Myocardial Ischaemia National Audit Project - UCL

Myocardial Ischaemia National Audit Project

How the NHS cares for patients with heart attack

Myocardial Ischaemia National Audit Project

MINAP Twelfth Public Report 2013

Myocardial Ischaemia National Audit Project How the NHS cares for patients with heart attack

Annual Public Report April 2012 - March 2013

This report is written for the public to show the performance of hospitals, ambulance services, Cardiac Networks in Wales and Local Area Teams in England national standards for the care of patients with heart attack in 2012/13. Report prepared by Lucia Gavalova, MINAP Project Manager Dr Clive Weston, MINAP Clinical Lead

Dr Emmanuel N. Lazaridis, NICOR Senior Analyst Prof Huon Gray, National Clinical Director (Cardiac), NHS England Caleb Stowell, Vice President, Research and Development. ICHOM

Heart attacks recorded in MINAP in 2012/13

Thomas Kelley, Project Leader, Coronary Artery Disease, ICHOM Electronic copies of this report can be found at: http://www.ucl.ac.uk/nicor/audits/minap/publicreports

With assistance from:

For further information about this report, contact:

Professor Adam Timmis, Chairman MINAP Academic Group Dr Peter Ludman, Clinical lead for BCIS audit for PCI Dr David Cunningham, NICOR Senior Strategist for National Cardiac Audits Dr Chris Gale, Co-chair of NICOR Research Group Mr Alan Keys, MINAP patient representative Mr Pete Glassock, Cardiac Rehabilitation patient representative

Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes Research University College London 3rd Floor, 170 Tottenham Court Road London W1T 7HA Tel: 0203 108 3926 Email: [email protected]

Sue Manuel, NICOR Senior Software Developer

Acknowledgements The MINAP team would like to thank all the hospitals and ambulance services for their continued collection of data about patients with a heart attack. This project/audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). For more information, please visit www.hqip.org.uk. Data from this report are available on the data.gov.uk website. The content of this report may not be published or used commercially without permission.

University College London (media enquiries) Media Relations Manager David Weston Tel: 020 3108 1056 Out of hours: 07917 271 364 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.

This report was published on 16 October 2013.

NICOR is a partnership of clinicians, IT experts, statisticians, academics and managers which manages six cardiovascular clinical audits and several new technology registries. Its mission is to provide information to improve heart disease patients’ quality of care, outcomes and help to reduce inequity in care. BCS is the voice for those working in cardiovascular health, science and disease management in the UK; we aim to promote and support both the healthcare professionals who work in cardiology and the patients for whom we want to encourage the best possible treatment. Our members are healthcare professionals, working in the field of cardiovascular health. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions Founded in 1826, UCL was the first English university established after Oxford and Cambridge, the first to admit students regardless of race, class, religion or gender, and the first to provide systematic teaching of law, architecture and medicine. We are among the world’s top universities, as reflected by performance in a range of international rankings and tables.

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Myocardial Ischaemia National Audit Project How the NHS cares for patients with heart attack Annual Public Report | April 2012 - March 2013


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Contents Foreword

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National Clinical Director (Cardiac), NHS England

Executive Summary

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Part One: Introduction

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1. Background to heart attacks 1.1 STEMI and nSTEMI 1.2 Aims of management 1.3 Reperfusion therapy 1.4 Patient outcomes following a heart attack

8 8 9 10 10

2. Background to MINAP 2.1 Origins 2.2 Organisation of MINAP 2.3 How the data are collected 2.4 Security and patient confidentiality 2.5 Case ascertainment 2.6 Data completeness and data quality 2.7 Improving analysis

12 12 13 13 13 13 14 14

3. Improving quality, improving outcome 3.1 Cardiovascular disease outcomes strategy 3.2 ICHOM: International Consortium for Health Outcomes Measurement 3.3 Use of primary PCI 3.4 nSTEMI and access to angiography

14 14 15 16 17

4. Patient perspective 18 4.1 Alan Keys: President of the Cardiovascular Care Partnership 18 4.2 Pete Glassock: the National Audit of Cardiac Rehabilitation Patient Representative 19

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Part Two: Analyses

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1. Characteristics of patients with heart attack in 2012/13

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2. Hospitals that perform primary PCI 2.1 Door-to-balloon time 2.2 Call-to-balloon time

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3. Hospitals using thrombolytic treatment 3.1 Door-to-needle time 3.2 Call-to-needle time 3.3 Future of thrombolysis and its use in the rural areas 3.4 PCI post thrombolysis

7.2 Cardiological care during admission 7.3 Angiography in nSTEMI

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8. Access to primary PCI

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9. Length of stay

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10. Results by hospitals, ambulance services and Cardiac Networks Table 1 Reperfusion treatment of patients with STEMI Table 2 Primary PCI in hospitals in England, Wales and Belfast Table 3 Thrombolytic treatment in hospitals in England, Wales and Belfast Table 4 Ambulance services in England, Wales and Belfast Table 5 Local Area Teams in England and Cardiac Networks in Wales Table 6 Secondary prevention medication by eligibility in England, Wales and Belfast Table 7 Care of patients with nSTEMI in England, Wales and Belfast

32 32 38 46 50 52 56 80

11. Difference in performance in England and Wales

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Part Three: Case Studies

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1 Collecting MINAP data can be challenging 2 How the North West Ambulance Service uses MINAP data 3 MINAP data collection – experience from a Cardiac Rehabilitation Nurse in a new ‘state-of-the-art’ DGH 4 Measurement of performance and outcome in PCI 5 Expanding the Role of the Heart Attack Centre – all of the out of hospital arrests? 6 MINAP Data Collection – Experience at a Tertiary Centre – by Sheila Jamieson, Cardiothoracic Services Information Manager at Freeman Hospital, Newcastle upon Tyne Hospitals Trust 7 Frimley Park Hospital NHS Foundation Trust’s primary PCI Service

