteria for national registries and completeness of data19 20. An international consensus on the definition of a heart attack is expected to improve the quality of comparison for the future.21 The MINAP team are working with our international partners in heart attack registries and professional societies to provide more robust international comparisons for the future, to help inform ongoing debate about the quality of cardiovascular care.

15. BBC News 16 March 2011 http://www.bbc.co.uk/news/uk-politics-12760865 16. Organisation for Economic Cooperation and Development. Health data 2010— October. www.ecosante.org/index2. 17. Department of Health. Evaluation of the Coronary Heart Disease National Service Framework. 2010 http://www.dh.gov.uk/en/FreedomOfInformation/ Freedomofinformationpublicationschemefeedback/FOIreleases/DH_126679 18. Appleby J. Does poor health justify NHS reform? BMJ 2011; 342: d566 19. Lozano R, Murray CJL, Lopez AD, et al. Miscoding and misclassification of ischaemic heart disease mortality. Global Programme on Evidence for Health Policy Working Paper No 12. World Health Organisation; 2001. p. 1-19 20. Widimsky P, Wijns W, Fajadet J, et al European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J. 2010 31(8):943-57 21. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525-38 MINAP Tenth Public Report 2011


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4. MINAP: a patient’s perspective Sirkka Thomas, Cardiac nurse, Health visitor, Cardiac carer and patient, member of Patient Network for London Cardiovascular Project 2011, member South West London Cardiac and Stroke Network and member of Healthcare Quality Improvement Partnership Patient Panel MINAP has become a major influence in my life in my demanding passage of nurse, carer, and finally cardiac patient. I turned to Cardiac nursing and trained at the Royal Brompton Hospital because I was inspired by the efforts of my native country Finland in managing such high incidence of heart conditions and I wanted to join the campaign against Britain’s greatest killer disease.

data to encourage speed of treatments and guidance to improve drug provision on discharge, (see the data in this 10th Report). Unfortunately, I turned from carer to patient two years ago, having experienced a non-STEMI which has required a pacemaker. Fortunately, I had MINAP to lift me up, along with that wonder treatment for heart patients, a caring, understanding husband. David Geldard, MINAP Patient representative and Steering Group member, past president Heart Care Partnerships (UK)

That knowledge was to help me so much when my husband suffered a heart attack 14 years ago followed by heart failure and the need for an Implantable Cardioverter Defibrillator (ICD). I was able to support him, medically as a nurse and psychologically as a carer. It is only being a close partner that one can understand the problems of a patient with a serious illness. Doctors are highly qualified to diagnose and give treatment and my husband and I have received first class therapy. However, it is our view that only the patient and close partner know the pain, physical and psychological, and the stress of their illness. That is when a carer’s understanding presence is so vital. We first became aware of MINAP when my husband recovered sufficiently to join the MINAP Steering Group, as he put it, “to repay in some way the high class cardiac treatment I had received from so many branches of the NHS”. MINAP was no magic remedy but it did provide a recovery incentive for me as a carer and for my husband as a patient. MINAP is not a Government target for heart treatment. But it is an encouragement for hospitals and ambulance services to demonstrate their performances in standards for coronary artery disease as set out by the National Service Framework of 2000.Those standards include the time from onset of heart symptoms until appropriate treatment, clot-busting drugs and now primary angioplasty, is received. They also include the use of secondary medication on hospital discharge. It was so important for my husband and me to learn from MINAP about hospital performances, the speed of immediate treatment and the attention given to the prescribing of drugs on discharge. Mortality rates due to coronary heart disease have been falling since the 1970s. Surely MINAP has helped in some way with its pursuit of excellence. MINAP has definitely contributed with its

14

At a recent national conference, Celebrating Leadership in Heart Disease and Stroke in London on 4th July, 2011, MINAP was frequently mentioned in the context of developing standards of care in the treatment of people with heart disease. Equally pleasing, and for the tenth year running, this Report is a record of steady change and improvement. With the advent of primary angioplasty as the preferred treatment for people suffering an ST elevation myocardial infarction, the need to treat these people at centres where round-the-clock equipment and appropriately trained staff are available is paramount. This shift in treatment from localised Accident and Emergency facilities, to heart attack centres that can provide 24/7 response is often a cause of concern to communities that feel they are losing a vital and local resource. People want the best treatment, but they also want it at their local hospital, and that is no longer realistic. This Report will do much to allay concerns. This year, with the assistance of NHS Improvement Heart, and the thirty two cardiac networks in England and Wales, and of Heart Care Partnership (UK), the patient arm of the British Cardiovascular Society, copies of this Report will be sent to local patient representatives at the time of publication. In this way patient representatives will be able to examine how things are going



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in their locality. Hopefully they will see improvement, and this will provide them with evidence to dispel local anxieties. They will discover many causes for passing on congratulations, and some, but not too many, “could do betters”. These local patient representatives will be the local banner bearers for their local heart attack services. Despite the success of hounding smoking and smoke from public places, tobacco smoking is still a significant contributing factor to poor health and heart attack. This report also provides evidence that shows how some heart attack victims and their companions are misjudging the event and neglecting to seek assistance in timely fashion. The success of primary angioplasty in hastening the recovery of victims has an unusual side effect in that many patients quickly seem to forget the seriousness of their condition and the responsibility they owe to themselves and their families to pay heed to the advice they receive concerning their future lifestyle, their medication, and their cardiac rehabilitation. It is extraordinary that nearly three times as many cardiac surgery patients participate in cardiac rehabilitation as do heart attack patients.

On the bright side, it is ten years after the first Public Report and it is wonderful to observe the continuing commitment of the ambulance services, the hospital services, primary care and the rehabilitation services, along with the those of the central support of Professor Sir Roger Boyle, National Clinical Director for Heart Disease and Stroke and his team, and all those colleagues on the front line and behind the scenes, for they have all gone “above and beyond” in their service to people who have suffered heart attack. It is through audit that one can objectively observe the success or otherwise of any activity, and it is to John Birkhead, the pioneer of MINAP, and the MINAP team who now bring it all together, that the heart patient community owes such a warm vote of thanks. I encourage all patient representatives for people with heart disease to read this Report carefully, and to share their joy and their aspirations; it is a good news story, in fact it is a great news story, and with their help it can get even better.



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part two: results Fig 3. Hearts attacks recorded in MINAP in 2010/11

All hospitals in England and Wales that treat heart attack patients submit data to MINAP. This year we also present data from 3 Belfast hospitals. The 204 hospitals in England and 18 hospitals in Wales are listed alphabetically in Tables 1-3, 5, 6, 8 and 9 with the location of the hospital alongside its name.

There was a total of 89511 records, the others having either another confirmed diagnosis or chest pain of uncertain cause.

79863 admissions with heart attack

The number of records eligible for analysis from each hospital is shown in the tables. Where a hospital reports less than 20 cases for the year analyses may not be meaningful. The number of cases are shown but not the percentages. There are several reasons why hospitals may report less than 20 patients. In hospitals providing a primary angioplasty service, most patients receive primary angioplasty rather than thrombolytic treatment. Different audit standards apply for timeliness of treatment with primary angioplasty and thrombolytic treatment, and delays for the two treatments cannot be combined.

48098 (60%) nSTEMI

31765 (40%) STE MI

Fig 5. Hypertension in 18042 (57%) referred for pPCI

4204 (13%) had thrombolytic treatment

8859 (28%) had no reperfusion treatment

660 (2%) treatment option not clear

1110 (27%) had thrombolytic treatment in an ambulance

Hospitals that do not provide primary angioplasty may report few, if any, cases having thrombolytic treatment, as patients from their area will be admitted directly to a primary angioplasty centre.

3094 (73%) had thrombolytic treatment in hospital

About 18% patients make their own way to hospital without involving either the ambulance service or their GP. These patients are excluded from analyses of call-to-needle time and may account for small numbers in some hospitals.

%

The average age for patients having a first heart attack in England and Wales was 69 years, for men 66 years and for women 74 years. Heart attack is more common in men, with Hospitals may have only recently started a primary two men having a heart attack for every woman. STEMI tends angioplasty service or have performed primary angioplasty to present in younger age groups than nSTEMI. The average on an occasional basis. age for a first STEMI is 65 years, while that of nSTEMI is 70 Fig 4. Frequency distribution of STEMI and nSTEMI in financial year 2011 years. Overall more than 52% of all heart attacks recorded in 1. Characteristics of patients with heart attack MINAP were in people over 70 years of age [Fig 4]. Smaller hospitals manage few heart attack patients.

Fig 6. Frequency of d heart attack

in 2010/11

In 2010/11, 89,511 records in England and Wales were submitted to the MINAP database and 79,863 were records of patients with a final diagnosis of myocardial infarction. Of these some 40% had STEMI. [Fig 3] MINAP recognises that not all patients having nSTEMI are entered into the database and that the true ratio for nSTEMI to STEMI should be at least 2:1.

Fig 4. Frequency distribution of STEMI and nSTEMI in 2010/11

STEMI is more common in younger age groups, while more than 60% of nSTEMI occur after age 70. 30 25 20 %

%

15 10 5 0

< 30

30-39

40-49

50-59

60-69

70-79

80-89

> 90

Years STEMI

16

nSTEMI



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ig 5.

Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission

Among those admitted with heart attack there is a continuing increase over time in the frequency of previously diagnosed hypertension and diabetes. The upwards trend for hypertension continues for females, but may be levelling out for males.[Fig 5] The increase in the frequency of diabetes on admission for first heart attacks continues in both males and females. Further analysis shows that the increase is limited to those having type 2 diabetes (non-insulin dependent diabetes) [Fig 6]. It is not clear to what extent this represents a real increase, or whether this in part reflects improved recognition of type 2 diabetes in primary care. The proportion already prescribed cholesterol lowering drugs (usually statins) at the time of admission may now be becoming constant at about 30% of those presenting with a first heart attack [Fig 7]. Hypertension in patients having first heart attack. This may reflect more efficient recognition and treatment in primary care of those at risk. Fig 5. Hypertension in patients having first heart attack

Patients with final diagnosis of AMI treated for hypertension at the time of admission.

Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission Hyperlipidaemia having treatment

35 30 25 %

20 15 10 5 0

2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10

2010-11

Cigarette smoking remains a major contributor to heart attacks in younger people, being a risk factor present in more than half of men and women under 55 years of age having a first heart attack. While the smoking rate in younger males is stable or falling slightly, that in females of less than 55 years continues to increase [Fig 8].

Females Males

Fig 8. Current smoking amongst patients admitted with heart attack

70

Fig 8. Current smoking amongst Fig 8. patients Current admitted smoking amongst patients admitted with heart attack. with heart attack.

65

Smoking amongst females presenting with first heart attack under 55 years continues to increase, against the generally decreasing trend for smoking rates.

60 55 50 %

Females

45 40

Females

35 30 25

20 ig 6. Frequency of diabetes2003-4 in patients having first 2004-5 2005-6 eart attack

2006-7

2007-8

2008-9

2009-10

2010-11

60

50

50

50

20

20

20

10

10

10

0 2003-4 2004-5

Males

Males

20-54 yrs

65-74 yrs

55-64 yrs

›75 yrs

55-64 yrs

›=75 yrs

Males

50

50

40 %

30

13

20

20

12

10

10

0 2003-4

2003-42012 2008-9 2009-10

40

%

30

10

0

0

2006-72003-4 2007-82004-5 2008-92005-6 2009-102006-7 2010-11 2007-8

65-74 yrs

17

11

2005-6

20-54 yrs

60

14

%

30

60

15

40

40 %

30

18

16 %

5

›75 yrs

60

Females

Females

2

65-74 yrs

60

30

The large majority of the increase in frequency of diabetes is in type 2 (non-insulin dependent) diabetics.

19

55-64 yrs

40

Fig 8. Current smoking amongst patients admitted

20

65-74 yrs 20-54 yrs ›75 yrs 55-64 yrs

%

Figwith 6. Frequency of diabetes in patients having first heart attack heart attack.

Males

Females

20-54 yrs

0 2003-4 2004-5

2004-5

2005-6

2005-6

2006-7

2006-7 2007-8

2007-8

2008-9 2009-10 2010-11

2008-9

2009-10

2010-11

2003-4 2004-5

2005-6

2006-7 2007-8

2008-9 2009-10 2010-11



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Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital in E&W.

2. Hospitals that perform primary angioplasty National and international guidance22 23 24 recommend that in the emergency treatment of patients with STEMI, primary angioplasty should be performed within 90 minutes of arrival at the angioplasty site (door-to-balloon time) and within 150 minutes of a patient’s call for help (call-to-balloon time). Results are presented against these best practice standards in Table 1. The use of primary angioplasty continued to increase in 2010/11. This year in England, 15,817 patients in England were treated by primary angioplasty compared to 12,505 in 2009/10, an increase of 26%. In Wales 301 patients were treated compared to 232 in 2009/10, an increase of 30%. Of patients who received reperfusion treatment in 2010/11, 82% of patients in England, 30% in Wales and 99% in Belfast received primary angioplasty. The overall median time from arrival at hospital to primary angioplasty was 43 minutes in 2010/11. In 25% of records this interval was less than 30 minutes and for 75% the interval was less than 64 minutes. This year, 68 hospitals in England performed primary angioplasty. In Wales 3 hospitals performed primary angioplasty. Hospitals performing primary angioplasty may provide this for their own patients only or may do so for groups of other hospitals. Of 62 hospitals in England reporting that they were performing primary angioplasty on a routine basis, 43 provided the service throughout the 24 hour period. A small number shared a night time rota on an alternate basis. An additional 10 hospitals have started to provide a 24/7 service from April 2010. In Wales two hospitals perform primary angioplasty with 24 hour availability. In Belfast, two hospitals performed primary angioplasty. The provision of primary angioplasty is complex and involves close collaboration between ambulance, portering, nursing, medical, and radiographic teams. This is particularly important for out of hours working. The percentage of patients with an admission diagnosis of STEMI who receive primary angioplasty within 90 minutes of arrival at the heart attack centre has increased from 52% in 2003/4 to 89% in 2010/11 and is a reflection of this close collaboration [Fig 9]. In particular direct transfer of the patient from ambulance to the catheter lab without involvement of other departments or wards, has reduced delays.

22. http://www.improvement.nhs.uk/heart/?TabId=66

Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital 100 90 80

79.7

70 %

88.2

89.3

72.3

60 50

84.5

52.8

56.5

58

2004-5

2005-6

40 30 20 10 0 2003-4

2006-7

2007-8

2008-9

2009-10 2010-11

In Belfast the Royal Victoria Hospital essentially provided a city wide service in 2010/11. In Northern Ireland routine use of primary angioplasty is presently limited to the Belfast area. Outside Belfast thrombolytic treatment is understood to be the primary reperfusion treatment of choice for STEMI, though primary angioplasty is occasionally available in some hospitals. The Northern Ireland cardiac network is currently developing a national strategy for the management of STEMI. We look forward to the other hospitals in Northern Ireland joining MINAP before long. Door-to-balloon time In England this year, 90% of eligible patients were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre compared to 89% in 2009/10. In Wales 68% of eligible patients were treated within 90 minutes compared to 71% in 2009/10. In Belfast 87% of eligible patients were treated within 90 minutes compared to 53% in 2009/10. Call-to-balloon time This reflects the interval from a call for professional help to the time that the primary angioplasty procedure is performed. This involves ambulance crews making an accurate diagnosis, including skilled interpretation of the ECG. Ideally all patients with a diagnosis of STEMI confirmed by a paramedic crew should then be taken to a heart attack centre. This however is not always possible, particularly where there is diagnostic uncertainty, or in remoter parts of the country. In 2010/11 75% of patients treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in Belfast.

23. Van de Werf F, Ardissino D et al. (2003) Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 24(1): 28–66. 24. Antman EM, Hand M, Armstrong PW et al. (2008) 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008; 51: 210–247.

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In England, 81% of all eligible patients were treated within 150 minutes of calling for professional help compared to 80% in 2009/10. In Wales 75% of patients were treated within 150 minutes compared to 76% in 2009/10. In Belfast 90% of patients were treated within 150 minutes compared to 77% in 2009/10. In England, 88% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help compared to 49% of patients taken first to a local hospital and then transferred to a heart attack centre. In Wales 76% of such patients were treated within 150 minutes. In Belfast 89% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help. The proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help continues to improve [Fig 10]. There is a limit to how rapidly ambulance services can assess patients and transfer them safely to hospital. The scope for further improvement in this interval may be limited. Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help

Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty Theof sudden improvement between within 150 minutes a call for professional help

2005/6 and 2006/7 is likely to be due to the rapid increase in new cardiac units performing angioplasty and the influence of the National Infarct Angioplasty Project (NIAP)

90

Normal coronary angiogram

to a heart attack centre is not yet available. This number is expected to fall further over the next 12 months. The national standard for thrombolytic treatment is for this to be given within 60 minutes of a call for professional help. This is a joint responsibility of acute hospital trusts and ambulance services. Performance against this standard continues to be monitored as an existing commitment within the NHS Operating Framework for England in 2010/11. The aim is for at least 68% of cases to achieve this standard in England, and 70% in Wales. Tables 2 and 3 show hospital thrombolytic treatment analyses for 2009/10 and 2010/11 for England and Wales respectively. The Belfast hospitals did not report use of any thrombolytic treatment in 2010/11.

85 80 75

Door-to-needle time

% 70

55

In England, 75% of eligible patients received thrombolytic treatment within 30 minutes of arrival at hospital compared to 79% in 2009/10. In Wales 62% of eligible patients received treatment with 30 minutes compared to 67% in 2009/10.

50

Call-to-needle time

65 60

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10

2010-11

Financial year

3. Hospitals using thrombolytic treatment Thrombolytic treatment is now used for a rapidly diminishing number of patients. At present approximately 15% of those eligible for reperfusion treatment have thrombolytic treatment, and this occurs mainly in a few areas where timely access

As more patients have primary angioplasty fewer receive thrombolytic treatment. However, the percentage of patients receiving thrombolytic treatment who do so within 60 minutes of a call for help is essentially unchanged. In England 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help compared to 69% in 2009/10. In Wales 53% of eligible patients received treatment within 60 minutes compared to 55% in 2009/10.



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4. Angiography for STEMI patients not having primary angioplasty

There has been a small increase in the number of patients with STEMI who do not receive reperfusion treatment, from about 25% in 2005/6 to 28.5% in 2010/11. The commonest reason why no reperfusion treatment is given is that the patient presents too late for treatment, which typically is not given more than 12 hours after onset of symptoms because of limited benefit by this time. In a small number of cases severe co-morbidity such as advanced malignancy or severe dementia may make reperfusion treatment inappropriate. These features do not change significantly over time. However, the performance of angiography before an intended primary angioplasty may demonstrate features that indicate that primary angioplasty is not required or is not feasible. These features can only be determined by angiography. Thus, angiography allows treatment to be offered only to those for whom benefit can be expected, and enables clinicians to exclude those where benefit is not anticipated. Trends in reperfusion treatment since 2003/4 are shown in Fig 12.

It is recognised that despite timely thrombolytic treatment some patients are at early risk of further heart attack. This risk is reduced by performance of angiography to determine the extent and severity of disease in coronary arteries, and where appropriate, angioplasty to the affected artery. The performance of angiography for STEMI patients not having primary angioplasty is now considered to be routine, whereas in 2003/4 only about one third of patients had angiography for this indication (Fig 11). Fig 11. Use of angiography for patients having STEMI who

do not receive primary angioplasty, but instead received 11. Use of angiography for patients having STEMI who not receive primary angioplasty, but instead received thrombolytic treatment or had no reperfusion treatment. iving thrombolytic treatment or had no reperfusion tment

Where angiography is thought inappropriate because of comorbidity or the patient refused, these are excluded from analysis. All age groups are included.

Fig 12. Use of reperfusion treatment for patients with a of STEMI

Fig 12. Use of reperfusion treatment for patients with a final diagnosis final diagnosis of STEMI

80 70

70.1

60 %

55.6

50

Primary angioplasty makes up more than 80% of reperfusion treatment.

58.6

50.1

100

45.5

40 30

73.2

63.3

90

31.1

20

80

10

70 60

0 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10

2010-11

%

50 40

Due to a database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the MINAP web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11. In 2010/11, 69% of STEMI patients in England, 83% in Wales, and 50% in Belfast who received thrombolytic treatment, or who had no reperfusion treatment were referred for coronary angiography or, in a minority, had this arranged to take place after discharge.

5. Reperfusion treatment by hospital Rates of reperfusion treatment by hospital have become difficult to present and interpret as so many patients who would previously have been treated with thrombolytic treatment in a local hospital now receive primary angioplasty in a heart attack centre, and may not even return to the local hospital after treatment. Performance of individual hospitals is not shown for 2010/11.

20

30 20 10 0

2003-4

2004-5 2005-6 2006-7 2007-8

2008-9 2009-10 2010-11

In-hospital lysis Pre-hospital lysis Primary angioplasty

As the intention is to treat patients by primary angioplasty as quickly as possible, those initially referred to a hospital without facilities for primary angioplasty are assessed rapidly for possible onwards transfer to the interventional hospital (heart attack centre), and will not be admitted. If patients are not formally admitted to the non-interventional hospital before onward transfer they do not appear in MINAP analyses for the non-interventional hospital. Only those patients that are formally admitted to a non-interventional hospital, a small minority, are included in the columns referring to transfer elsewhere for primary angioplasty.



16/08/2011 14:03

6. Ambulance service performance

Fig 13. Use of secondary prevention medication for myocardial infarction

Fig 13. Use of secondary prevention medication.

All heart attacks, [transfers, deaths, contraindicated and patient refused are all excluded.]

Ambulance services collaborate closely with receiving hospitals and networks to improve care. For many, the focus has shifted from provision of pre-hospital thrombolytic treatment to identifying those patients with heart attack who might benefit from primary angioplasty, and transferring them rapidly to a heart attack centre. So, for many ambulance services, the number of patients receiving pre-hospital thrombolytic treatment has declined. Table 4 shows ambulance service performance in England and Wales. In England in 2010/11, 824 patients received prehospital thrombolytic treatment compared to 1,633 in 2009/10. In Wales 219 patients received pre-hospital thrombolytic treatment compared to 250 in 2009/10.

Aspirin

Beta blocker

Statin

ACEI/ARB

Clopidogrel/thienopyridine inhibitors

100 95 90 85 %

80 75 70 65 60 55 50 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9 2009-10 2010-11

7. Use of secondary prevention medication Use of secondary prevention medication after the acute event is proven to improve outcomes for patients. These benefits apply after both STEMI and nSTEMI. NICE guidance25 recommends that all patients who have had an acute heart attack should be offered treatment with a combination of the following drugs: ACE inhibitor aspirin beta blocker statin. Tables 5 and 6 show the percentage of patients prescribed secondary prevention medication on discharge by hospital in England, Wales and Belfast in 2010/11. For each hospital those patients surviving to be discharged home from that hospital are included but those transferred to another hospital and those patients in whom such drugs were contraindicated are excluded. Historically, we have used the NSF audit standard of 80% for aspirin, beta blockers and statins treatment. There are no national standards for the prescription of ACE inhibitors, Clopidogrel/thienopyridine inhibitors and newer antiplatelet agents. Use of secondary prevention medication at discharge from hospital is very satisfactory, continuing to exceed the national standards, and there is little room for further improvement [Fig 13]. In England prescription of aspirin was 99%, beta blockers 96%, statins 97%, ACE inhibitors 94% and Clopidogrel/thienopyridine inhibitors 95%. In Wales prescription of aspirin was 98%, beta blockers 95%, statins 95%, ACE inhibitors 91% and Clopidogrel/thienopyridine inhibitors 92%. In the Belfast hospitals prescription of aspirin was 99%, beta blockers 99%, statins 99%, ACE inhibitors 97% and Clopidogrel/thienopyridine inhibitors 98%.

8.Cardiac networks Cardiac networks (also known as ‘heart and stroke networks’ since they also now facilitate improvements in stroke care) are local NHS organisations that seek to improve the way that services are planned and delivered. Bringing together clinicians, managers, commissioners and patients, and aware of the entire ‘cardiac pathway’, the networks can provide a powerful voice in the local health economy to enable frontline staff to secure the changes needed to deliver best care. They provide a forum through which the public can influence their services. Some cardiac networks have patient carer representatives providing a voice among the professionals. Table 7 shows the performance of the call-to-needle and callto-balloon targets and the percentage of patients that received pre-hospital thrombolytic treatment, in-hospital thrombolytic treatment, primary angioplasty and no reperfusion treatment by cardiac network. The two cardiac networks in Wales are shown separately. Countrywide access to primary angioplasty remains incomplete, although the picture is changing rapidly. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5-93% and in 6 cardiac networks less than 50% of their patients received primary angioplasty.

25. http://guidance.nice.org.uk/CG48/QuickRefGuide/pdf/English MINAP Tenth Public Report 2011


21

16/08/2011 14:03

g 13. Use of secondary prevention medication for yocardial infarction

Fig 14. Call-to-needle within 60 minutes by cardiac network

National audit lends itself to the demonstration of variation in practice and outcome. The MINAP Public Reports repeatedly have shown this. Variation in practice is an expected phenomenon in healthcare, and there is a difficulty determining whether such variation is simply the ‘play of chance’ or whether it represents some systematic difference in performance. One of the methods being considered, to more clearly describe such variation is the funnel plot.

100 90 80

GMCN

70 %

60 South Wales

50

North Wales

40 30 20

West Yorkshire

10 SE London g 13. Use of secondary prevention medication for yocardial infarction 0 100

200

300

400

500

Admissions UCL 99.6%

LCL 99.6%

National Average

CTN60%

Fig 15. Call-to-balloon within 150 minutes for direct admissions only by cardiac network 100

Lancs/Cumbria NEYNL

CMCN

80 %

Peninsula SE London Kent

70

North England

NE London

90

NW London

9. Care for patients with non ST elevation infarction

50 g 13. Use of secondary prevention medication for ocardial infarction40 200

400

600

800

1000

Admissions UCL 99.6%

LCL 99.6%

National Average

Avg of CTB150

Fig 16. Call-to-balloon within 150 minutes for inter-hospital transfers by cardiac network

80

SW London Kent Cov Warks

70 %

North England

60 50 30 West Yorkshire

NC London

For some years the focus of heart attack management has been upon the early provision of reperfusion treatment to those patients presenting with STEMI, and MINAP Public Reports have reflected this. Patients with 1200 nSTEMI have a lower early risk of death and perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to CCUs, nor always cared for by cardiologists. However, specialist involvement is important, and it is recognised that performance of angiography and coronary intervention within the first 4 days is an important facet of treatment for the majority. Ideally admission should be to a cardiac facility where nursing staff have a cardiac background, and there is easy access to cardiological expertise. As mentioned above the numbers of nSTEMI reported in MINAP are incomplete, and in particular it is likely that patients who are not admitted to a CCU are omitted. Failure to enter all cases often reflects a lack

40 20

The width of the control limits is determined by the statistical significance level from which they are calculated. To diminish the risk of a false positive ‘outlier’ we use +/- 3 standard deviations, which means that the chance of an outlier happening ‘accidentally’ (i.e. by random chance) is no more than 0.4%.

West Yorkshire

60

100 90

Funnel plots were first introduced26 27 in 1984 as a means of estimating bias in meta-analysis of clinical trials that contained varying numbers of subjects. In essence, each individual value is compared to the overall mean, 600 and the control limits around that mean diminish as the number of subjects (or admissions) increases (as one would expect). A value which falls outside the ‘funnel’ is considered an outlier, and can represent abnormally high performance as well as abnormally low performance.

10 0

26. RJ Light, DB Pillemer. Summing up: The Science of Reviewing

50

100

150

200

250

300

350

400

Admissions UCL 99.6% 22

LCL 99.6%

National Average

Avg of CTB150

450 Research. Cambridge, Massachusetts.: Harvard University Press. 1984. ISBN 0674854314.

27. Egger M, Smith GD, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 1997; 315:629–634.



16/08/2011 14:03

10. Change in mortality of heart attack patients

of resources, but it remains the case that the quality of care for patients not entered into MINAP remains unknown. In addition the variable nature of recording nSTEMI between hospitals may distort some analyses.

Mortality data are obtained from the NHS Central Register by CCAD. The percentage of patients having STEMI and nSTEMI who die within 30 days of admission to hospital has fallen annually from 2003/4-2010/11 [Figs 18, 19].

Table 8 shows the percentage of nSTEMI patients that were Fig 18. admitted to a cardiac unit or ward and the percentage of nSTEMI patients seen by a cardiologist or member of their team, by hospital, in 2009/10 and 2010/11. The same analyses for hospitals in Wales and Belfast are shown in Table 9. In England in 2010/11, 50% of nSTEMI patients were admitted to a cardiac unit or ward compared to 47% in 2009/10. In Wales 59% of patients were admitted to a cardiac unit or ward compared to 55% in 2009/10. In the Belfast hospitals, 81% of patients were admitted to a cardiac unit or ward compared to 82% in 2009/10. In England in 2010/11, 91% of nSTEMI patients were seen by a cardiologist or member of their team compared to 89% in 2009/10. In Wales 84% of nSTEMI patients were seen by a cardiologist or member of their team compared to 74% in 2009/10. In the Belfast hospitals 99% of nSTEMI patients were seen by a cardiologist or member of their team compared to 100% in 2009/10. The frequency with which patients are referred for angiography for nSTEMI also continues to increase, [Fig 17]. Due to a Fig 19. database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11. In 2009/10, 63% of nSTEMI patients in England were referred for angiography after nSTEMI, and 70% in 2010/11. In Wales 74% were referred in 2009/10, and 81% in 2010/11. In Belfast 82% were referred in Use of angiography for patients within a diagnosis 2009/10 and 85% 2010/11.of

g 17. n ST segment elevation MI. [Inappropriate of refused mall numbers) excluded. All age groups.]

Fig 17. Use of angiography for patients with a diagnosis of non ST segment elevation MI.

Inappropriate or refused (small numbers) excluded. All age groups.

Fig 18. 30 day mortality, (with 95% confidence limits) for all patients having STEMI.

The data for 2010/11 are provisional and may be revised. 14 13 12 11 % 10 9 8 7 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10 2010-11

Financial year

Fig 19. 30 day mortality (with 95% confidence limits) for nSTEMI.

The data for 2010/11 are provisional and may be revised. 14 13 12 11 % 10 9 8

80

7

70

71

60

64.1

50 %

44.8

40 30

47.8

49.6

51.6

2005-6

2006-7

2007-8

54.4

6 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10 2010-11

Financial year

35.1

20 10 0 2003-4

2004-5

2008-9

2009-10 2010-11



23

16/08/2011 14:03

24 89% 80% 97% 93% 83% 85% 83% 81% 90% 87% 83% 86% 88%

Barts & the London, London

Basildon Hospital, Basildon

Basingstoke & North Hampshire Hospital, Basingstoke

Birmingham Heartlands Hospital, Birmingham

Bristol Royal Infirmary, Bristol

Castle Hill Hospital, Hull

Cheltenham General Hospital, Cheltenham

City Hospital, Birmingham

Conquest Hospital, St Leonards on Sea

Derriford Hospital, Plymouth

Dorset County Hospital, Dorchester

East Surrey Hospital, Redhill

%

England national average

Year

48

22

69

60

62

36

139

328

278

82

396

533

11466

n

Primary angioplasty within 90 mins of arrival at interventional centre

91%

84%

75%

96%

85%

75%

70%

77%

93%

85%

56%

80%

%

45

19

64

53

56

33

125

318

264

67

347

500

10012

n

Primary angioplasty within 150 mins of calling for help

91%

84%

75%

96%

88%

77%

84%

86%

93%

86%

78%

86%

%

2009/10

45

19

64

53

56

32

122

241

192

67

335

297

8336

n

Primary angioplasty within 150 mins of calling for help for patients with direct admission to interventional centre

27%

50%

23%

45%

%

0

0

0

0

0

1

3

78

72

0

14

203

1689

n

Primary angioplasty within 150 mins of calling for help for patients transferred to interventional centre

%

94%

95%

93%

88%

91%

90%

93%

73%

69%

81%

84%

56%

75%

% of patients with direct admission to interventional centre

94%

92%

81%

90%

78%

93%

89%

90%

84%

94%

96%

96%

90%

%

52

25

136

61

67

74

348

559

262

104

609

485

14545

n


90%

80%

77%

82%

88%

86%

89%

74%

85%

95%

84%

80%

81%

%

50

25

136

55

52

73

300

535

249

85

589

418

12868

n


90%

80%

77%

82%

88%

86%

92%

82%

90%

95%

90%

95%

88%

%

n

49

25

136

55

52

73

285

415

209

85

457

330

10713

2010/11


48%

58%

61%

25%

49%

%

1

0

0

0

0

0

15

120

40

0

132

88

2157

n


taken directly to an interventional centre, especially where there is diagnostic uncertainty. This inevitably takes longer than direct transfer, but cannot be avoided in some cases.