105 106 108 110 112 113

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Part Four: MINAP and research

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Part Five: Conclusions/Recommendations

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Part Six: Appendices

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1. MINAP Steering Group Membership

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4. Patients that receive no reperfusion

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2. MINAP Academic Group Membership

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5. Ambulance service performance

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3. Glossary

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6. Use of secondary prevention medication

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4. MINAP Publications

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7. Care for patients with nSTEMI 7.1 Admission to cardiac unit/ward

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5. Contacts for information on heart and heart related conditions

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MINAP How the NHS cares for patients with heart attack

Foreword This, the twelfth annual public report of the Myocardial Ischaemia National Audit Project (MINAP), appears at a particularly challenging period in the history of the National Health Service. Far reaching changes to the organisation of healthcare and financial pressures, coupled with the discovery of unacceptable failings in the quality of care provided in certain hospitals, have put the NHS and its staff even more in the spotlight than it has been in the past.

Much time and effort has been expended in determining the ‘diagnosis’ and proposing a ‘remedy’ for this state of affairs. Common themes to emerge include the involvement of patients in the monitoring and improvement of services; the collection and sharing of data on fundamental standards of care within and between organisations; the recognition and questioning of variations in care; a willingness to be transparent and make such data available. The very existence of this report, as much as its analysis of approximately 81,000 cases, provides some reassurance that as far as the care of heart attack is concerned, these common themes are being addressed – though there is still some way to go. MINAP has been a major driving force in improving services for heart attack across the country. Developed by clinicians some years before these most recent difficulties, it reflects a professional approach to practice that goes beyond the immediate care of an individual patient, to include a readiness to describe and understand variations in care between hospitals. At its best it nurtures a culture of pride in performance and collaborative learning that promotes best and improved practice. Such a culture, combined with true caring and compassion, represents that which is good in the NHS. Participation in national clinical audits, such as MINAP and the other cardiac audits hosted within NICOR, remains extremely important. I am grateful to all those involved in this enterprise and to the Health Improvement Quality Partnership for their financial support.

Professor Huon H Gray National Clinical Director (Cardiac), NHS England Consultant Cardiologist, Southampton University Hospital.


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Executive Summary The Myocardial Ischaemia National Audit Project (MINAP) is a national clinical audit of the management of heart attack. It supplies participating hospitals and ambulance services 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. Its findings are made public through an annual report. Researchers work with the MINAP dataset to further understand the presentation, treatment and prognosis of this type of heart disease.

This is the twelfth annual MINAP Public Report. It contains analyses from all hospitals and ambulance services in England, Wales and Belfast, that provided care for patients with suspected heart attack between April 2012 and March 2013 (2012/13). The report also presents some data from previous years for comparative purposes. Its primary aim is to inform the public, clinicians and the commissioners 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. Specialist treatment, combined with cardiac rehabilitation, leads to better outcomes and optimal quality of life. 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 percutaneous coronary intervention (primary PCI) or thrombolytic drugs, is beneficial, and non-ST-elevation myocardial infarction (nSTEMI), which represents the majority, and for which a different approach is required.

Initial treatment of patients with STEMI 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. The great majority of patients now receive primary PCI, where the artery is re-opened mechanically using a balloon catheter inserted into the blocked artery and a stent is deployed within the artery. Thrombolytic treatment, where the clot is dissolved by a drug given by ambulance or hospital staff, is also available. Delay to providing either treatment is associated with poorer outcomes.

Patients who received primary PCI for STEMI Primary PCI is the preferred treatment if it can be provided promptly. Most patients who are recognised as having a heart

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attack characterised by ST-elevation are taken by ambulance directly to the catheter laboratory of the nearest Heart Attack Centre, often bypassing smaller hospitals and the Accident and Emergency (A&E) department of the receiving hospital. This year, in England, 97% of patients who received any reperfusion treatment received primary PCI compared to 95% in 2011/12. In Wales, there has been a considerable increase in the proportion of patients receiving primary PCI compared to thrombolytic treatment, from 50% in 2011/12 to 72% in 2012/13. In the Belfast hospitals all patients eligible for reperfusion treatment received primary PCI. Of those treated with primary PCI, 92% of eligible patients in England, 85% in Wales and 85% in Belfast received it within 90 minutes of arrival at hospital. Of those treated with primary PCI, 82% of eligible patients in England, 70% in Wales and 89% in Belfast were treated with primary PCI within 150 minutes of calling for professional help. The proportion achieving the more stringent call-to-balloon time, of treatment within 120 minutes of the call for help, was: in England 60%, in Wales 48% and in Belfast 80%. The proportion receiving primary PCI within 150 minutes of calling for help was 87% for those transported directly to Heart Attack Centres in England (compared with 56% for those who were transferred to the Heart Attack Centre following initial assessment in another hospital). The equivalent value in Wales was 76% of those directly transported and 18% for those transferred from other hospitals. In Belfast the route of admission made little difference: 90% and 86%. Considering the provision of primary PCI at the Local Area Team level, the percentage of patients that received primary PCI ranged between 49% and 83%. In the two Welsh cardiac networks 8% (North Wales Cardiac Network) and 69% (South Wales Cardiac Network) of their patients received primary PCI. 80% of patients that were treated with primary PCI were admitted directly or self-presented at a Heart Attack Centre in England and similarly in Wales (80%). In the Belfast hospitals 79% of patients were taken directly to or selfpresented at a Heart Attack Centre.