91%

79%

99%

83%

74%

80%

83%

75%

68%

75%

16/08/2011 14:13

94%

96%

100%

%


hospital performance and that of the emergency services in identifying STEMI and taking the patient to the interventional centre (which may not be the closest hospital). Not all patients are

Primary angioplasty within 90 minutes of arrival reflects the ability of a hospital to provide treatment in a timely manner. Primary angioplasty within 150 minutes of calling for help reflects

MINAP Public Report LandscapeVisuals Blue.indd 24

MINAP

table 1 primary angioplasty in hospitals in england, wales and belfast

11. Results by hospitals, ambulance services and cardiac networks - percentages are not shown for less than 20 cases

MINAP

25

MINAP

99%

Freeman Hospital, Newcastle

70% 91% 99% 93% 93%

Glenfield Hospital, Leicester

Hammersmith Hospital, London

Harefield Hospital

James Cook University Hospital, Middlesborough

John Radcliffe Hospital, Oxford

64% 88%

King's College Hospital, London

Leeds General Infirmary, Leeds

98% 91%

Liverpool Heart & Chest Hospital, Liverpool

Manchester Royal Infirmary, Manchester

95% 83% 83%

Norfolk & Norwich University Hospital, Norwich

Northampton General Hospital, Northampton

Northern General Hospital, Sheffield

92% 97%

Nottingham City Hospital, Nottingham

Papworth Hospital, Cambridge

Northwick Park Hospital, Harrow

89%

New Cross Hospital, Wolverhampton

Medway Maritime Hospital, Gillingham

96%

Lister Hospital, Stevenage

Lincoln County Hospital, Lincoln

71%

Kettering General Hospital, Kettering

Kent & Sussex Hospital, Tunbridge Wells

72%

Frimley Park Hospital, Frimley

Frenchay Hospital, Bristol

73%

Eastbourne DGH, Eastbourne


25

409

98

1

289

36

365

447

0

341

400

74

0

833

270

28

1

224

542

508

324

215

50

7

835

30

74%

83%

70%

85%

85%

80%

77%

84%

90%

80%

64%

71%

75%

83%

88%

71%

67%

82%

86%

73%

372

92

1

274

26

353

369

0

194

387

70

0

661

238

24

1

212

500

421

286

181

38

5

750

30

87%

84%

79%

85%

87%

90%

89%

97%

97%

86%

65%

71%

87%

92%

90%

86%

68%

83%

96%

72%

279

89

1

217

26

329

311

0

140

217

58

0

503

235

24

1

148

404

414

192

180

35

5

570

29

40%

39%

54%

26%

46%

68%

61%

48%

42%

38%

54%

97

3

0

57

0

24

58

0

54

170

12

0

158

3

0

0

64

96

12

94

1

3

0

181

1

68%

92%

100%

64%

75%

91%

73%

41%

54%

77%

63%

93%

89%

100%

65%

75%

93%

61%

86%

70%

71%

68%

97%

98%

96%

88%

92%

96%

91%

89%

98%

94%

85%

65%

83%

93%

95%

75%

90%

84%

76%

98%

61%

419

188

3

606

36

402

498

10

326

670

78

11

985

316

102

3

347

549

408

318

267

140

2

765

38

76%

86%

75%

96%

86%

81%

74%

82%

93%

64%

68%

87%

78%

87%

85%

74%

85%

81%

90%

71%

413

176

3

581

28

389

385

10

247

601

69

11

793

239

93

3

331

476

379

284

232

127

2

672

31

90%

87%

84%

96%

89%

89%

89%

98%

95%

75%

68%

88%

93%

92%

91%

89%

87%

86%

98%

71%

293

173

3

422

28

357

324

10

169

359

63

11

625

239

92

3

244

413

329

176

227

94

2

527

31

40%

51%

53%

34%

42%

57%

22%

38%

49%

48%

49%

67%

62%

120

3

0

159

0

32

61

0

78

243

6

0

168

0

1

0

87

63

50

108

5

33

0

145

0

16/08/2011 14:13

70%

93%

100%

70%

78%

89%

70%

100%

53%

53%

81%

100%

66%

90%

93%

100%

70%

76%

81%

63%

85%

69%

100%

69%

84%

26 71%

Royal Sussex County Hospital, Brighton

109

61%

303

St Thomas Hospital, London

84%

St George's Hospital, London

166

16

86%

Southampton General Hospital, Southampton

102

0

27

63

161

St Peter's Hospital, Chertsey

75%

Sandwell District Hospital, West Bromwich

Russells Hall Hospital, Dudley

100%

93%

Royal Free Hospital, London

Royal United Hospital Bath, Bath

86%

Royal Devon & Exeter Hospital, Exeter 196

28

93%

93

Royal Derby Hospital, Derby

90%

Royal Bournemouth General Hospital, Bournemouth

145

99

63

12

94%

Royal Berkshire Hospital, Reading

n

Royal Cornwall Hospital, Truro

99%

Queen Elizabeth Hospital, Birmingham

% 95%


MINAP

Queen Alexandra Hospital, Portsmouth

Year


51%

87%

82%

83%

100%

78%

92%

86%

92%

95%

96%

62%

95%

%

84

61

101

11

278

150

80

0

26

58

155

147

25

10

78

137

n


62%

88%

88%

83%

100%

78%

93%

86%

92%

94%

96%

63%

95%

%

2009/10

82

61

71

11

269

138

80

0

26

58

148

147

25

10

69

136

n


27%

%

n

0

0

0

0

7

0

0

0

9

1

2

0

30

0

9

12


%

68%

69%

93%

83%

79%

96%

91%

92%

91%

89%

92%

76%

93%

80%

97%


83%

96%

89%

91%

77%

92%

94%

93%

91%

89%

97%

92%

96%

68%

88%

%

132

27

342

194

95

1

51

190

186

176

62

33

72

147

124

193

n


73%

96%

90%

89%

92%

92%

86%

91%

79%

87%

94%

96%

95%

74%

81%

%

120

26

306

170

76

1

48

176

184

141

55

33

68

134

109

176

n


83%

96%

89%

91%

92%

91%

86%

91%

79%

87%

94%

95%

95%

76%

92%

%

2010/11

87

26

218

162

76

1

47

176

183

141

55

32

63

134

106

136

n


48%

91%

43%

%

n

33

0

88

9

0

0

1

0

1

0

0

1

5

0

3

40


91%

93%

97%

89%

89%

97%

88%

92%

86%

70%

16/08/2011 14:13

65%

96%

67%

78%

80%

100%

%


MINAP

27

MINAP

89

85% 94% 86% 83% 77% 92%

Torbay Hospital, Torquay

University College Hospital, London

University Hospital Coventry, Coventry

University Hospital of North Staffordshire, Stoke-on-Trent

Victoria Hospital, Blackpool

Watford General Hospital, Watford

91%

53%

Wythenshawe Hospital, Manchester

Belfast average

University Hospital of Wales, Cardiff

Morriston Hospital, Swansea 72%

72%

71%

Wales national average

Glan Clwyd DGH Trust, Bodelwyddan

56

59%

Royal Victoria Hospital

32

180

3

215

16

Belfast City Hospital

72

257

31

90%

Wycombe General Hospital, High Wycombe

0

Worcestershire Royal Hospital, Worcester 19

0

William Harvey Hospital, Ashford

Worthing Hospital, Worthing

3

Wexham Park Hospital, Slough

60

173

289

329

154

18

The Great Western Hospital, Swindon

66

Taunton & Somerset Hospital, Taunton 94%

4

Sunderland Royal Hospital, Sunderland


27

76%

76%

80%

77%

78%

72%

92%

88%

84%

90%

55%

88%

93%

19

159

2

180

40

7

47

205

29

17

0

0

2

60

144

240

274

117

73

14

56

3

76%

76%

78%

75%

89%

72%

92%

88%

86%

90%

86%

88%

92%

19

157

2

178

37

7

44

122

29

17

0

0

2

60

144

231

273

58

73

14

48

3

60%

24%

0

2

0

2

3

0

3

83

0

0

0

0

0

0

0

9

1

59

0

0

8

0

69%

88%

75%

85%

71%

44%

65%

50%

85%

89%

100%

100%

50%

100%

83%

81%

94%

38%

89%

89%

72%

75%

52%

76%

68%

87%

87%

92%

93%

77%

88%

83%

90%

87%

89%

88%

93%

87%

97%

99%

89

190

4

283

159

1

160

312

30

22

11

519

41

48

154

341

330

168

77

33

156

2

67%

79%

75%

90%

90%

73%

90%

75%

95%

88%

95%

73%

85%

65%

93%

97%

98%

63

159

3

225

124

0

124

245

21

19

11

425

39

42

140

282

304

126

70

29

145

2

67%

81%

76%

89%

89%

82%

90%

74%

95%

88%

96%

85%

85%

85%

93%

97%

98%

63

155

3

221

89

0

89

201

21

19

10

381

39

42

139

225

292

88

70

29

124

2

36%

84%

26%

18%

100%

0

4

0

4

0

44

0

0

1

44

0

0

1

57

12

38

0

0

21

0

16/08/2011 14:13

75%

81%

80%

79%

60%

0%

60%

67%

69%

86%

93%

75%

93%

87%

90%

67%

91%

53%

95%

88%

80%

89%

28

100%

14

Bassetlaw District General Hospital, Nottingham

Chesterfield Royal, Chesterfield


Charing Cross Hospital, London

86%

88

19

11 44

1

1

76%

4

4

Calderdale Royal Hospital, Halifax

54

12

12

Bradford Royal Infirmary, Bradford

30

0

0



9

7

Bedford Hospital, Bedford

76%

39

87%

18


70%

1

1


25

15

20

75

3

3522

85%

77%

69%

n

Barnsley District General Hospital, Barnsley

1

2984

%

89

79%

n

89%

%

2009/10

Thrombolytic treatment within 60 mins of calling for help

Arrowe Park Hospital, Wirral

Airedale General Hospital, Steeton


Year

Thrombolytic treatment within 30 mins of hospital arrival

treatment to 20 or more patients, and in 2010/11 this had fallen to 28. Further falls can be anticipated.


MINAP

%

75%

n

6

0

1

3

2

5

2

3

0

1

1

1

18

1

1526

%

77%

68%

n

16/08/2011 14:13

9

2

0

2

1

5

2

1

3

26

1

1

17

4

1790


2010/11


The small numbers having thrombolytic treatment reflects the dominance of primary angioplasty as the reperfusion treatment of choice for STEMI. In 2009/10 62 hospitals gave thrombolytic

table 2 thrombolytic treatment in hospitals in england

MINAP

29

MINAP

40 34

75% 85%

Cumberland Infirmary, Carlisle

Darent Valley Hospital, Dartford

17

Grantham & District General, Grantham

17

57%

11

Gloucestershire Royal Hospital, Gloucester

21

12

78

George Elliot Hospital, Nuneaton

74%

27

14

63%


27

100%

14

0

22

82%

0

Furness General, Barrow-in-Furness


5

27

2

78%


43

86%

Fairfield General Hospital, Bury

11

22

0

24

63%

Epsom Hospital, Epsom

82%

0

20

80%


20

34

40

29

2

32

47

29

45


31

81%


75%

50%

24

79%

Doncaster Royal Infirmary, Doncaster


95%

20

75%

90%

78%

51%

76%

76%

Diana, Princess of Wales Hospital, Grimsby

4

22

64%

County Hospital Hereford , Hereford

Dewsbury District Hospital, Dewsbury

48

77%

Countess of Chester Hospital, Chester

12

8

23


83% 19

31 11

77%

Colchester General Hospital, Colchester

Chorley Hospital, Chorley


29

100%

73%

72%

70%

80%

79%

22

2

2

1

18

0

1

1

15

14

12

30

16

1

25

5

2

37

35

10

8

1

28

90%

77%

74%

70%

82%

88%

16/08/2011 14:13

18

1

52

1

22

1

1

1

12

7

5

16

15

1

31

5

3

53

45

24

7

1

19

30

29 32 39 26 33

84% 92% 65% 79%

Leighton Hospital, Crewe


Macclesfield District General, Macclesfield

Maidstone General Hospital, Maidstone

9

51

62%

88%

3

Leicester Royal Infirmary, Leicester


Kings Mill Hospital, Nottingham



89%

52%

65%

58%

26%

69%

81%

0

0


18

0

0


27

21

63

43

23

7

68

2

47

24

7

8

Huddersfield Royal Infirmary, Huddersfield

96%

2

2

Horton General Hospital, Banbury

36

0

0

Hope Hospital, Manchester

81%

0

0

Hinchingbrooke Hospital, Huntingdon

Kent & Canterbury Hospital, Canterbury

0

n

0

%

Hillingdon Hospital, Uxbridge

n

0

%

2009/10


0


MINAP

Harefield Hospital

Year


%

84%

86%

75%

19%

n

2

18

31

43

2

4

67

31

10

1

1

1

1

0

1

2

1

1

%

71%

73%

72%

0%

n

16/08/2011 14:13

1

15

51

49

2

4

76

26

19

0

1

1

1

1

0

2

1

1


2010/11


MINAP

31

MINAP

Queen Elizabeth the Queen Mother, Margate

78%

83

77%


32

1

30

80%

Queen's Hospital, Burton-upon-Trent


24

16

22

88%

77%

Princess Royal Hospital, Telford

Princess Royal Hospital, Haywards Heath

Poole Hospital, Poole

48%

81%

75%

81%

17

1

84

21

28

13

27

4

6

52

Pontefract General Infirmary, Pontefract

67%

5

39 6

79%

Pinderfields General Hospital, Wakefield

Pilgrim Hospital, Boston

8

0

44

Peterborough City Hospital, Peterborough

66%

1

57

10

21

82%

1

76%

1

25





0

0

North Middlesex Hospital, London

35

18 0

4

2 74%

10

14

45 3

93%

2

43

1

0

88%

91%

2

North Manchester General Hospital, Manchester

North Devon District Hospital, Barnstable


Newark Hospital, Newark





31

75%

70%

87%

4

1

28

3

1

6

20

2

4

39

0

0

16

1

12

1

3

9

0

3

2

2

2

53%

59%

63%

52%

90%

16/08/2011 14:13

4

1

30

3

1

4

27

1

2

46

2

8

23

0

31

1

2

13

7

4

2

1

2

32

56 46 36

82% 59% 86%




Royal Victoria Infirmary, Newcastle


3

33

79%

18

Royal Surrey County Hospital, Guildford

20

14

Royal Shrewsbury Hospital, Shrewsbury

100%

65%

43

84%

Royal Preston Hospital, Preston


71%

59

80%

Royal Oldham Hospital, Oldham

54%

95%

65%

39

58%

81%

71%

77%

74%

74%

67%

93%

69%

%

Royal Lancaster Infirmary, Lancaster

0

95

89%

Royal Bolton Hospital, Bolton

Royal Devon & Exeter Hospital, Exeter

115

83%

0

Royal Blackburn Hospital, Blackburn


85

96%

Royal Albert Edward Infirmary, Wigan

0 46

n

98%

%

n

3

50

21

14

26

35

46

45

0

73

104

52

80

129

2

72

28

0


2009/10

Rochdale Infirmary, Rochdale


MINAP

Queen's Hospital, Romford

Year


%

77%

70%

77%

89%

68%

79%

85%

81%

94%

n

1

3

0

5

5

48

20

30

2

44

34

28

66

98

1

84

16

1

%

92%

55%

69%

67%

80%

67%

69%

88%

n

16/08/2011 14:13

1

5

2

4

3

38

17

29

2

74

82

35

55

95

1

72

13

1


2010/11


MINAP

33

MINAP

93%

14

Southend Hospital, Westcliffe on Sea

0 6 2 1 1

7 0 1 1

University Hospital Aintree, Liverpool


University Hospital of Hartlepool, Hartlepool


31

0

58%

32

43

48



22

72%

18

The Ipswich Hospital, Ipswich

59%

86%

18


The Alexandra Hospital, Redditch

52%

87%

28

15

71%

0

0

26

9

38

Taunton & Somerset Hospital, Taunton

Tameside General Hospital, Ashton Under Lyme

Stoke Mandeville Hospital, Aylesbury

69%

23

12

31

61%

St Richard's Hospital, Chichester

100%

38

10

31

94%


74%

29

27

34

30

0

37

3

23

87%

St Mary's Hospital, Newport

Stepping Hill Hospital, Stockport

33

94%

Southport & Formby District General, Southport

79%

85%

Scarborough General Hospital, Scarborough

18

59%

Scunthorpe General Hospital, Scunthorpe

0

31

57%

89%

90%

28


Salisbury District Hospital, Salisbury


33

96%

90%

0

1

4

5

1

16

0

3

26

0

2

10

1

18

20

12

7

2

18

18

1

15

58%

74%

84%

89%

45%

16/08/2011 14:13

1

1

3

2

1

24

1

6

31

1

2

7

3

18

14

25

7

2

36

18

1

20

34

York District Hospital, York

10

11

22

82%

46

9

35%

26

Yeovil District Hospital, Yeovil

49

76%


69%

64

35

3

40

31

4

29

5

73

0

0

23

61%


53%

86%

78%

61%

83%

44%

n

1

57

81%

Worcestershire Royal Hospital, Worcester

%


42

90%

3


Whiston Hospital, Prescott

35

74%


7

35

5

56

0

25

83%

68%

n

72%

%


2009/10

West Cumberland Hospital, Whitehaven

West Cornwall Hospital, Penzance

Warrington District General Hospital, Warrington


University Hospital Queens Medical, Nottingham


MINAP

University Hospital of North Tees, Stockton on Tees

Year


%

83%

81%

74%

n

2

2

3

11

13

29

5

2

2

36

5

4

6

27

1

%

59%

78%

48%

n

16/08/2011 14:13

1

2

3

10

13

39

4

1

1

41

0

4

3

33

1


2010/11


35

MINAP


35

Senior Research Fellow at Oxford Heart Centre

Consultant Nurse and Dr Robin Choudhury,

Jan Keenan

current and future work.”

service development, identifying areas for

“MINAP data is a significant tool supporting

16/08/2011 14:13

36

24

13

Princess of Wales Hospital, Bridgend

29 23 22 27

26

55% 74% 82% 56%

46%


West Wales General, Camarthen

Withybush General Hospital, Haverfordwest

Ysbyty Gwynedd , Bangor

Belfast average

2

46

57%

Royal Gwent Hospital, Newport

Singleton Hospital, Swansea

27

74%

Royal Glamorgan, Llantrisant

48%

44%

59%

42%

69%

56%

51%

67%

8

14

Prince Philip Hospital, Llanelli

31

45

27

26

51

0

70

35

35

71%

17

Prince Charles Hospital, Merthyr Tydfil

39

49%

Nevill Hall Hospital, Abergavenny

29

59%

3

4

48

Neath Port Talbot Hospital, Neath

46% 0

49 0

71%

Morriston Hospital, Swansea

Maelor Hospital, Wrexham

13

50

5

484

8

58%

55%

n

Llandudno General Hospital, Llandudno

32

6

356

%

5

84%

67%

n

8

%

2009/10


Llandough Hospital, Llandough


Bronglais General Hospital, Aberystwyth


Year


MINAP


%

44%

72%

60%

59%

66%

66%

97%

62%

n

2010/11

0

36

11

29

5

0

40

4

14

10

22

29

3

1

44

4

3

30

13

298


table 3 thrombolytic treatment in hospitals in wales and belfast

%

42%

46%

88%

52%

60%

56%

46%

56%

59%

53%

n

16/08/2011 14:13

0

48

18

26

32

0

62

7

25

6

32

28

2

1

48

3

2

49

13

402


MINAP

37

MINAP

837 198 820 212 206 394 219 377

489

60% 72% 59% 79% 81% 50% 70%

55%

Yorkshire

East Midlands

West Midlands

East of England

South East Coast

South Central

South Western

Welsh

6

156

70%

71%

North West

North East

Great Western

10

38

74%

Isle of Wight

London

3473

n

70%

%

2009/10


Year

Patients having thrombolytic treatment within 60 mins of calling for help

%

53%

68%

38%

72%

71%

66%

72%

37%

74%

52%

85%

69%

2010/11 n

406

203

52

103

48

125

513

41

576

8

29

8

26

1732

Patients having thrombolytic treatment within 60 mins of calling for help

n

250

238

38

215

192

99

487

89

165

1

89

1

19

1633

2009/10

Patients having pre-hospital thrombolysis

table 4 ambulance services in england and wales


37

n

219

133

4

45

76

65

309

12

146

1

14

2

17

824

2010/11

Patients having pre-hospital thrombolysis

%

75%

89%

92%

80%

90%

88%

89%

84%

92%

97%

84%

88%

88%

n

221

465

861

823

1300

1189

675

1007

865

886

547

1375

2

9995

%

97%

29%

74%

52%

46%

22%

19%

47%

61%

58%

51%

50%

n

16/08/2011 14:13

7

34

58

88

282

125

27

104

297

192

79

256

1

1543


2010/11


38

170 192 252 42 159 985 679 201 230 77 595 547

99% 98% 100% 100% 96% 99% 99% 100% 100% 96% 100% 100%

Addenbrooke's Hospital, Cambridge



Barnet General Hospital, Barnet









52189

n

99%

%


Year

Aspirin

93%

99%

99%

96%

98%

95%

97%

100%

95%

99%

95%

93%

100%

%

Beta blocker

486

529

78

219

188

655

950

151

39

201

169

151

47008

n

99%

99%

97%

98%

90%

99%

99%

97%

97%

100%

97%

100%

100%

%

2010/11

Statins

553

591

79

251

202

682

988

162

43

277

198

179

52723

n

99%

98%

96%

93%

97%

71%

99%

99%

94%

97%

95%

96%

100%

%

n

532

573

80

246

197

658

962

146

39

241

179

136

48856

ACE inhibitor

Patients discharged on secondary prevention medication

99%

96%

96%

96%

97%

89%

89%

99%

95%

98%

99%

92%

100%

%

16/08/2011 14:13

537

599

79

213

199

661

989

147

39

222

209

142

49755

n

Clopidogrel/ Thienopyridine inhibitor

hospital for further treatment. Patients are also excluded from analysis if there is a contraindication to a drug, if they refuse treatment, or have severe non cardiac co-morbidity that limits prognosis.


MINAP

These analyses are based on all patients discharged from hospital with a diagnosis of myocardial infarction. Patients are excluded if they are transferred from the admitting hospital to another

table 5 secondary prevention medication in england

MINAP

39

MINAP

835 108 41 105 22 178 274 85 216 354 270 211 20 191 206 125 26 286 167

95% 98% 95% 97% 100% 100% 99% 99% 100% 100% 100% 99% 95% 97% 96% 99% 100% 98% 99%


Central Middlesex Hospital, London


Chase Farm Hospital, Enfield

Chelsea & Westminister Hospital, London








County Hospital Hereford, Hereford



Darlington Memorial Hospital, Darlington




296

292

99%


100%

310

94%

Broomfield Hospital, Chelmsford


791

98%



39

100%

94%

96%

98%

93%

97%

95%

99%

98%

98%

100%

88%

99%

100%

99%

92%

88%

90%

98%

89%

90%

281

159

253

11

126

188

150

20

206

229

304

174

91

234

157

17

97

38

96

844

245

256

790

99%

98%

97%

84%

92%

94%

80%

95%

97%

99%

98%

100%

99%

99%

99%

100%

100%

93%

95%

94%

97%

91%

96%

315

180

298

25

133

208

199

20

236

282

361

219

93

279

172

22

108

41

110

847

299

312

790

100%

84%

94%

61%

90%

90%

78%

99%

97%

99%

100%

89%

97%

100%

95%

100%

94%

92%

88%

99%

88%

90%

292

166

278

23

125

192

180

19

187

261

335

192

92

259

172

20

93

36

106

846

256

250

789

92%

95%

95%

95%

96%

91%

89%

100%

99%

100%

99%

100%

87%

99%

99%

100%

5%

100%

94%

92%

99%

88%

92%

16/08/2011 14:13

309

176

270

42

125

197

196

20

179

264

346

216

94

265

174

21

106

40

107

848

281

273

791

40

62 413 226 59 190 1505 256 22 402 25 134 573 98 173 72 374 838

94% 99% 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 100% 100% 96% 97% 96%