Patients who received thrombolytic treatment for STEMI The number of patients having thrombolytic treatment, either before, or on, arrival at hospital, continues to fall, reaching 1026 in 2012/13. 48% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help in

England (median was 64 minutes); 45% in Wales (median was 67 minutes). Thrombolytic treatment is not used in the Belfast hospitals. 69% of patients who received thrombolytic treatment or had no reperfusion treatment had, or were later referred for, coronary angiography in England; 89% in Wales and a small proportion of patients who did not have any reperfusion all received angiography in the Belfast hospitals.

Thrombolytic treatment given by paramedics before the patient reached 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 PCI, 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 or stopped entirely. 144 patients received pre-hospital thrombolytic treatment in England in 2012/13 compared to 252 in 2011/12. In Wales, 85 patients received pre-hospital thrombolytic treatment compared to 148 in 2011/12. Pre-hospital thrombolytic treatment is not used in Belfast.

Patients that received no reperfusion treatment Some patients arriving at hospital with evidence of STEMI receive neither primary PCI nor thrombolytic treatment – no reperfusion therapy is provided – often because they present to hospital too late to benefit from such treatments, or during emergency coronary angiography they are found to have coronary arteries that do not require intervention. The proportion of patients with STEMI that received no reperfusion therapy was 26% in England, 23% in Wales (both similar to the previous year) and 20% in Belfast (compared with 24% in 2011/12).

Care of patients with nSTEMI Patients with nSTEMI have a smaller risk of death within the first month after the heart attack, 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, and within the first 2-4 days, is an important facet of treatment for the majority of these patients. Ideally, admission should be to a cardiac facility

where nursing staff have cardiac nursing expertise and there is easy access to cardiological advice. This year: 53% of nSTEMI patients were admitted to a cardiac unit or ward in England, 60% in Wales and 93% in Belfast. 94% of nSTEMI patients were seen by a cardiologist or member of their team in England, 83% in Wales and 99% in Belfast.. 73% of nSTEMI patients were referred for or had angiography in England, 80% in Wales and 93% in Belfast.

Prescription of secondary prevention medication Taking secondary prevention drugs after the acute event reduces the risk of death and further heart attack following discharge from hospital. Currently there are five secondary prevention drugs that are commonly prescribed at discharge, however not every patient is eligible to receive all five drugs. The use of these drugs remains high. Considering each drug in isolation, the proportions prescribed to eligible patients were: aspirin, 99%; beta-blockers, 97%; ACE inhibitors/ARB, 95%; statins, 98%; clopidogrel/other thienopyridine inhibitor, 96%. Considering the drugs in combination, the proportion of patients who survived to be discharged and who received all the drugs for which they were eligible was 90% in England, 81% in Wales and 97% in Belfast.

Length of stay The median length of stay for patients with STEMI was three days (interquartile range (IQR) 2-5 days), with 75% of patients leaving hospital by day 5. For nSTEMI, the median length of stay was five (IQR 3-10) days, with a quarter of patients remaining in hospital until at least day 10. The length of hospital stay for nSTEMI patients is likely to be longer than currently reported as only direct admissions (not inter-hospital transfers) were taken into account in this calculation.

Mortality Over the last three years the MINAP public report has included national unadjusted 30-day mortality rates for both England and Wales, for STEMI and nSTEMI. During the later stages of developing this year’s report it has become clear that a greater degree of ‘granularity’ and explanation is required with respect to mortality reporting. Therefore, we will be producing a subsidiary “Outcomes Report’ in the spring of 2014.


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Part One: Introduction 1. Background to heart attacks The term ‘heart attack’, while used widely in discussions between clinicians and their patients, and therefore in this report, is too imprecise to define the condition that is the subject of this national clinical audit. The preferred term is Acute Coronary Syndrome (ACS). 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 slowly progressive buildup of fibro-fatty material (atheroma) within the wall of the coronary artery, occurring over years and often without symptoms, followed by sudden disruption of the internal artery wall. This readily causes blood to clot within the artery – a coronary thrombosis – and leads to a state of myocardial ischaemia, in which the demands of the affected heart muscle for oxygen-rich blood exceed the supply of such blood down the clot-containing artery.

If ischaemia is sufficiently prolonged, death of heart muscle results. This is myocardial infarction and is confirmed when evidence of heart muscle cell death is found on blood testing. Such evidence, of elevated concentrations of cardiac enzymes in circulating blood, 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). Ischaemia often can be detected indirectly – as electrical alterations on the electrocardiogram (ECG). When symptoms first appear, it is uncertain whether the ischaemia will be transient, and of no long-term consequence, or whether it will be prolonged and progress to infarction and consequent failure of the heart to pump strongly. Rather than waiting to find out, all patients require urgent treatment to reverse ischaemia and prevent, or limit, infarction. Heart attack can occur at any age, but it is very rare to experience one before middle age – most patients in MINAP are older than 65 years. This is because the deposition of atheroma (see above) in the walls of coronary arteries takes place over many years. Detailed investigations can demonstrate coronary atheroma in many people in their 30’s and 40’s who have no symptoms, yet who eventually suffer a sudden coronary thrombosis many years later.