Friarage Hospital, Northallerton





Good Hope General Hospital, Sutton Coldfield



Harefield Hospital

n

Ealing Hospital, Southall

%

236




MINAP

100%

Year

Aspirin

95%

91%

97%

87%

89%

92%

100%

100%

100%

98%

81%

97%

100%

92%

100%

100%

98%

100%

%

Beta blocker

n

826

334

64

148

82

548

128

21

322

20

250

1414

178

58

179

360

64

215

94%

96%

96%

92%

95%

90%

99%

100%

100%

98%

92%

98%

100%

91%

100%

100%

100%

100%

%

2010/11

Statins

n

835

371

82

183

96

573

139

26

397

22

264

1504

197

59

231

425

68

235

99%

93%

97%

94%

83%

89%

90%

99%

100%

100%

93%

87%

95%

100%

86%

100%

100%

100%

%

ACE inhibitor


n

834

359

67

173

86

554

127

23

366

20

244

1454

185

60

194

383

60

225

95%

82%

98%

73%

96%

90%

99%

100%

96%

99%

92%

99%

92%

100%

99%

100%

100%

%

n

16/08/2011 14:13

829

373

70

179

96

584

120

26

398

11

251

1506

191

60

187

399

60

234


MINAP

41

MINAP

41 222

98% 100%

308 74 245 34 756 38 764 184 83 378 115 629 279 22 861 40 281

99% 100% 100% 85% 100% 87% 100% 99% 98% 100% 100% 99% 97% 100% 100% 100% 98%







King George Hospital, Goodmayes



Kingston Hospital, Kingston-upon-Thames





James Paget Hospital, Great Yarmouth


Hull Royal Infirmary, Hull

20

95%

10

280

100%

Homerton Hospital, London



Hexham General Hospital, Hexham

Harrogate District Hospital, Harrogate


41

97%

100%

97%

95%

95%

100%

97%

97%

94%

100%

85%

99%

53%

99%

100%

98%

95%

100%

84%

99%

245

46

777

17

252

626

100

329

66

154

670

39

712

38

209

59

287

20

8

150

38

232

97%

98%

99%

96%

95%

98%

99%

99%

99%

91%

100%

87%

99%

59%

98%

100%

97%

95%

99%

93%

98%

313

41

848

27

277

628

122

377

81

195

729

39

760

37

248

71

313

21

9

205

41

283

95%

100%

96%

91%

90%

96%

98%

97%

90%

98%

100%

85%

99%

53%

96%

100%

96%

95%

100%

97%

99%

286

39

788

22

262

615

105

340

73

151

717

39

736

38

225

54

294

20

9

186

38

256

97%

68%

97%

97%

84%

100%

99%

96%

95%

100%

87%

99%

65%

100%

100%

94%

86%

100%

91%

100%

16/08/2011 14:13

277

41

67

19

279

627

99

375

81

178

730

38

730

37

237

66

299

21

11

170

35

260

42

189 198 124 226 82 76 312 42

100% 96% 97% 98% 96% 86% 100% 98%

Luton & Dunstable Hospital, Luton




Manor Hospital, Walsall

Mayday University Hospital, Croydon


Milton Keynes General Hospital, Milton Keynes



Newham General Hospital, London



827 35 133 1115 179

100% 97% 100% 98% 100%

19

741

100%


Montagu Hospital, Mexborough

271

98%


n

351

%

96%


MINAP


Year

Aspirin

98%

85%

100%

100%

100%

89%

99%

86%

100%

82%

84%

92%

88%

88%

99%

100%

%

Beta blocker

n

119

957

102

36

714

15

42

301

67

76

215

106

171

146

719

262

341

95%

100%

100%

100%

92%

99%

90%

100%

99%

89%

96%

97%

96%

92%

100%

100%

100%

%

2010/11

Statins

n

170

1085

133

39

832

20

41

323

79

84

233

116

197

206

743

271

354 97%

86%

100%

100%

100%

97%

93%

88%

100%

79%

86%

83%

84%

85%

99%

100%

%

ACE inhibitor


n

142

1023

84

36

745

14

40

303

72

78

222

111

185

166

735

266

346

99%

98%

90%

100%

96%

100%

94%

98%

86%

100%

83%

84%

94%

97%

82%

100%

%

n

16/08/2011 14:13

146

1120

119

36

803

19

35

316

71

80

225

124

194

187

743

265

346


MINAP

43

MINAP

168 440 909 292 353 541 260 198 295 206

100% 100% 99% 99% 99% 99% 100% 90% 100% 100%

North Tyneside General Hospital, North Shields








218 550 442 241 274

86% 98% 100% 96% 93%

Princess Royal University Hospital, Orpington



Queen Elizabeth Hospital, Gateshead

Queen Elizabeth Hospital, King's Lynn

Queen Elizabeth Hospital, Woolwich

104

81

100%

100%

142

99%



199

88%

Princess Alexandra Hospital, Harlow



17

121

94%



192

99%



43

99%

85%

95%

99%

96%

81%

99%

98%

76%

99%

99%

79%

100%

95%

93%

89%

99%

100%

100%

86%

99%

90

245

198

367

541

218

69

121

200

12

196

286

201

191

524

325

261

741

380

149

110

169

100%

86%

94%

100%

97%

83%

95%

93%

91%

99%

99%

83%

100%

99%

98%

97%

99%

100%

100%

92%

99%

103

274

247

439

543

218

84

137

203

16

215

308

208

264

541

352

303

875

425

174

123

190

94%

80%

86%

100%

88%

81%

86%

90%

85%

94%

96%

81%

100%

96%

94%

89%

98%

100%

98%

87%

97%

90

254

197

400

504

218

77

120

202

15

204

285

205

224

531

344

289

736

367

129

120

186

99%

83%

90%

100%

92%

68%

96%

92%

91%

97%

99%

82%

100%

77%

95%

92%

99%

100%

99%

81%

98%

16/08/2011 14:13

98

261

233

428

547

218

72

121

203

12

203

289

204

255

539

353

293

644

410

158

116

185

44

108 192 321 379 412 538 442 199 651 483 411 306 112

100% 100% 100% 100% 100% 99% 99% 100% 100% 100% 100% 97% 100%



Rotherham General Hospital, Rotherham









Royal Hampshire County Hospital, Winchester


182

100%

12


Queen Mary's Hospital, Sidcup

146

98%


n

69

%

99%


MINAP

Queen Elizabeth II Hospital, Welwyn Garden City

Year

Aspirin

90%

93%

100%

97%

99%

100%

100%

95%

94%

96%

99%

100%

100%

97%

100%

100%

%

Beta blocker

n

70

306

376

409

483

181

397

500

392

356

244

158

88

162

12

126

72 86%

97%

99%

97%

97%

100%

100%

98%

98%

96%

99%

100%

99%

100%

100%

100%

%

2010/11

Statins

n

99

306

423

463

595

200

441

560

412

388

323

195

106

195

13

157

70

98%

99%

83%

95%

100%

97%

96%

100%

100%

96%

89%

94%

95%

100%

100%

100%

%

ACE inhibitor


n

94

304

400

390

478

197

403

523

380

368

280

184

86

185

13

117

64

99%

99%

99%

99%

84%

90%

100%

97%

96%

100%

98%

96%

86%

97%

98%

100%

%

n

16/08/2011 14:13

91

305

417

449

622

203

420

535

401

367

309

170

100

142

12

135

62


MINAP

45

MINAP

100

99%


103 183 205 236 138 278

100% 99% 100% 100% 98% 95%






141 700 370 252 114

100% 99% 100% 94% 100%

South Tyneside District Hospital, South Shields


Southmead Hospital, Bristol



52

96%

Solihull General Hospital, Birmingham

Selly Oak Hospital, Birmingham

1

260

100%



311

100%


19

105

95%



281

99%


4

138

99%

Royal Liverpool University Hospital, Liverpool

Royal London Hospital, London

99

99%



45

98%

94%

100%

98%

100%

94%

89%

92%

99%

98%

93%

100%

97%

97%

98%

90%

98%

100%

100%

87

224

340

663

107

49

1

263

121

187

185

167

85

231

280

16

86

102

252

2

141

91

98%

91%

100%

99%

99%

96%

95%

97%

100%

99%

93%

100%

99%

98%

97%

92%

99%

100%

99%

119

253

385

703

136

52

1

295

142

245

204

185

108

252

308

18

97

105

290

4

150

100

92%

83%

100%

94%

100%

94%

89%

93%

100%

98%

92%

100%

96%

95%

96%

85%

90%

95%

100%

100%

98%

112

186

324

689

122

49

1

266

137

218

197

180

97

220

291

25

71

107

273

20

86

99

100%

85%

100%

95%

100%

100%

96%

92%

100%

96%

92%

100%

99%

97%

88%

93%

88%

96%

99%

97%

16/08/2011 14:13

117

233

350

643

116

51

1

295

146

233

194

170

97

232

302

26

89

107

281

17

137

99

46

67 138 215 114 262 152 437 71 170 292 399 164 368 329 368

100% 91% 100% 97% 100% 97% 96% 100% 99% 99% 99% 96% 99% 92% 99%


St Mary's Hospital, London


Staffordshire General Hospital, Stafford












70

100%

St Helier Hospital, Carshalton

n

444

%

99%


MINAP


Year

Aspirin

74%

98%

97%

94%

80%

71%

96%

86%

89%

98%

95%

98%

94%

91%

100%

90%

100%

%

Beta blocker

n

316

319

291

158

376

258

165

51

435

139

244

112

207

138

51

67

435 99%

98%

96%

78%

96%

93%

94%

95%

97%

98%

95%

95%

100%

89%

100%

85%

100%

%

2010/11

Statins

n

366

365

365

164

413

317

172

65

490

161

264

123

215

138

59

69

445 97%

93%

86%

63%

93%

87%

87%

97%

95%

97%

92%

90%

100%

85%

100%

69%

100%

%

ACE inhibitor


n

339

350

321

163

386

280

164

64

443

141

248

110

199

138

52

72

442

99%

95%

77%

98%

92%

95%

89%

98%

97%

81%

89%

100%

88%

100%

77%

98%

100%

%

n

16/08/2011 14:13

354

327

337

164

390

300

166

66

493

132

256

97

201

138

56

72

444


MINAP

47

MINAP

287 436 61 102 95 1050 88 51 648 141 270 32 330

100% 100% 95% 100% 97% 96% 100% 100% 100% 100% 100% 100% 99%



University Hospital Lewisham, London


University Hospital of North Durham, Durham





Wansbeck General Hospital, Ashington


Warwick Hospital, Warwick

West Suffolk Hospital, Bury St Edmunds

West Middlesex University Hospital, Isleworth




92 48 152

92% 100% 97%

2

173

100%


University College Hospital Gower Street, London

56

19 95%

Trafford General Hospital, Manchester


47

94%

100%

93%

99%

82%

100%

100%

100%

80%

100%

88%

90%

100%

93%

96%

99%

98%

93%

135

46

81

3

301

28

215

121

606

46

77

921

91

75

59

413

225

157

54

19

94%

100%

90%

97%

97%

98%

100%

98%

93%

96%

95%

93%

100%

95%

98%

96%

99%

98%

161

47

97

2

334

32

285

151

653

54

83

1052

94

94

62

439

324

179

57

19

92%

94%

80%

100%

94%

98%

99%

98%

84%

96%

83%

89%

100%

87%

96%

94%

99%

94%

142

48

86

0

309

32

244

134

591

49

69

1051

85

82

62

435

213

174

53

19

95%

93%

81%

98%

100%

100%

100%

98%

92%

97%

90%

77%

100%

85%

97%

98%

96%

70%

16/08/2011 14:13

149

44

95

3

325

32

250

131

596

52

72

1053

102

95

61

436

231

175

57

18

48

172 205 301 59 662 178 228 175 307 84 422

96% 100% 100% 100% 99% 99% 100% 99% 100% 100% 100%

Whipps Cross Hospital, London


Whittington Hospital, London






n


%

127



Weston General Hospital, Weston-Supermare


MINAP

100%

Year

Aspirin

97%

83%

98%

99%

95%

99%

99%

96%

99%

94%

100%

100%

%

Beta blocker

n

329

59

288

164

192

157

602

58

255

148

169

90

99%

98%

88%

98%

99%

85%

98%

98%

94%

100%

98%

100%

%

2010/11

Statins

n

411

80

308

179

218

179

680

59

302

206

172

127

99%

97%

87%

98%

99%

87%

96%

99%

98%

100%

94%

100%

%

ACE inhibitor


n

359

69

306

176

204

172

619

59

278

174

170

114

99%

97%

93%

99%

100%

96%

98%

93%

98%

100%

96%

100%

%

n

16/08/2011 14:13

410

77

304

178

210

174

660

58

277

174

170

119


49

MINAP


49

National Director for Heart Disease and Stroke

Professor Sir Roger Boyle CBE

match the best in the world.”

population so that the outcomes in this country

have improved year on year despite an ageing

“The chances of survival after heart attack

16/08/2011 14:13

50

26 75 22 33 27

96% 97% 100% 100% 100%






23 163

96% 100%



127

99%


3

193

100%



135

100%


99%

86%

100%

100%

94%

100%

97%

100%

99%

100%

149

22

101

3

21

32

22

64

23

181

123

9

9

308


87%

31

1179

1

309

96%


90%

95%

n

1

32

97%


%

Beta blocker


1279

n

98%

%

Aspirin


Year


MINAP

99%

89%

89%

95%

98%

100%

95%

100%

91%

96%

93%

96%

100%

%

2010/11

Statins

162

24

130

4

27

34

23

75

25

199

152

9

1

317

37

1319

n

99%

99%

75%

83%

91%

97%

98%

100%

85%

96%

96%

100%

%

ACE inhibitor


table 6 secondary prevention in wales and belfast

150

19

124

3

24

33

24

75

23

192

118

8

1

299

35

1220

n

92%

87%

96%

96%

99%

99%

82%

91%

92%

96%

86%

95%

100%

%

16/08/2011 14:13

164

21

119

3

24

36

23

70

24

194

92

9

1

310

33

1213

n


MINAP

51

MINAP

31

483 149 99 235

100%

99% 99% 100% 99%


Belfast average



Mater Infirmorum Hospital

59

100%

11




51

100%

98%

99%

99%

97%

96%

223

95

141

459

30

47

12

100%

100%

98%

99%

97%

93%

230

99

151

480

31

57

12

100%

98%

91%

97%

93%

96%

196

91

121

408

30

51

11

97%

100%

98%

98%

100%

94%

16/08/2011 14:13

221

97

141

459

31

49

10

52

84

69%

70%

Anglia Cardiac Network

Avon, Gloucestershire, Wiltshire & Somerset Cardiac & Stroke Network

76%

Cheshire & Merseyside Cardiac Network

613

126

141

200

68%

87%

70%

57%

82%

59%

East Midlands Cardiac Network

Essex Cardiac Network

Greater Manchester & Cheshire Cardiac Network

Herefordshire & Worcestershire Cardiac Network

Kent Cardiac Network

North & East Yorkshire & Northern Lincolnshire Cardiac Network

125 272 500

1

1

North Central London CHD Network

North East London Cardiac Network

1

0

399

347

348

97

274

387

144

105

328

113

70%

2

190

264

Dorset Cardiac & Stroke Network

Coventry & Warwickshire Cardiac Network

70%

369

3

Black Country Cardiac Network

Cardiac & Stroke Networks in Cumbria & Lancashire

484

130

4

10

452

725

10012

%

56%

76%

75%

77%

85%

75%

95%

90%

84%

88%

80%

77%

91%

77%

80%

80%

n


Birmingham, Sandwell & Solihull Cardiac Network

Bedfordshire & Hertfordshire Cardiac Network

3458

69%


222

n

%

Year


MINAP


0

1

95

106

67

32

110

343

44

2

26

78

10

1

3

137

100

1646

%

13%

14%

18%

2%

13%

20%

13%

2%

10%

11%

7%

6%

n

2009/10

Patients having pre-hospital lysis

4

5

157

458

210

600

153

628

163

1

412

338

2

18

19

280

76

5183

%

22%

59%

56%

34%

18%

36%

47%

31%

42%

22%

6%

20%

n

Patients having in-hospital lysis

554

357

155

5

2

628

382

426

120

368

413

195

476

638

152

507

814

12505

%

86%

83%

22%

1%

1%

36%

44%

24%

34%

92%

31%

24%

77%

80%

56%

40%

61%

49%

n

Patients having primary angioplasty

85

65

308

209

94

492

226

345

22

30

499

186

131

139

97

329

348

6374

%

13%

15%

43%

27%

25%

28%

26%

20%

6%

7%

37%

23%

21%

17%

36%

26%

26%

25%

n

Patients having no reperfusion treatment

table 7 cardiac networks in england and wales

57%

72%

74%

72%

70%

70%

82%

73%

53%

80%

68%

%

2

2

21

13

115

245

29

429

77

4

55

206

2

4

1

38

20

1723

n


418

310

300

441

11

492

589

595

93

304

601

140

386

486

111

832

802

12868

%

n

80%

81%

89%

75%

74%

84%

87%

91%

85%

82%

95%

81%

84%

91%

81%

81%

81%

2010/11


0

2

43

2

64

26

43

245

43

0

19

56

7

1

0

18

46

848

%

6%

0%

21%

2%

5%

13%

15%

8%

1%

3%

3%

n

Patients having pre-hospital lysis

5

4

54

53

183

395

7

462

102

7

89

274

3

7

4

61

17

2450

%

8%

7%

60%

24%

1%

24%

37%

8%

41%

5%

1%

10%

n

Patients having in-hospital lysis

557

360

370

555

14

679

588

728

106

370

715

173

537

680

135

917

897

15817

%

89%

81%

52%

69%

5%

41%

64%

38%

38%

93%

62%

26%

83%

81%

61%

69%

67%

62%

n

Patients having primary angioplasty

67

77

249

196

45

540

278

468

28

20

326

164

100

155

81

334

379

6217

%

16/08/2011 14:13

11%

17%

35%

24%

15%

33%

30%

25%

10%

5%

28%

25%

15%

18%

37%

25%

28%

25%

n

Patients having no reperfusion treatment

MINAP

53

MINAP

82

120

44

484

156

328

31

79%

25%

55%

51%

57%

48%

Sussex Heart Network

West Yorkshire Cardiac Network


North Wales Cardiac Network

South Wales Cardiac Network

Belfast average

278

1

South West London Cardiac Network

80%

339

3

South East London Cardiac Network

Surrey Heart & Stroke Network

658

252

54%

South Central Vascular Network

47

178

2

180

661

158

94

240

87

66%

Shropshire & Staffordshire Cardiac Network

294

69%

Peninsula Cardiac Managed Clinical Network

205

709

3

North West London CHD Network

274

170

82%

North Trent Network of Cardiac Care

1253

84

52%

North of England Cardiovascular Network


53

77%

77%

76%

80%

77%

88%

87%

60%

85%

84%

84%

81%

70%

85%

13

168

71

239

12

63

46

0

1

60

36

141

0

105

27

7%

17%

20%

18%

9%

9%

4%

5%

13%

10%

1%

41

416

192

608

89

242

234

4

8

352

153

216

9

211

141

23%

42%

53%

45%

6%

36%

44%

22%

23%

20%

20%

6%

78

228

4

232

999

194

134

319

414

835

353

455

829

371

1410

45%

23%

17%

66%

29%

25%

80%

82%

52%

53%

42%

84%

35%

64%

43

183

93

276

408

181

119

77

82

365

129

260

145

383

620

25%

18%

26%

20%

27%

27%

22%

19%

16%

23%

19%

24%

15%

36%

28%

0

54%

52%

53%

13%

69%

83%

0%

55%

66%

71%

124

254

148

402

23

49

42

0

26

76

8

121

2

14

99

90%

222

3

225

793

281

203

306

359

956

282

380

666

581

1150

0

76%

75%

64%

83%

85%

90%

70%

85%

73%

82%

80%

75%

89%

0%

140

72

212

10

26

19

1

2

34

12

79

0

10

40

1

15%

21%

17%

4%

4%

2%

2%

8%

1%

2%

0%

306

170

476

44

110

124

1

4

106

39

124

9

25

137

173

33%

50%

38%

3%

16%

23%

6%

7%

13%

3%

7%

70%

295

6

301

1032

346

255

346

491

1189

410

498

950

570

1349

74

32%

24%

65%

50%

48%

89%

86%

72%

71%

52%

78%

60%

69%

30%

185

89

274

502

211

135

42

74

323

115

264

265

342

437

16/08/2011 14:13

99%

20%

26%

22%

32%

30%

25%

11%

13%

20%

20%

27%

22%

36%

22%

54

53% 50% 65% 41% 89% 99% 93% 64% 79% 47% 67% 32% 55% 23%

150 75 263 31 187 85 229 60 168 50 156 119 112 79







Broomfield Hospital, Chelmsford





Barnet General Hospital, Barnet



Addenbrooke's Hospital, Cambridge

%

47%

n

281

203

369

233

102

180

35

240

86

190

72

352

122

282

41269

n

81%

100%

99%

100%

95%

85%

37%

98%

100%

90%

96%

87%

81%

100%

89%

%

nSTEMI patients seen by a cardiologist or member of team

2009/10

21843

Year

nSTEMI patients admitted to cardiac unit or ward

73

101

178

189

53

181

45

356

433

127

23

269

84

179

23286

n

19%

51%

46%

61%

55%

72%

42%

97%

98%

73%

46%

66%

53%

68%

338

193

381

308

95

212

107

364

440

153

50

341

155

263

42555

n

16/08/2011 14:13

88%

97%

99%

99%

99%

84%

99%

99%

100%

88%

100%

83%

98%

100%

91%

%


2010/11

50%

%


have no nSTEMI are participating in a project for direct admission of these patients to a heart attack centre in a manner similar to that for primary angioplasty for STEMI.

unit are less likely to be entered. Thus the percentages reported below do not take into account every patient admitted to hospital with nSTEMI. In addition some hospitals in the London area that