1 http://www.bhf.org.uk/heart-health/prevention/risk-factors.aspx 2 www.nice.org.uk/guidance/CG94

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A variety of genetic and potentially modifiable lifestyle factors may, when present, increase the likelihood that a person will develop atheroma and later heart attack. The most easily recognised of these include higher levels of blood lipids (e.g. cholesterol), blood glucose (i.e. diabetes) and blood pressure (hypertension), a family history of premature coronary disease, a sedentary lifestyle with limited physical exercise, and cigarette smoking1. Many of these risk factors may be found in one individual. Their combined presence appears substantially to magnify the likelihood of suffering heart attack, or other vascular disorders. Some of them can be altered, with consequent reduction in the chances of heart attack and stroke; even in those who have already experienced such an event. This forms part of the rationale for both secondary preventive drug therapy and cardiac rehabilitation programmes. 1.1 STEMI and nSTEMI Based upon the ECG (Figure 1), patients with characteristic symptoms are categorised into those with, and those without, ST segment elevation – leading to the final diagnosis, once elevated levels of cardiac enzymes confirm myocardial infarction, of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (nSTEMI). ST-elevation usually indicates complete blockage of a coronary artery and, in most cases, warrants immediate treatment to re-open the artery – see Reperfusion therapy below. The absence of ST-elevation usually indicates that any coronary thrombosis is only partially occluding the artery. Although patients 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 – who are generally an older group. Each year MINAP reports more patients with nSTEMI than STEMI. Within the last four years the National Institute for Health and Clinical Excellence (NICE)2 has published guidelines for the management of patients with nSTEMI, as well as the supporting evidence upon which the guidelines are based. In addition to drug treatments, many patients with nSTEMI benefit from an early referral for coronary angiography and some sort of intervention to restore efficient blood supply to the heart – revascularisation.

Figure 1. ECG transferred via LIFENET system to St George’s Hospital by the ambulance crew showing acute ST segment elevation MI in inferoposterior leads.

1.2 Aims of management The aims of management of acute coronary syndrome are presented in Figure 2, which also contains examples of some interventions that are 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. For patients with symptoms of ACS presenting without STelevation there appears to be a clinically important spectrum of risk. This allows the identification of patients who would benefit most from a more interventional approach – in particular an early coronary angiogram. Risk can be predicted by considering such factors as the patient’s age, their blood pressure and heart rate on admission to hospital and certain aspects of their ECG and blood analyses. The NICE guideline supports the use of risk scoring in nSTEMI and the MINAP dataset contains data fields to assist and record this risk stratification.

Figure 2. Aims of management of Acute Coronary Syndrome 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 percutaneous coronary intervention (PCI) Thrombolytic therapy Nitrates Elective PCI/Coronary Artery Bypass Grafting (CABG)

Prevention of further coronary thrombosis

Anticoagulants

Reduction & reversal of ischaemia

Reperfusion treatment

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

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 Community heart failure services Cardiac Rehabilitation classes Patient support groups Public Health Initiatives


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1.3 Reperfusion therapy These are treatments given to restore coronary blood flow by re-opening the blocked coronary artery that is causing the ACS. Adequate reperfusion should relieve symptoms and prevent further heart muscle damage. If reperfusion 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. Two forms of treatment exist: primary percutaneous coronary intervention (PCI) – where the coronary artery is opened mechanically using a balloon catheter (inserted, under local anaesthetic, via an artery in the wrist or groin) and a stent is then left in the artery to prevent re-occlusion; and thrombolytic therapy – where the clot is dissolved by a drug. Thrombolytics are 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 PCI requires specialised equipment and highly-trained clinical staff within the hospital. Patients tend to wait longer to receive primary PCI than they would to receive thrombolytic treatment, but the final results are more reliable in terms of complete restoration of coronary blood flow. Primary PCI is therefore the reperfusion treatment of choice, with thrombolytic therapy being reserved for cases where rapid access to primary PCI is impossible. Each year MINAP reports significant numbers of patients who do not receive such treatment. These patients, with ‘no reperfusion’, are a mixed group. Researchers continue to investigate their characteristics and the circumstances surrounding their initial management. Hospitals should aim to minimise the proportion of patients in this category. However, our present understanding is that for the most part the decision not to provide reperfusion therapy is justifiable, including such situations as: Delayed presentation – patients presenting to hospital so long after the onset of symptoms as to make reperfusion therapy valueless, Contraindication – patients with contraindications to treatment (e.g. increased risk of bleeding), Inappropriateness – patients whose heart attack occurs in the presence of other terminal illnesses, Spontaneous improvement – patients whose ST-segment elevation shown on an initial ECG (for example an ECG 3. Lyon AR, Rees PS, Prasad S, et al. Stress (Takotsubo) cardiomyopathy – a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008;5:22-9.

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recorded in the ambulance) normalises before reperfusion therapy can be given, Coronary intervention not required – patients whose emergency coronary angiogram shows that primary PCI is not required. Among patients in this last category are those with the increasingly recognised, but still poorly understood, syndrome of Takotsubo cardiomyopathy3. This condition, presenting as an ACS with typical chest discomfort, ECG changes and evidence of heart muscle damage – often in post-menopausal women and following an extremely stressful event such as a bereavement – appears not to be related to coronary artery occlusion at all. Rather the heart damage, from which a full recovery is possible, is driven by the effects of naturallyoccurring though excessive catecholamine (adrenaline and adrenaline-like chemicals) stimulation. Working with national and international lead researchers, participants in MINAP are now able to furnish additional detailed information about such cases, in the hope that analysis of this data will lead to a deeper understanding of the condition – its presentation, best treatment and prognosis. 1.4 Patient outcomes following a heart attack MINAP has, and continues to, largely present information on the process of care – what and how components of care are provided to patients in the pre-hospital and hospital settings. Good quality care can be defined through these processes because they represent interventions that have been the subject of clinical trials, have been subject to rigorous assessments of effectiveness and/or appear in influential clinical guidelines – there is evidence that they are beneficial. Process measures describe what a patient might expect to receive during the management of their heart attack; they may also be useful in the planning of, and paying for, such management. However representing hospital or clinician performance through measurement of process is really only valid if there is a clear link between process and outcome, that is, if improving the provision of a process measure leads to more patients achieving the desired consequences of treatment. The process measures presented in this report fulfil this criterion. Increasingly, the quality of healthcare is being defined in terms of outcomes rather than processes. In the case of heart attack – a life-threatening event – the most obvious outcome, and the easiest to recognise, is survival (expressed as the converse – case fatality or mortality rate). Yet even for something as apparently ‘black-and-white’ as this there are complexities associated with using mortality to describe the performance of hospitals and clinical teams.

First, unlike process measures, there is no ‘standard’ death rate against which to audit. Second, in order to make reasonable and fair comparisons between hospitals it is necessary to take into account (perform case-mix adjustment) those characteristics of patients which influence survival, yet are beyond the control of the admitting hospital – such as age, co-existing medical conditions, admission heart rate and blood pressure. So, death rates tend to be reported as the observed rate compared with the rate that would be expected having adjusted for the patients admitted to that hospital, and the national mortality rate. They are best presented on a funnel plot4. Third, when the care of a patient with heart attack involves transfer between two hospitals, it becomes difficult to represent the performance of just one of those hospitals in the mortality statistic. Finally, it is unclear how long survival should be monitored. Clearly, it matters more to a patient that they survive 5 years after a heart attack rather than just 30 days, yet can a hospital still be held accountable for the survival of patients for prolonged periods after discharge? Over the last three years the MINAP public report has included national unadjusted 30-day mortality rates for both England and Wales, for STEMI and nSTEMI. During the later stages of developing this year’s report it has become clear that a greater degree of ‘granularity’ and explanation is required with respect to mortality reporting. Therefore, we will be producing a subsidiary “Outcomes Report’ in the spring of 2014. This will contain adjusted mortality, at least at the level of the four English Commissioning Regions and their 25 NHS Area Teams, as well as the two Welsh Cardiac Networks. We will work towards the presentation of individual hospital-

associated mortality data. This will require development, testing and implementation of a robust risk-adjustment model and an agreed policy of reporting of ‘outliers’. In the meantime, we would point to the recent establishment of publicly available information on outcomes of PCI (in the management of both ACS and stable angina) performed by individual cardiologists.5 The target audience for the outcomes report will be the commissioners of health care at a Regional & Area level, though as the initiative develops smaller Clinical Commissioning Groups may find the results useful. Additionally, the Funnel plots will be made public, and will be fed back to Trust/Health Board Chief Executives and Medical Directors as well as local clinicians, in order to promote quality improvement. A number of other outcomes matter to patients: length of stay in hospital; readmission following discharge; adverse effects of interventions; symptoms after discharge; return to reasonable levels of physical activity and confidence; quality of life. Collecting information on any of these outcomes that occur following discharge from hospital is challenging and in some cases requires electronic data-linkage. Some only can be appreciated by asking patients ‘directly’ through use of Patient Reported Outcome Measures (PROMs). The work of NICOR with ICHOM (see article in section 3.2 by Kelley & Stowell) will address these various measures. 4 Spiegelhalter D. Funnel plots for comparing institutional performance. Stat Med 2005. Available from http://www.ncbi.nlm.nih.gov/pubmed/15568194 5. http://www.bcis.org.uk/pages/page_box_contents. asp?pageid=775&navcatid=157 MINAP Twelfth Public Report 2013

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2. Background to MINAP 2.1 Origins The development of clinical audits to assure and improve quality of care was largely a response by clinicians to the recognition that there were significant, and unsupportable, variations in care, at a time when an evidence-based approach to practice – providing interventions that had been shown to be effective after rigorous study – was being introduced. Measurable targets for treatment, such as door-to-needle time and call-to-needle time (for thrombolysis) appeared in national guidelines, together with advice that hospitals “should provide audit data of delays to treatment” (against agreed standards)6. Some cardiologists established the Myocardial Infarction Audit Group and began, from 1992, to share their data7. At the same time Government officials began to recognise the potential gain to public 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 indicators8 and the standards of care expected by patients with coronary disease, expressed within a National Service Framework (NSF)9. This mandated every acute hospital to make 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”. A 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,

6 Weston CFM, Penny WJ, Julian DG. Guidelines for the early management of patients with myocardial infarction. BMJ 1994;308:767-71. 7 Birkhead JS. Thrombolytic treatment for myocardial infarction: an examination of practice in 39 United Kingdom hospitals. Myocardial Infarction Audit Group. Heart 1997;78:28-33 8 Birkhead J, Goldacre M, Mason A, et al. Health Outcome Indicators: Myocardial Infarction. Oxford, Centre for Health Outcomes Development, 1999. 9 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 10 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. 11 www.cabinetoffice.gov.uk/content/transparency- overview 12 Godlee F. Publish your team’s performance. BMJ 2012;344:e4590 13 The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Executive Summary. Available at: www.midstaffspublicinquiry.com 14 http://www.data.gov.uk/dataset/myocardial-ischaemia-national-audit-project