MINAP

It is recognised that not all nSTEMI are entered into MINAP. A number of hospitals report a lack of resources to collect data on nSTEMI, and more generally those patients not admitted to a cardiac

table 8 care of patients with non st elevation infarction(nSTEMI) in england

MINAP

55

MINAP

119

99% 28% 38% 48%

118 23 45 155

Chelsea & Westminister Hospital, London


57% 86% 41% 37% 92% 27% 82% 27%

300 177 167 46 22 86 170 64




County Hospital Hereford, Hereford

County Hospital Louth, Louth



58% 27%

151 69



224

250

165

49%

117



3

211

203

283

17

83

382

204

3

Darlington Memorial Hospital, Darlington

192

20%

39


430

2

7

295



109

82

43

8


Chase Farm Hospital, Enfield

117

333

4

94%

317


254

Central Middlesex Hospital, London

43%

126



55

87%

96%

69%

89%

98%

89%

66%

94%

100%

82%

100%

91%

93%

100%

100%

100%

97%

99%

86%

90

161

102

11

52

253

76

0

40

126

163

220

39

21

110

40

9

155

5

5

383

134

31%

65%

38%

24%

80%

30%

29%

29%

72%

56%

24%

25%

48%

31%

100%

90%

39%

268

229

217

33

193

311

225

0

103

386

201

342

163

67

216

113

82

155

40

111

420

291

16/08/2011 14:13

92%

93%

82%

59%

91%

98%

89%

74%

89%

89%

87%

100%

81%

95%

88%

100%

100%

100%

98%

98%

85%

56

49% 72% 84% 25% 95% 51% 82% 42% 40% 49% 75% 69% 30% 34% 64% 98% 86%

136 157 165 36 707 68 81 146 27 64 148 70 84 100 96 206 291







Friarage Hospital, Northallerton





Good Hope General Hospital, Sutton Coldfield

Harefield Hospital

Harrogate District Hospital, Harrogate




91%

42

Ealing Hospital, Southall

%

49%

n

n

294

207

148

284

278

97

198

125

25

332

99

118

741

138

197

178

94

46

186

94%

87%

99%

99%

98%

98%

96%

100%

96%

37%

95%

100%

88%

100%

97%

100%

81%

34%

100%

%


2009/10

96


MINAP


Year


n

288

136

101

82

54

88

144

77

28

122

65

137

776

36

121

170

177

70

97

91%

93%

62%

43%

24%

72%

77%

46%

50%

40%

64%

41%

99%

23%

85%

81%

46%

91%

n

278

119

148

191

229

115

185

162

21

290

101

263

786

151

143

193

315

76

177

92%

83%

99%

94%

16/08/2011 14:13

88%

82%

91%

100%

100%

94%

98%

96%

38%

95%

100%

78%

100%

97%

100%

%


2010/11

51%

%


MINAP

57

MINAP

53%

38

85 313

17 129


201

95% 61% 25% 47% 41% 48% 32% 39% 21%

190 132 110 112 28 120 89 73 85


James Paget Hospital, Great Yarmouth




King George Hospital, Goodmayes







Kingston Hospital, Kingston-upon-Thames


583

80% 48% 44% 30%

475 63 161 91

286

344

129

113

9

385

160

265

232

66

153

340

203

61

Hull Royal Infirmary, Hull

7

36%

282

90



15

1 27%

292

80%

263 69

9

17

Homerton Hospital, London



Hexham General Hospital, Hexham


57

93%

95%

98%

98%

97%

97%

86%

94%

92%

97%

65%

78%

94%

100%

18%

86%

69%

83%

96%

89%

74

132

34

508

2

62

162

125

149

31

129

172

153

163

1

102

9

78

20

24

359

27

29%

33%

49%

84%

18%

45%

71%

63%

36%

55%

36%

89%

89%

39%

26%

80%

60%

84%

24%

236

374

67

597

29

336

197

156

224

85

162

421

172

183

35

237

58

278

25

40

368

12

16/08/2011 14:13

93%

94%

97%

99%

52%

100%

55%

88%

95%

99%

69%

89%

100%

100%

55%

91%

48%

92%

100%

100%

86%

58

54% 14% 48% 86% 33% 84%

61 27 108 107 123 46



Manor Hospital, Walsall

Mayday University Hospital, Croydon


61% 17% 20% 50% 35%

490 56 31 60 124





North Tyneside General Hospital, North Shields

278

116

155

286

809

227

99%

237


Newham General Hospital, London

225

39

52

14

0

49

340

117

1

181

109

0


Montagu Hospital, Mexborough

Milton Keynes General Hospital, Milton Keynes

17%

23%

71


272

437

19%

233

84

46%

n

Luton & Dunstable Hospital, Luton

122

%

9

n

2009/10

89%

92%

94%

93%

97%

89%

98%

89%

79%

96%

99%

89%

100%

95%

68%

100%

%


6



MINAP


Year


n

110

101

38

55

387

187

0

50

0

39

161

72

128

19

90

56

72

5

143

34%

62%

21%

17%

55%

99%

19%

78%

49%

99%

59%

57%

26%

16%

n

277

159

183

283

704

188

29

270

14

48

293

64

176

139

157

196

443

5

223

96%

90%

88%

81%

99%

99%

92%

98%

91%

16/08/2011 14:13

85%

98%

99%

87%

100%

99%

63%

100%

%


2010/11

58%

%


MINAP

59

MINAP

8 244

10 186

38% 32% 20% 17%

67% 80%

10 107 128 60 47 10 137 105






Princess Alexandra Hospital, Harlow


7 351 190 217

38%

43% 53% 40% 77%

147 15 228 13 100 109 76 33



Queen Elizabeth Hospital, Gateshead

Queen Elizabeth Hospital, King's Lynn

Queen Elizabeth Hospital, Woolwich

Queen Elizabeth II Hospital, Welwyn Garden City


Queen Mary's Hospital, Sidcup

57%

258

22%

66

Princess Royal University Hospital, Orpington

41

118

187

388

188

17

100

222

221



346

1



1

592 463

45%

341


381

11

81%

319



59

95%

62%

91%

94%

80%

88%

100%

87%

88%

76%

92%

80%

75%

85%

87%

98%

78%

97%

34

80

108

27

24

252

229

50

97

17

100

144

8

30

64

121

175

16

44

2

366

336

97%

37%

56%

22%

6%

66%

99%

16%

35%

82%

59%

15%

20%

32%

49%

51%

48%

75%

35

135

169

119

305

338

231

310

262

116

99

230

11

175

266

323

316

15

85

369

686

434

16/08/2011 14:13

100%

63%

88%

97%

73%

89%

100%

100%

94%

92%

81%

93%

86%

84%

86%

89%

99%

99%

90%

97%

60

16% 70% 76% 40% 35% 100% 39% 60% 37% 75% 16% 74% 53%

41 172 178 237 118 30 223 278 117 64 55 71 132

Rotherham General Hospital, Rotherham









Royal Hampshire County Hospital, Winchester


234

37 10



35

0

232

94

315

82

293

458

389

30

337

548

235

238

175

142

216

386

0

n

Royal London Hospital, London

Royal Liverpool University Hospital, Liverpool

15%

28%

41



82%

212


%

25%

n

98%

67%

97%

84%

93%

100%

96%

92%

98%

94%

96%

92%

99%

69%

100%

99%

93%

100%

%


2009/10

103


MINAP


Year


n

6

28

12

154

65

43

89

115

237

254

55

135

245

210

203

104

66

190

212

11%

64%

77%

16%

98%

45%

75%

41%

89%

41%

45%

77%

65%

33%

46%

79%

n

52

233

0

231

83

249

91

240

316

419

60

321

496

261

309

252

141

216

282

68%

97%

98%

91%

96%

99%

81%

97%

89%

75%

16/08/2011 14:13

87%

94%

95%

99%

94%

100%

94%

100%

%


2010/11

57%

%


MINAP

61

MINAP

347 178

54%

87% 42% 27% 88% 14% 82% 76% 24% 81% 77% 55% 41% 71% 75% 80% 77% 99%

75 16 155 79 50 95 51 98 61 65 300 251 115 62 81 129 147 127 160







Selly Oak Hospital, Birmingham

Solihull General Hospital, Birmingham

South Tyneside District Hospital, South Shields



Southmead Hospital, Bristol



St Helier Hospital, Carshalton

St Mary's Hospital, London




77

95%

73


159

166

166

172

110

149

183

310

367

244

80

119

246

93

182

186

128

37

14

116


51%

66



61

98%

100%

91%

99%

96%

98%

88%

95%

99%

91%

100%

99%

68%

86%

100%

99%

100%

100%

93%

100%

100%

89%

156

112

114

94

91

61

136

301

342

54

43

5

41

159

45

91

314

8

111

75

6

34

96%

82%

85%

74%

75%

29%

41%

79%

79%

26%

45%

13%

82%

29%

34%

100%

49%

74%

29%

161

135

134

127

120

207

280

363

428

196

95

5

252

191

155

268

315

277

185

102

27

108

16/08/2011 14:13

99%

99%

100%

100%

99%

100%

85%

96%

98%

94%

99%

82%

98%

99%

100%

100%

99%

82%

100%

96%

92%

62

45% 44% 27% 90%

86 303 32 101

Staffordshire General Hospital, Stafford

164

45% 19% 26% 67% 68%

75 22 116 442 190






417

39 152

59% 100%

292 49 19 148



University Hospital Lewisham, London

60%

20

17



64

2

University College Hospital Gower Street, London

49

15

3

Trafford General Hospital, Manchester

254

537

403

116

326

108

95

546

178

97

201

13

n





48%

48


%

15%

n

85%

95%

98%

91%

81%

89%

98%

99%

98%

96%

80%

80%

93%

98%

97%

62%

87%

100%

%


2009/10

31


MINAP


Year


n

164

32

82

256

22

8

6

188

369

83

33

55

21

150

23

217

74

75

38

59%

53%

87%

44%

81%

70%

52%

18%

20%

23%

5%

87%

20%

39%

37%

68%

n

205

56

94

516

26

57

18

251

479

402

163

229

375

171

64

441

190

111

189

97%

16/08/2011 14:13

74%

93%

100%

89%

96%

93%

94%

67%

86%

96%

96%

97%

99%

56%

80%

96%

100%

%


2010/11

20%

%


MINAP

63

MINAP

93% 41%

483 95


23%

114


0 139

64% 43% 28% 71% 30% 11% 29% 89% 21% 44% 65% 92%

0 96 55 73 176 47 27 167 66 43 73 76 152



West Middlesex University Hospital, Isleworth

West Suffolk Hospital, Bury St Edmunds


Whipps Cross Hospital, London

Whittington Hospital, London






Weston General Hospital, Weston-Supermare

335

60


159

113

159

178

70

531

206

155

189

236

103

42

16

481

Warwick Hospital, Warwick

17%

47%

219

Wansbeck General Hospital, Ashington

337

338

30%

123



4

203

447

284

3


62%

180

University Hospital of North Durham, Durham


63

96%

97%

95%

85%

95%

93%

85%

98%

77%

91%

81%

92%

96%

100%

98%

72%

83%

88%

86%

98%

162

141

29

154

66

239

37

111

104

61

21

125

0

25

12

129

191

126

80

104

498

160

92%

71%

22%

68%

89%

40%

13%

100%

61%

22%

49%

60%

8%

31%

52%

27%

60%

40%

94%

63%

154

194

128

195

73

551

262

107

142

254

38

181

0

294

37

414

331

375

103

235

466

250

16/08/2011 14:13

87%

98%

99%

86%

99%

92%

90%

96%

83%

93%

88%

87%

99%

100%

98%

91%

81%

77%

90%

88%

99%

64

26%

117


37%

63


%

30%

n

n

397

164

216

%

88%

96%

91%


2009/10

71


MINAP


Year


n

103

43

45

23%

34%

n

390

125

155

%

16/08/2011 14:13

86%

98%

98%


2010/11

28%

%


65

MINAP


65

Clinical Director of MINAP

Dr Clive Weston

promote the values of national clinical audit.”

through their participation in MINAP, continue to

clinicians, managers and administrators who,

not changed is the commitment of individual

to people who suffer heart attack. What has

documented major changes in the care provided

“ During the past decade, MINAP has

16/08/2011 14:13

66

48

64% 68%

35 240

81% 82% 43% 79% 78% 21%

129 23 32 69 49 50







233

52

87

62

28

156

33

24%

20



215

1

1

159

16%

31

1215 2

55%

n

1

890

%

1

n

2009/10

99%

83%

100%

83%

100%

98%

40%

61%

87%

84%

74%

%


1







Year


unit are less likely to be entered. Thus the percentages reported below do not take into account every patient admitted to hospital with nSTEMI.


MINAP

n

108

0

62

14

42

147

19

4

221

4

0

57

63

948

38%

86%

76%

76%

79%

25%

85%

284

0

72

48

55

190

46

4

228

5

0

202

67

1354

n

16/08/2011 14:13

99%

100%

86%

100%

98%

65%

82%

89%

91%

84%

%


2010/11

59%

%


It is recognised that not all nSTEMI are entered into MINAP. A number of hospitals report a lack of resources to collect data on nSTEMI, and more generally those patients not admitted to a cardiac

table 9 care of patients with non st elevation (nSTEMI) in wales and belfast

MINAP

67

MINAP


Mater Infirmorum Hospital


Belfast average







67

65%

134

345

82% 64% 90% 96%

282 84 106 92

96

118

131

0

0

63

29

71%

24

46 0

85%

0

51

100%

100%

99%

100%

31%

85%

77%

109

116

80

305

0

133

32

0

42

88%

94%

62%

81%

68%

80%

79%

123

123

127

373

0

64

39

0

50

16/08/2011 14:13

99%

100%

98%

99%

33%

98%

94%

Fig 19.

12. Difference in performance in England and Wales

Fig 20. 30 day mortality for STEMI (mean and 95% confidence intervals) for England and Wales.

In the last three reports we have commented on differences in performance between Wales and England. These differences have been felt to reflect the largely rural nature of Wales, and the effect this has had on the configuration of cardiac services – with an emphasis on the delivery of pre-hospital thrombolytic treatment. The move from thrombolytic therapy to primary angioplasty has occurred more slowly in Wales than in most (but not all) of the English regions. So, it is still the case that in Wales the majority (70%) of patients receiving reperfusion therapy for STEMI receive thrombolytic therapy rather than primary angioplasty – 53% within 60 minutes of calling for help. In keeping with best practice, most (81%) of those who receive thrombolytic treatment for STEMI, or have no reperfusion treatment at all, subsequently undergo coronary angiography. Two cardiac centres (in Swansea and Cardiff) are now able to offer primary angioplasty to their local populations, with continuous availability, and there has been a 29% increase in the number of patients so treated. 75% of these patients were treated within 150 minutes of calling for help. The Welsh cardiac networks are working closely with the Welsh Ambulance Service and local hospitals to develop management strategies that promote the use of primary angioplasty. This will include an increase the number of centres providing continuously available primary angioplasty and the number of patients transported directly to these centres. These strategies will be put in place over the next 12 months. Importantly, a review of 30-day mortality rate after STEMI and nSTEMI for both England and Wales is presented in Fig 20 and Fig 21. It should be noted that these data are unadjusted for known predictors of outcome, such as age and co-morbidity and so formal statistical analysis has not been performed. Reassuringly the figures show falling mortality rates in both countries and the mean 30 day mortality for STEMI is now virtually identical for England and Wales. It is of continuing concern that, as shown within the relevant tables, some of the Welsh hospitals are not submitting data on the management they provide to patients with nSTEMI (the most common type of acute coronary syndrome). This weakens the capacity of the National Audit to assure good quality care is being provided in these hospitals. Fig 21 shows 30 day mortality following nSTEMI, though obviously this only reflects those patients managed in hospitals that enter data. For that group mortality rates have continued to fall and are similar to results from England.

All age groups, and all treatment modalities England

Wales

18 17 16 15 14 13 % 12 11 10 9 8 7 6 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10 2010-11

Financial year

Fig 19.

Fig 21. 30 day mortality for nSTEMI (mean and 95% confidence intervals) for England and Wales.

The wider confidence limits for Wales reflect the smaller numbers recorded England

Wales

15 14 13 12 11 % 10 9 8 7 6 5 2003-4

2004-5

2005-6

2006-7

2007-8

2008-9

2009-10 2010-11

Financial year

The use of secondary preventive medication remains good and equivalent to English hospitals.

68


MINAP Public Report Part 3 to 5 Blue.indd 68

16/08/2011 14:06

part three: case studies MINAP data is an a significant tooldiagnosis supporting service Fig 9. Percentage of patients with admission How hospitals, ambulance services and cardiac networks development, identifying areas for current of STEMI having primary angioplasty within 90 minutes of and future work. have used MINAP data to improve patient care. arrival in hospital in E&W. Achieving national standards offers no room for complacency in an era in which we know that the impact of early treatment means better survival, and whilst MINAP data demonstrates the achievement of national standards, for those interested in improving the lot of our patients it shows us where to focus our efforts.

Implementing a primary PCI service in Oxford Oxford Heart Centre Jan Keenan, Consultant Nurse Dr Robin Choudhury, Senior Research Fellow

Chart one: Increase in total number of PPCI cases since 2008

The Oxford Heart Centre began developing a PPCI service in late 2006. Like other areas of the UK we began by introducing a daytime service, rolling out to develop a 24/7 service from the summer of 2007. With the opening of the new Heart Centre in October 2009 direct access to the angiography suite became possible, and further developments came in 2009/10 with the roll-out of a regional service to Buckinghamshire and parts of Northants and Wiltshire. Chart one shows the increase in activity over the three years to date, and it is interesting to reflect on the continuing achievements for people in our care.

400 350 300 250 200 150 100

To introduce a new service and roll this out to a 24/7 service places demands on the clinical teams to develop new ways of working across the patient pathway, and to give up conventional professional boundaries and to use and develop skills that best serve patient needs, at the point of presentation, often in an unfamiliar environment. We have seen our ambulance crews and CCU nursing team supporting patients and medical colleagues in the lab, focusing on more active management of the acute care team. Importantly we were able to use MINAP data to see developments over time as we focused our energies on improving team working and availability to see a significant reduction over time in door to balloon time (see chart two).