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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 bodies 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 hospitals10. Data collection began in October 2000 and by mid-2002 all acute hospitals in England and Wales were participating in the audit. Latterly, the government has championed ‘Transparency and Open Data’11, wishing to promote ready access to health data, and the Editor of the British Medical Journal has challenged the British Cardiovascular Society, and others, to show clinical leadership in “pushing for public access to performance data of individual clinical teams”12. The Francis report into failings at the Mid Staffordshire NHS Foundation Trust recommended “openness, transparency and candour throughout the system” and the development of “ever improving means of measuring and understanding the performance of individual professional teams, units and provider organisations”13. MINAP is one of the first audits to have data available on the data.gov.uk website as part of the Transparency Agenda14. Data from MINAP was also included by Professor Sir Bruce Keogh in the ‘data packs’ that

informed his recent review of 14 hospital Trusts with persistently high mortality rates, and that he recommends to the new Chief Inspector of Hospitals15. His intention is that provider and commissioning organisations, patients and the public will have “rapid access to accurate, insightful and easy to use data about quality at service line level”. 2.2 Organisation of MINAP MINAP is one of seven national cardiac clinical audits that are managed by the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of the Institute of Cardiovascular Science at University College London (UCL). NICOR was established in 2006 by Prof Sir Bruce Keogh (now Medical Director of the NHS England) and is led by Prof John Deanfield. Its purpose is to provide information on quality and outcomes of care provided to people with heart disease and to provide technical infrastructure, project management and statistical support for the national cardiac audits. NICOR is a collaborative partnership between various cardiovascular professional societies, NHS England and the Welsh Government. For more information visit our website16. MINAP is overseen by a Steering Group of key stakeholders, including national government and patient representatives. The British Cardiovascular Society is the ‘parent’ professional body for MINAP, providing clinical direction and support. Additionally, in order to more closely align national cardiac audits, the Clinical Lead for the British Cardiovascular Intervention audit for PCI is a member of the MINAP Steering Group. (Appendix 1). It is commissioned by the Healthcare Quality Improvement Partnership (HQIP) – the organisation that holds commissioning 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; for membership see part six. 2.3 How the data are collected The current dataset, version 10.3.1, contains 130 fields. The dataset is revised every two years (the latest version being implemented after the period of this report, in June 2013) so as to allow both continuing collection of data regarding established practice and information about newly introduced treatments. It is designed in a way so that it can capture the entire patient pathway – from the time the patient calls for professional help to

the point of discharge, including patient demographics, medical history and clinical assessment, investigations, treatments, drug therapy prior to admission, during hospital stay and at discharge. The last two versions of the MINAP dataset are available on the MINAP web pages17. Participating hospitals are requested to enter all patients with suspected myocardial infarction. Approximately 91,000 records are uploaded annually and the database now contains over 1.25 million records, making it the largest database of its kind in the world. Data are collected by nurses and clinical audit staff (many with support from a local cardiologist) and entered in a dedicated data application (either Lotus Notes or web based). Alternatively hospital personnel may collect data using 3rd party software, which is often linked to their local clinical information system. The project uses a highly secure electronic system of data entry, transmission and analysis developed by the NICOR Technical Team. The audit has been running continuously since 2000 and all hospitals in England, Wales and Belfast that admit patients with ACS contribute data (except Scarborough General Hospital which stopped submitting data in 2011). 2.4 Security and patient confidentiality All data uploaded by hospitals are encrypted on transmission and stored encrypted on the NICOR servers. NICOR manages access control to the servers via user IDs and passwords. All patient identifiable data are pseudonymised by the NICOR Technical Team before release to the project management and analysis team via a secure drop box on the NICOR server. Patient-identifiable data are only available for the purpose of record linkage. Data held within NICOR are managed within a secure environment for storage and processing provided by the UCL network and in accordance with the UCL information governance and security policy. NICOR is registered under the Data Protection Act by the Information Commissioner’s Office. Additionally, NICOR - of which MINAP is a part - has support under section 251 of the National Health Service (NHS) Act 2006 (Ref: NIGB: ECC 1-06 (d)/2011). 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 information. 2.5 Case ascertainment In practice MINAP records the great majority of patients having STEMI in England, Wales and Belfast; for example the number

15 Keogh B. (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. Accessed at www.nhs. uk_NHSEngland_bruce-keogh-review_Documents_outcomes_keogh-reviewfinal-report.pdf 16 http://www.ucl.ac.uk/nicor 17 http://www.ucl.ac.uk/nicor/audits/minap/dataset MINAP Twelfth Public Report 2013

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of STEMI patients that received primary PCI is closely aligned with the number of primary PCI cases in the Adult Coronary Intervention Audit. However it is recognised that a minority of hospitals do not enter information on all their nSTEMI patients, although in recent years there has been an improvement in this area. nSTEMI is therefore under-represented in MINAP. The true number is difficult to establish, as it is not possible to verify MINAP data against Hospital Episode Statistics (HES), the only available comparator. HES do not distinguish the clinical categories (STEMI/nSTEMI) used within MINAP. However, with the expanding analytical capacity within NICOR, there are now plans to explore other ways of establishing the case ascertainment rate in MINAP and to provide a clearer picture on the incidence of heart attacks in England and Wales. Where all patients with acute coronary syndromes are admitted to the same ward or area patients can be readily identified. It is much harder where patients are not all cared for in one area, and are looked after in several wards. Underreporting of nSTEMIs varies between hospitals and reflects variations in resources allocated to data collection. 2.6 Data Completeness and Data Quality Assessment of data completion 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 that is refreshed daily. Currently these fields continue to be 99% complete. MINAP also performs an annual data validation study to assess the agreement of data held on the NICOR servers. Hospitals are required to re-enter data from case notes in 20 key fields (mainly different fields to the data completeness fields, though with some overlap) in 20 randomly selected nSTEMI records in an online data validation tool. Agreement between the original and re-entered data is assessed for each variable and each record. Reports showing the agreement of each variable compared to national aggregate data are sent to hospitals to allow them to identify areas of improvement. The MINAP data application contains error-checking routines, including range and consistency checks, designed to minimise common errors. There are a number of checks on imported data where 3rd party software is used, that highlight issues resulting from an import, whilst records with more serious problems get rejected.