0 2008-9

2009-10

2010-11

Chart two: Increase in call-to-door time with increasing geographical spread with concurrent decrease in door to balloon time with pathway development 120 100 80 Mins

Alongside a rollout of PPCI across the region however, come longer transit times and to an extent this is understandable. However significant variation in call to door times for people arriving from the same areas, again seen within MINAP data, offers further opportunities for development in terms of transit time to hospital and, using the data, we are able to work closely with our ambulance service colleagues to expedite the patient pathway. Importantly however as also shown in chart two, we are also able to continue to progress important developments in the in-hospital pathway that allow us to continue to reduce the call to balloon time overall, particularly by making significant reductions in door to balloon time. In terms of national drivers in addition to this, we are able to examine trends in length of hospital stay (see chart three).

50

60 40 20 0 2008-9

2009-10

2010-11

Call-to-door time Door-to-balloon time Call-to-balloon time



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referrals to cardiac rehabilitation services, and the use of anti-platelet agents, statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers in patients post primary PCI. The interventional cardiology integrated care pathway was modified to include a checklist of secondary prevention interventions for the physicians responsible for discharging the patients (see figure below). A weekly feedback project also included discussion of these metrics in a multidisciplinary coronary care unit hand over. We also continue this surveillance after discharge via a quality scorecard owned by our heart failure team.

Chart three: Whilst median hospital stay has remained relatively constant, there is a downward trend in mean length of stay

6 5 4 3

MINAP has thus helped shape the long term as well as the short term management of patients undergoing primary PCI at our unit.

2 1

Patients discharged on secondary prevention medication 100

0 2008-9

2009-10

2010-11 80

Median length of stay

MINAP, promoting prevention. The Heart Hospital, University College London Hospitals Foundation Trust Dr Costas O’Mahoney, Cardiology Dr Clare Dollery, Clinical Director. The Heart Hospital (University College Hospitals NHS trust) is a heart attack centre with an established 24 hour primary PCI service. Monthly multidisciplinary MINAP meetings, with the participation of cardiologists, nurses, physiologists, London Ambulance Service representatives, Accident and Emergency department staff and other support personnel scrutinise challenging cases in a constructive and transparent manner. Feedback is given to the primary PCI team and other stakeholders to maintain and improve the quality of the service. Analysis of data provided by MINAP have led to a number of interventions over the years which helped reduce the time to reperfusion (MINAP public report 2009).

% of patients

Mean length of stay

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40

20

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2004

2005

2006

2007

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ACEi

beta-blocker

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Aspirin

Clopidogrel

Even though shortening the time to reperfusion remains a central aim of our service, review of routinely collected MINAP data has also been used in the local implementation of NICE guidelines on secondary prevention interventions in post MI patients. We use our monthly MINAP meetings to review

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Establishing a primary angioplasty service in Lincolnshire

ST elevation and non-ST elevation myocardial infarction as recorded in MINAP.

United Lincolnshire Hospitals NHS Trust

The Lincolnshire Heart Attack Centre started a primary angioplasty service in December 2010. This new service is currently limited to a restricted geography on an 8 a.m. until 6 p.m. basis, five days a week. In order to realise our aspiration to provide the service 24/7 and county-wide, plans are currently underway to build a second cardiac catheter laboratory, a cardiac short stay unit and a larger recovery ward. These plans aim to deliver the service to all eligible patients within Lincolnshire in 2012.

Dr David O’Brien, Interventional Cardiologist, Alun Roebuck, Consultant Nurse Critical and Acute Care A review by the East Midlands Strategic Health Authority considered the clinical case for change in primary reperfusion practice and established that a 24/7 primary angioplasty service must be provided within Lincolnshire; with the provision of a new heart attack centre based at Lincoln County Hospital. Without such service, Lincolnshire would remain the only region within England without a primary angioplasty service for its population. The decision and justifications to base such a service in Lincolnshire were largely based on assessment of the number of patients presenting with both

This huge change in how cardiac care is delivered has only been achievable by team work between United Lincolnshire Hospitals NHS Trust, Lincolnshire Primary Care Trust, East Midlands Ambulance Service and the East Midlands Heart and Stoke Network. Initial feedback from patients and relatives needing to access this service has been overwhelmingly positive and we all look forward to rolling out the service fully next year.



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Improvement in call-balloon times at the London Chest Hospital, Barts and the London NHS Trust London Chest Hospital, Barts and the London NHS Trust Eileen Ferguson, Heart attack centre coordinator Ajay Jain, HAC lead clinician Andrew Wragg, Clinical Effectiveness Lead Anthony Mathur, Cardiology lead clinician Charles Knight, CAU director Andrew Archbold, North East London Cardiac Network lead London Ambulance Service NHS Trust Mark Whitbread, Clinical Practice Manager/ Cardiac Lead Joanne Smith, Clinical Advisor to the Medical Director The London Chest Hospital is the heart attack centre for North East London cardiac network and serves a large population spread over a large geographical area and receives referrals from 6 district general hospitals. This referral base posed significant logistical problems to get patients with STEMI treated in a timely manner. The MINAP and BCIS audits demonstrated that we had to evolve our service to achieve the important call-to-balloon standard (CTB) and improve the outcome of our patients with STEMI. In 2010/11 Barts and the London NHS Trust was successful in achieving the national standard for call-to-balloon times and this was based on using MINAP/ BCIS data to drive a quality improvement program. We initially invested in improving the quality and reporting of our audit data. The trust and local cardiac network invested significant manpower resources. This included a Heart Attack Centre (HAC) coordinator to manage the whole HAC pathway, a dedicated HAC team and investment in data analysis. This resulted in high quality audit data that could be analysed in real time and support a process of formal weekly reporting. Once this audit process was established we could then focus on improving the clinical pathway. The first challenge was to increase the direct transfer rate as patients who came via the network A&Es rarely achieved the call-to-balloon national standard. Armed with accurate audit data of performance, the HAC team set about working in collaboration with the London Ambulance Service (LAS) and A&E departments. This was based around sharing audit data, education using case by case feedback and formal study days. A weekly HAC meeting was established with LAS where audit data was studied in great detail. 72

Simultaneously we worked on our internal pathway to improve our door-to-balloon times. Producing weekly reports from MINAP helped focus organisational and individual attention on performance. These weekly reports demonstrated the immediate benefit from locally implemented changes and the team members were encouraged by seeing the real time audit result. Changes that had positive effects included a policy of going direct to lab 24 hours a day (instead of going to CCU out of hours), employing a dedicated nurse to meet all heart attack patients and setting an internal door-to-balloon national standard of 60 minutes (the national standard being 90 minutes). To focus the team on the clock- every individual breach was investigated. These improvements led to a marked transformation in our call-to-balloon performance for 2010-2011. 80% of STEMI patients now receive reperfusion within 150 minutes from call for help, a great achievement in view of the geographical challenges of North East Thames. This improvement has been associated with a reduction of mortality of our heart attack patients according to data from Dr Foster Intelligence. MINAP and BCIS proved great tools to drive these changes but it was recognition by our Trust and local Network that service improvements of this kind do require significant investment to be successful, coupled with a lot of hard work by the entire HAC team.



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Using data from MINAP to model a PPCI service in the Cheshire and Merseyside network area Cheshire and Merseyside Cardiac and Stroke Network Ruth Grainger, Clinical Information Analyst Cheshire and Merseyside is now one of the largest Cardiac and Stroke Networks in England and covers a geographical area with a population of approximately 2.3 million. MINAP has been used in our network area for many years to audit and improve reperfusion times and numbers of those receiving the appropriate medication. We have recently improved our services for patients who have a heart attack known as a ST elevation Myocardial Infarction (STEMI) by introducing a primary percutaneous coronary intervention (PPCI ) service. PPCI is the preferred treatment if it can be provided promptly, providing faster perfusion and better outcomes for patients. Whilst thrombolysis treatment offers benefits to patients suffering from a STEMI, PPCI is a far more effective and safer option, with the added benefits of shorter recovery times and reduced morbidity. In 2008, working with management consultants, Cap Gemini, we used MINAP data to demonstrate how a new PPCI service would look. One of the main aims when setting up the service was to quantify the impact on current services. It was necessary to know how many patients would be accessing this service and by what method. In order to do this an extract of data was downloaded from MINAP to establish firstly, how many STEMIs would be expected at the tertiary centre, Liverpool Heart and Chest Hospital (LHCH), secondly, were there any trends in day/ time of presentation and thirdly, what impact would the new service have on the North West Ambulance Service (NWAS). The intended outcome was to understand the balance of risks and benefits of service change.

Comparing with previous years’ data it was concluded that the numbers, channels and locations of STEMI presentations would continue to be similar in future years and that there would be no expected differences in ambulance handover and turnaround times. All data sources and assumptions used in the model were agreed during a series of meetings between LHCH, NWAS and the network. Using both MINAP data and modelled ambulance journey times it was possible to establish an average extra journey time for each patient. This was then used to gauge both worst case and best case scenarios, and combined with financial information provided by NWAS, to establish how many extra ambulance shifts NWAS would need, how much this would cost, and using postcode information where to locate the extra ambulances. Funds were secured and it was agreed that PPCI should be rolled out in two phases. Phase one would cover the three hospitals nearest to LHCH (Aintree, Whiston and Royal Liverpool) and was implemented on 26th January 2009. Phase two was then rolled out to the rest of the Cheshire and Merseyside area (Southport, Warrington, Wirral and Countess of Chester) on 1st June 2010. MINAP data is still used to audit and improve services for STEMI patients. Staff from local district general hospitals, NWAS, LHCH and the network meet regularly as part of the PPCI monitoring group to discuss any local issues and suggest areas for improvement. Since the full roll-out we have seen patient outcomes improve greatly, national standards are consistently being met and the service is running smoothly. After 1st June 2011 we will have one full year’s worth of complete Cheshire and Merseyside PPCI data and are looking forward to validating the model used to implement our PPCI service.



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Use of MINAP data to analyse and improve the PPCI service Papworth Hospital NHS Foundation Trust Dr Sarah Clarke, Clinical Director for Cardiac Services Hayley Dimmock, Cardiac Information Analyst Papworth Hospital NHS Foundation Trust opened a Primary Percutaneous Coronary Intervention (PPCI) service in September 2008. Since then there have been over 1500 activations of the service and for the year 2010-11 Papworth averaged 60 PPCI patient activations per month. MINAP is used within Papworth hospital to accurately record data on each patient who arrives at the heart attack centre following a PPCI activation. We believe data accuracy is extremely important and ensure that each individual PPCI patient’s MINAP entry is validated and checked alongside their hospital notes post discharge to ensure excellent data completeness. MINAP is used as an analysis tool as much as for data collection in order to produce figures for activity, outcomes and especially to monitor Papworth hospital’s performance in achieving national standards.

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In 2010-11 there were 702 activations of the PPCI service with two thirds of patients continuing to have an intervention and the remaining third either not going into the lab or not proceeding to PCI post angiogram for various reasons. The national standard of door to balloon time (90 minutes) was achieved in 98% of all cases with an average time of 37 minutes. The use of MINAP was instrumental in improving communication with our colleagues from the East of England Ambulance Service NHS Trust (EEAST) and has been particularly helpful in increasing the accuracy of timings. This has helped facilitate information flow concerning the patients’ journey including any delays or complications encountered which could affect their overall outcome. Papworth hospital use the data collected in MINAP to look in detail at every patient who breaches either the national or local standards. These reports are discussed in multi-disciplinary team meetings on a bi-weekly basis and the information used to highlight ways of improving patient flow and patient’s clinical care.



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part four: research use of minap data 1. MINAP Academic Group – five year overview

1.3 How to apply

Professor Adam Timmis, Chairman, MINAP Academic Group

For more information on how to make an application for MINAP data please email Lucia Gavalova, MINAP Project Coordinator at [email protected].

1.1 Background We recognise the value of the MINAP data certainly in improving patient care but also in its secondary use for research. The MINAP Academic Group (MAG) was established in 2005 to maximise the research potential of MINAP database and to establish processes for the safe distribution and return of sub-sets of MINAP data to research groups. The MAG is responsible for ensuring that data are only accessed by researchers with bona fide projects of high scientific probity who respect the conditions of confidentiality and security. The MAG was delegated the responsibility for releasing MINAP data by the Health Quality Improvement Partnership (HQIP) through which MINAP is funded. All datasets issued to research groups are sourced from the dataset that is collected from CCAD annually and cleaned in a way that it is not significantly changed by this process. Although NICOR (UCL) was granted Section 251 exemption of the NHS Act 2006 for all the cardiac audits, including MINAP to hold patient identifiable data without consent, this approval is not extended to release of patient identifiable data. We are however in a position to release data for research in anonymised, or pseudo-anonymised for and the linkage with other dataset(s) can be performed by the trusted 3rd party. 1.2 Current position The last year has seen major developments driven by the MINAP Academic Group. We now have a truly nationwide programme incorporating many of the top cardiological and epidemiological research groups in the UK. In the last 12 months alone approvals have been given for data-sharing with researchers in London, Birmingham, Belfast, Leeds, Leicester, Surrey and Edinburgh Previous applications have already led to seven publications in major cardiovascular and general journals in 2010, more than ever before, with a further four publications by May 2011. Particularly significant has been the establishment of international collaborations with the SWEDEHEART investigators in Upsalla (Sweden) to complement the international collaborative analysis of pre-hospital thrombolysis previously undertaken in Europe and North America. The development that will underpin research activity through the next decade and beyond has been the successful bid by the NICOR executive to become responsible for the management of MINAP and five other national cardiovascular registries. Leaders within MINAP and MAG played a key role in securing the bid which will now allow direct involvement of the management and linkage of this unique data resource. Only in the UK are national registry data on this scale available providing opportunities for cardiovascular researchers that cannot be found elsewhere.


2. Use of MINAP data to evaluate the impact of acute coronary syndrome care by patient age: resolving inequities in care? Dr Chris Gale, University of Leeds Dr Robert West, University of Leeds Professor Keith Fox, University of Edinburgh Evidence suggests that primary percutaneous coronary intervention (pPCI) results in better outcomes than thrombolysis for the treatment of STEMI provided it is delivered promptly. Due to initial perceived risk of complications in pPCI in very elderly (80 years of age or older), pPCI was not considered to be a preferred treatment option in this age group. Recently Shelton28 and colleagues compared outcomes in patients aged ≥80 years presenting with STEMI who were treated pPCI with patients who received thrombolytic treatment. Their work suggested that primary PCI can be effectively delivered to very elderly patients resulting in a substantial reduction in mortality compared to patients treated by thrombolytic treatment. So is there inequality in care in patients presenting with ACS in England and Wales? Current data suggest that elderly patients who are hospitalised with an ACS are less likely to receive the preferred treatment (PCI) and that they have higher mortality rates than their younger counterparts. We studied 616,011 ACS events at 255 hospitals in England and Wales recorded in MINAP between 2003 and 2010 to establish whether age-dependent inequalities in care existed and to measure effects on inhospital mortality over time for ACS in different age groups. This revealed that almost 40% admissions with ACS in England and Wales were elderly (≥75 years). They were less likely to receive specialist care and evidence-based treatments including pPCI for STEMI. As a result, the elderly were found to have significantly longer hospital lengths of stay and higher in-hospital mortality rates. Although progressive improvements in risk of in-hospital mortality were noted, for example, STEMI ≥85 years, inhospital mortality reduced from 30.1% in 2003 to 19.4% in 2010 and for nSTEMI ≥85 years from 31.5% in 2003 to 20.4% in 2010, overall rates of emergency reperfusion (primary PCI and thrombolysis) for STEMI in those 10.0 mmol/L, infused (intravenous) insulin was given to, 14.6% of non-diabetics, 39.8% of diabetics who normally took tablet treatment and 47.4% of diabetic patients who normally took subcutaneous insulin.