18 https://www.gov.uk/government/publications/improving-cardiovasculardisease-outcomes-strategy 19 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 20 http://www.healthmetricsandevaluation.org/gbd/publications/policy-report/ global-burden-disease-generating-evidence-guiding-policy

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MINAP provides detailed guidelines for data entry and provides a dedicated helpdesk to support colleagues who experience problems regarding data entry, clinical definitions and a variety of clinical scenarios. 2.7 Improving analysis This is the second year that NICOR’s Analysis Team are using the R statistical programming language to help standardise processing of data across the HQIP audits. Their programs run on a set of meta-data tables that define many aspects of analytic work. The amount of meta-data required to define one MINAP analysis is quite large. For example, the meta-data for recoding categorical variables in the MINAP data currently consists of 3608 records. These meta-data are regularly curated by the Team and reviewed by the audit leads to ensure that analyses are properly specified, transparent and reproducible. This year the Analysis Team introduced modules for the cleaning of categorical variable and for template reporting. Hospitals and ambulance services received and reviewed, in advance of publication of the annual report, draft unit-specific reports that were generated using the same template of calculations as were later used to compute annual MINAP statistics. By leveraging the group review process in this way NICOR seeks to guarantee that all published statistics will be well-vetted and trustworthy. The next year will see increased automation in the generation of reports based on the report templates, which will also undergo substantial revision and development based on feedback from the MINAP stakeholders. MINAP will also be implementing record-level cleaning algorithms that will allow us to shift from record-based analyses to whole-patient views of the data.

3. Improving quality, improving outcome 3.1. Cardiovascular Disease Outcomes Strategy18 Since the National Service Framework19 for coronary heart disease was published in 2002 there has been much improvement both in the care provided to, and outcomes of treatment of, patients with ACS. However there remains room for improvement. The Cardiovascular Disease Outcome Strategy was published in March 2013 to make this potential improvement a reality. Following the publication of the Global Burden of Disease Study20, the emphasis has shifted from simply getting the ‘process of care’ right (even though this may itself demand significant effort) to improving patients’ outcomes. This does not simply equate to single focus on mortality, though this is of primary importance and a relatively easily measured outcome, but also improving quality of life, experiences of care

and aspects of safety of that care. The strategy also focuses on reducing inequalities of care and outcomes. The first and the most important recommendation of this strategy is that cardiovascular disease (CVD) should be considered a single family of disorders. It is not unusual for someone who has suffered one cardiovascular event (e.g. a stroke or heart attack) to have, on closer examination or inquiry, evidence of other CVD. The co-existing condition may cause symptoms, but is often asymptomatic. In any case, opportunities to identify and manage these co-existing conditions are often missed. A more coordinated and integrated approach should be deployed to better prevent and treat the different manifestations of CVD. Ten action points have been identified to achieve improved outcomes in people with, or at risk of, CVD. These address prevention and risk management, acute care, continuing care of patients living with CVD, improvements in monitoring of care, research, and support of the commissioning process. Specifically, action point 10 focuses on increased use of available information (such as clinical audit data) to facilitate improvements in care and outcomes, through a combination of monitoring and research. MINAP has, for over 10 years, provided clinicians and policymakers with benchmarked data that has been of use in a number of quality improvement initiatives (e.g. see case studies in part three of this report). In addition, data from MINAP has been made available to experienced research groups to further explore and describe aspects of the care of patients with ACS and the outcomes associated with various groups of patients and interventions (e.g. see research studies in part four of this report). Increasingly, linkage with other datasets will allow a more holistic understanding of care and its effectiveness. This might enable an examination of the experiences of patients both before and after a heart attack – what medication were they taking in the months preceding the event; were there missed opportunities to diagnose CVD prior to the ACS; did they attend cardiac rehabilitation classes; did they continue to receive secondary prevention medication following discharge; were patients readmitted with other manifestations of CVD; what was the mortality rate 30 days,180 days, 1 year & 5 years after ACS?

Competitiveness at Harvard Business School, The Boston Consulting Group and The Karolinska Institute. It is our belief that future healthcare systems must be based on value i.e. outcomes per pound spent. We believe that measuring outcomes that matter to patients in a consistent way allows providers to set goals and gauge their success—and enables payers to reward those who deliver the best results. It encourages knowledge-sharing from provider to provider, facility to facility, and country-to-country, ensuring that successful practices can be implemented on a global scale. Perhaps most importantly, transparent, universal outcome standards empower patients and their families to make wellinformed decisions about the treatments and providers best suited to their needs. At ICHOM, we define on a condition basis a minimum set of outcomes that we recommend every provider, across the world, track. We define this set by bringing together international working groups composed of patient advocates, outcome measurement leaders, and physician leaders to agree on what should be included in the minimum set. We have a dedicated Coronary Artery Disease (CAD) working group that has senior representatives from eminent academic institutions, registries and national audit programmes across four continents. In our CAD group we have now reached the stage where we have defined the outcomes that we believe should be measured. We are now working on the risk model to ensure that we can appropriately risk adjust the outcomes. It is so important that we provide data that patients, providers and payers can trust and believe. It is our intention to launch this standard set at our international conference in November, following which our focus will turn to driving adoption around the world. Ultimately, we believe that by measuring a global, standard set of ‘outcomes that matter to patients’ healthcare professionals and managers will be able to work together to identify how they can improve. We think this will be very powerful and will help to ensure that we are all providing the very best care and treatment for our patients.