25 20 % 15

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Interval to death (days) Routine treatment Insulin infusion

29. Anantharaman R, Heatley M, Weston CFM. Hyperglycaemia in acute coronary syndromes: risk marker or therapeutic target? Heart 2009;95:697-703. 30. Weston CFM, Walker L, Birkhead JS. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007;93:1542-6. MINAP Tenth Public Report 2011


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part five: appendices Appendix 1: MINAP Steering Group Chairman

Dr Clive Weston Clinical Director MINAP Dr John Birkhead Previous Clinical Director MINAP

Department of Health

Royal College of Nursing

Professor Tom Quinn University of Surrey

MINAP Patient/Carer Group

Mr Iain Thomas South West London Cardiac and Stroke Network Patient Carer Group

MINAP Patient/Carer Group

Mr David Geldard MBE Past President, Heart Care Partnership (UK)

MINAP Hospital User

Ms Fiona Dudley Lead Nurse for Cardiology, Mid Yorkshire Hospitals NHS Trust

MINAP Academic Group

Professor Adam Timmis Chairman

Professor Sir Roger Boyle CBE National Director for Heart Disease and Stroke (to Aug 2011) Ms Sue Dodd Emergency and Acute Care Manager, Vascular Programme (to July 2011)

NICOR

Dr David Cunningham Senior Strategist for National Cardiac Audits

Royal College of Physicians

Dr Jonathan Potter Director, Clinical Effectiveness and Evaluation Unit (to May 2011)

British Heart Foundation

Professor Peter Weissberg Medical Director

NHS Improvement

Dr Mark Dancy National Clinical Chair

Ambulance Services

Dr Steven Rawstone Medical Director, Great Western Ambulance Service

British Cardiovascular Intervention Society

Dr Mark de Belder President

Cardiac Networks

Mr Mark Walsh Network Director, Black Country Cardiovascular Network

Welsh Assembly Government

Dr Phillip Thomas Lead Cardiac Clinician

British Cardiovascular Society

Professor Keith Fox President

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Appendix 2: Glossary ACE inhibitors A class of drug with powerful dilating effects on arteries. Used – in the context of heart attack - for the treatment and prevention of heart failure. Also used widely for treatment of high blood pressure. Angiotensin receptor blockers (ARBs) have broadly similar effects. Acute coronary syndrome This term covers all cardiac episodes that result from sudden and spontaneous blockage or near blockage of a coronary artery; often resulting in some degree of heart muscle damage. The usual underlying cause is rupture of the fine lining of a heart artery, which allows blood to come in contact with the tissues of the wall of the artery, promoting the development of a blood clot (thrombus). The degree of damage, and the type of syndrome (heart attack), that results from the blockage depends on the size of the artery, where in the course of the artery the blockage occurs, the amount of clot that develops and how long it persists within the artery. Not all acute coronary syndromes are suitable for treatment with primary angioplasty or thrombolytic drugs, and the decision is mainly guided by the appearances of the ECG when such treatments are being considered. Angina Symptoms of chest discomfort that occur when narrowing of the coronary arteries prevent enough oxygen-containing blood reaching the heart muscle when its demands are high, such as during exercise. Angiogram An X-ray investigation, performed under a local anaesthetic, which produces images of the flow of blood within an artery (in this case the coronary artery). Narrowings and complete blockages within the arteries can be identified during the angiogram and this allows decisions to be made regarding treatment. Often an angiogram is an immediate precursor to an angioplasty and stent implantation or to later coronary artery bypass grafting. Anti-platelet drugs Drugs, including aspirin, clopidogrel, prasugrel and ticagrelor, which prevent blood clotting. These drugs act by reducing the ‘stickiness’ of the small blood cells (platelets) that can clump together to form a clot. Aspirin An anti-platelet drug used to help prevent blood clots forming. Beta-blockers Beta-blockers are drugs that block the actions of the hormone adrenaline (that makes the heart beat faster and more vigorously). They are used to help prevent attacks of angina, to lower blood pressure, to help control abnormal heart rhythms

and to reduce the risk of further heart attack in people who have already had one. They may also be used in small doses in heart failure. Call-to-balloon (CTB) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the performance of primary angioplasty. Call-to-needle (CTN) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the administration of thrombolytic therapy. Cholesterol A fatty substance that plays a vital role in the functioning of every cell wall throughout the body and in the production of various hormones. However, too much cholesterol in the blood increases the risk of coronary heart disease and heart attacks. Clopidogrel An anti-platelet drug that has been shown to produce added benefit when given with aspirin during an acute coronary syndrome. Clot-dissolving drugs Drugs used to dissolve the clot (or thrombus) within a heart artery which is the underlying cause of heart attack, see ‘thrombolytic treatment’. Contraindication The presence of a reason why a treatment is unsuitable in a particular patient. Door-to-balloon (DTB) time The interval between the ambulance arriving at a hospital and the performance of primary angioplasty. Door-to-needle (DTN) time The interval between the ambulance arriving at a hospital and the administration of thrombolytic therapy. Electrocardiogram Also known as ‘ECG’. A test to record the rhythm and electrical activity of the heart. The ECG can often show if a person has had a heart attack, either recently or some time ago. It can also tell if reperfusion therapy is appropriate and if it has been effective. Heart attack The term applied to the symptoms, usually, but not always, including chest pain, which develop when a clot (thrombus) develops within a heart artery as a result of spontaneous damage to the inner lining of the artery (plaque rupture). The heart muscle supplied by the blocked artery suffers permanent damage if the blood supply is not restored quickly. The damage to heart muscle carries a risk of sudden death, and heart failure in people who survive. MINAP Tenth Public Report 2011


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Heart failure Heart failure occurs when a damaged heart becomes less efficient at pumping blood round the body. This may result from damage to the heart muscle caused by a heart attack – either at the time of the attack or many months or even years afterwards. There are typically symptoms of breathlessness during exertion and, later, swelling (oedema) of ankles. Hyperglycaemia A high concentration of glucose (sugar) in the blood Meta-analysis A statistical technique for combining the findings from independent studies. Median The number falling in the middle of a ranked series of numbers. IQR Interquartile range; the value at 25% and 75% of an ordered set of values.

Primary PCI Primary percutaneous coronary intervention – see Primary angioplasty Re-infarction The development of evidence of re-occlusion (further blockage) of, or development of blood clot within, the coronary artery that was responsible for the original heart attack. This would normally occur after the original blockage had been successfully treated. Reperfusion treatment The term used to cover both techniques, thrombolytic treatment and primary angioplasty, for urgently reopening a coronary artery. These treatments are suitable only for certain types of heart attack characterised by typical electrocardiographic appearances described as ST segment elevation.

Myocardial infarction A heart attack in which heart muscle damage is confirmed by blood testing.

Secondary prevention treatment Medication that reduces the risk of further heart attack, or the risk of complications such as heart failure. See aspirin, beta blockers, ACE inhibitors and ARBs, clopidogrel and statins. These medications are usually initially prescribed to all patients who can tolerate them.

Non ST elevation myocardial infarction (nSTEMI) A heart attack that occurs in the absence of ST segment elevation on the ECG. In these patients urgent admission to hospital is mandated but immediate reperfusion therapy is not required.

Statins Drugs used to reduce cholesterol levels in the blood. These have been shown to reduce the risk of further heart attacks when taken regularly after a first heart attack

PCI Percutaneous coronary intervention (see Primary angioplasty)

ST elevation myocardial infarction A heart attack characterized by a specific abnormal appearance on the ECG (ST segment elevation) thought to be indicative of complete occlusion of a coronary artery. Reperfusion therapy with thrombolysis or angioplasty has been shown to do more good than harm in these cases.

Pre-hospital thrombolysis Thrombolytic treatment given before arrival in hospital, usually in the ambulance by paramedics. This saves time in providing treatment and is used where journey times to hospital are prolonged. Primary angioplasty A technique to re-open the blocked coronary artery responsible for the heart attack. A fine catheter (tube) is passed, under local anaesthetic, from an artery in the leg or arm into the blocked heart artery. A small inflatable balloon is then passed through the catheter and across the blockage, allowing the artery to be re-opened by temporary inflation of the balloon. This technique is called angioplasty and when used as the initial treatment for heart attack it is referred to as ‘primary angioplasty’. Following opening of the artery, this is normally kept open by a small expandable metal tube (stent) which is passed into the artery with the angioplasty balloon. The umbrella term that encompasses both balloon dilatation (angioplasty) and stent insertion (stenting) is ‘percutaneous coronary intervention’ (PCI) and primary PCI is increasingly used to describe what in this report we refer to simply as primary angioplasty. 80

Thienopyridine inhibitors Antiplatelet agents, of which clopidogrel and prasugrel are presently licensed for use. Thrombolytic treatment The outcome for certain types of heart attack can be improved by using clot-dissolving (thrombolytic) drugs. Thrombolytic treatment is effective up to about 12 hours after the onset of symptoms but is most effective when given very early after the symptoms started. Thrombolytic drugs are not given unless there are typical changes on the electrocardiogram (ECG). Patients at significant risk of bleeding may not be given this treatment where the risk of bleeding is greater than any potential benefit. Where this risk exists primary angioplasty may be an effective alternative. Thrombus A blood clot, the development of which is known a thrombosis.



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Appendix 3: MINAP publications 1999 Rickards A, Cunningham D. From quantity to quality: the central cardiac audit database project. Heart 1999;82: 1118-1122. Birkhead JS, Norris RM, Quinn T et al. Acute myocardial infarction: a core dataset. Royal College of Physicians 1999.

2000 Birkhead JS. Responding to the requirements of the National Service Framework for coronary heart disease: a core dataset for myocardial infarction. Heart 2000; 84: 116-7.

2001 Birkhead JS, Pearson M, Norris RM et al. Measurement of Clinical Performance: Practical approaches in acute myocardial infarction. Eds Robert West and Robin Norris. Royal College of Physicians 2001. Birkhead JS, Georgiou A, Knight L et al. (eds) A baseline survey of facilities for the management of acute myocardial infarction in England 2000. London: Royal College of Physicians 2001.

2002 Birkhead JS. The National Audit of Myocardial Infarction: A new development in the audit process. Journal of Clinical Excellence 2002; 4: 379-85.

2004 Norris RM, Lowe D, Birkhead JS. Can successful treatment of cardiac arrest be a performance indicator for hospitals? Resuscitation. 2004; 60: 263-269. Birkhead J, Walker L. MINAP, a project in evolution. Hospital medicine 2004; 452-53. Birkhead J, Walker L, Pearson M, at al. Improving care for patients with acute coronary syndromes; initial results from the National Audit of Myocardial Infarction (MINAP). Heart 2004; 90: 1004-9.

2006 Birkhead, J, Weston, C, Lowe, D on behalf of the National Audit of Myocardial Infarction project (MINAP) Steering Group. Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study. BMJ 2006; 332:1306-1311. Gale CP, Roberts AP, Batin PD, Hall AS. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34.

2007 Weston C, Walker L, and Birkhead J. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007; 93: 542-1546. Birkhead J, Pearson J, Walker L on behalf of the MINAP Steering Group. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians, London 2007. ISBN 978-1-86016-314-2.

2008 Weston C. Performance indicators in acute myocardial infarction: a proposal for future assessment of good quality care. Heart 2008; 94:139-1401. Gale CP, Manda SO, Batin PD, et al. Predictors of inhospital mortality for patients admitted with ST-elevation myocardial infarction: a real-world study using the Myocardial Infarction National Audit Project (MINAP) database. 2008 Nov;94(11):1407-12. Ben-Shlomo Y, Naqvi H, Baker I. Ethnic differences in healthcare-seeking behaviour and management for acute chest pain: secondary analysis of the MINAP dataset 2002– 2003. Heart 2008; 94: 354 - 359. Gale CP, Manda SO, Weston CF, et al. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database. 2009 Mar;95(3):221-7.

2009 2005 Quinn T, Weston C, Birkhead J, et al on behalf of Steering Group. Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 20032005. Quarterly Journal of Medicine 2005; 98 (11): 797-802.

Bhaskaran K, Hajat S, Haines A, et al. Effects of air pollution on the incidence of myocardial infarction. Heart, 2009; 95, 1746-59. Horne S, Weston C, Quinn T, et al. The impact of pre-hospital thrombolytic treatment on re-infarction rates: analysis of the Myocardial Infarction National Audit Project (MINAP). Heart 2009; 95: 559-563. MINAP Tenth Public Report 2011


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2009 cont. Birkhead J, Weston C, Chen R. Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Heart 2009; 95:1593-9.

2010 Herrett E, Smeeth L, Walker L, Weston C; on behalf of the MINAP Academic Group. The Myocardial Ischaemia National Audit Project (MINAP). Heart 2010;96:1264-1267. Bhaskaran K, Hajat S, Haines AP, et al. The short term effects of temperature on the risk of myocardial infarction in England and Wales – a multicity daily time series study using the Myocardial Ischaemia National Audit Project (MINAP) database. BMJ 2010;341: c3823. Bhaskaran K, Hajat S, Haines AP, et al. Effects of ambient temperature on the incidence of myocardial infarction. Heart 2009, 95, 1760-9. Gale CP, Roberts AP, Batin PD, et al. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34. West RM, Cattle BA, Bouyssie M, et al. Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales. Eur Heart J. 2010.

Huynh T, Birkhead J, Huber K, et al. Pre-hospital Fibrinolysis in Europe and North America. JACC: Cardiovascular Interventions (in press). Cattle BA, Greenwood DC, Gale CP, et al. Multiple Imputation of a Large Clinical Audit Dataset. Statistics in Medicine (in press).

Appendix 4: Contacts for information on heart conditions American Heart Association http://www.americanheart.org/hearthub/index.htm Blood Pressure Association http://www.bpassoc.org.uk/Home British Cardiac Patients Association http://www.bcpa.co.uk/ British Cardiovascular Society http://www.bcs.com/pages/default.asp British Heart Foundation http://www.bhf.org.uk/ NB: The British Heart Foundation runs a heart information line that provides information about heart conditions and their management. It cannot respond to questions about services in individual hospitals. Tel: 08450 70 80 70

Diabetes UK http://www.diabetes.org.uk/

McNamara RL. Cardiovascular registry research comes of age. Heart 2010; 96:908-10.

Department of Health website http://www.dh.gov.uk/en/Home

Brophy S, Cooksey R, Gravenor MB, et al. Population based absolute and relative survival to 1 year of people with diabetes following a myocardial infarction: a cohort study using hospital admissions data. BMC Public Health 2010;10:338.

HEART UK http://www.heartuk.org.uk/

Widimsky P, Wijns W, Fajadet J, et al. European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J 2010; 31:943-57.

NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

NHS Evidence – cardiovascular http://www.library.nhs.uk/cardiovascular/

NHS Direct Tel: 0845 4647

2011 Gale CP, Cattle BA, Moore J, et al. Impact of missing data on standardised mortality ratios for acute myocardial infarction: evidence from the Myocardial Ischaemia National Audit Project (MINAP) 2004-7. Heart 2011. Gale C, West RM, Cattle BA et al. Impact of hospital proportion and volume on primary PCI performance in England and Wales European Heart Journal (in press)

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This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11. Report prepared by: Lucia Gavalova, Project co-ordinator MINAP With assistance from: Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinator Lynne Walker, MINAP Programme manager Professor Tom Quinn, MINAP Steering Group member Professor Adam Timmis, Chairman MINAP Academic Group Mrs Sirkka Thomas, MINAP Patient/carer representative Mr David Geldard, MINAP Patient representative Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap For further information about this report, contact: Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes Research Institute of Cardiovascular Science University College London 175 Tottenham Court Road London W1T 7NU Tel: 0203 108 3931 Email: [email protected] University College London (media enquiries) Media Relations Manager Ruth Howells Tel: 020 3108 3845 Email: [email protected]

Department of Health Enquiries to the Department should be directed to the Customer Service Centre Tel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform

heart attacks recorded in minap in 2010/11

In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS Welsh Assembly Government Ms Cathy White Head of Adult & Children’s Health Medical Directorate Department for Health, Social Services & Children Welsh Government Cathays Park, Cardiff CF10 3NQ Tel: 029 20826108 Email: [email protected] Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/ HomePage.aspx

Acknowledgements The MINAP team would like to thank all the hospitals and ambulance services that have collected data. This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.

MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk. This report may not be published or used commercially without permission.

The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.

Designed and published by:

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How the NHS cares for patients with heart attack

NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH



myocardial ischaemia national audit project [minap] MINAP Tenth Public Report 2011


How the NHS cares for patients with heart attack Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group

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