3.2 ICHOM: International Consortium for Health Outcomes Measurement Caleb Stowell, MD. Vice President, Research and Development. Thomas Kelley, MD. Project Leader, Coronary Artery Disease. ICHOM is a not for profit organisation located in Boston, USA, that focuses on standardising outcomes measurement across the globe. We were founded by the Institute for Strategy and MINAP Twelfth Public Report 2013

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Our collaborators:

does the continual availability of expert teams of clinicians and ‘High Tech’ equipment. This has led to centralisation of services. Substantial numbers of district general hospitals no longer routinely admit patients with STEMI. Rather, such patients are taken directly to a smaller number of ‘high-volume’ Heart Attack Centres, serving large populations – for example the two Heart Attack Centres in Manchester serve 3 million people – and a network of smaller feeder hospitals. In some networks patients are ‘repatriated’ from the Heart Attack Centre to their local hospital following primary PCI, but often patients are discharged directly home after a stay in hospital of as little as 3 days. Additionally, some of the main metrics for describing hospital performance – the door-to-needle and call-to-needle times – have become meaningless with respect to the early treatment received by the majority of these patients. Newer metrics have been introduced. National and international guidance22 23 recommend that in the emergency treatment of patients with STEMI, primary PCI should be performed as soon as possible: within 90 minutes of arrival at hospital (door-to-balloon time) and within 150 minutes of a patient’s call for help (call-toballoon time). Results are presented against these best practice standards, and against a more stringent (‘aspirational’) call-toballoon target of 120 minutes, in Table 1 in the Results section.

3.3 Use of primary PCI Perhaps the most important, and certainly the most high profile, change in the management of heart attack since the inception of MINAP has been the implementation of a policy that proritises immediate primary PCI, rather than thrombolytic therapy, in cases of STEMI. The rationale for this change has been described above. Largely the transition has been driven by local clinical leaders and professional networks, and promoted by members of the British Cardiovascular Interventional Society in response to a government challenge to ‘roll-out’ a primary PCI service. Consecutive annual MINAP reports have recorded the changes and a final NHS report on the ‘roll-out’ project was published in 201221. The policy has had major knock-on effects on the organisation of hospital-based cardiac services, requiring as it

21 NHS Improvement. Growth of primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks. January 2012. Available at: http://www.improvement.nhs.uk/LinkClick. aspx?fileticket=PWttejHG45M%3D&tabid=63 (accessed 6 Aug 2012) 22 The Task Force on the Management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology, (2012) ESC guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. Eur Heart J doi:10.1093/eurheartj/ehs215. 23 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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The call to balloon time reflects the interval from a call for professional help to the time that the primary PCI procedure is performed. To reliably achieve this within 120 minutes, or even 150 minutes, requires significant coordination between ambulance and hospital services. Ideally, ambulance crews make an accurate diagnosis, through expert assessment of the patient and interpretation of an ECG, before taking the patient directly to the nearest Heart Attack Centre (see the case history from Professor Tom Quinn in part four of this report). At the hospital the provision of timely primary PCI is complex and involves close collaboration between ambulance, portering, nursing, medical, and radiographic teams. This is particularly important during ‘out of hours’ working. In particular direct transfer of the patient from the ambulance to the cardiac catheter laboratory, without involvement of other hospitals, departments or wards has reduced delays. Some hospitals that are not designated ‘Heart Attack Centres’ within their locality, provide diagnostic angiography and interventional cardiac services, including elective PCI – for example to patients with stable angina or those with nSTEMI. Often the cardiologists working in such hospitals also provide out-of-hours primary PCI services at neighbouring Heart Attack centres. When a patient ‘self-presents’ with, or develops, STEMI at these hospitals it is possible, and would seem sensible, to provide primary PCI on-site, if it is immediately available. It would be unwise directly to compare the call-to-balloon times and rates of provision of reperfusion of such interventional (non-Heart Attack Centre) hospitals with

those of Heart Attack centres. The characteristics of patients and routes of admission would differ widely between the two types of hospital. For example the interventional (non-Heart Attack Centre) hospitals are likely to receive a disproportionate number of patients who self-present or who are judged by ambulance personnel to present difficulties in diagnosis and decision making with respect to suitability for primary PCI. However, it remains the case that an initial assessment at a local non-interventional hospital is associated with added delay and prolonged call-to-balloon times. In some areas a new metric has been introduced to record this added delay and promote the shortest possible safe assessment and stabilisation period in the initial receiving local hospital – the Door-In-Door-Out interval (DIDO). 3.4 nSTEMI and access to angiography The absence of ST-elevation on the presenting ECG of the patient with ACS (nSTEMI) is thought to indicate that any coronary thrombosis is not totally blocking the affected coronary artery. As such, immediate coronary angiography with a view to proceeding straight to PCI, or immediate administration of a powerful thrombolytic drug, is not essential. Often the event can be managed with a combination of drug treatments. However, some patients with nSTEMI either do not ‘settle’, and continue to suffer ischaemic pain, or initially appear to stabilise but soon afterwards have further heart attack. Rather than waiting for this to happen patients can be assessed within hours of admission to hospital using a variety of validated risk scores24. For those of at least moderate risk a policy of routine early angiography (and revascularisation where possible)

appears to prevent more heart attacks and readmissions to hospital than medical treatment alone. The 2009 NICE Guideline, that used MINAP data to model the implications of its recommendations, suggested that ACS patients at moderate risk, and those in whom it is possible to demonstrate residual ischaemia on testing after the acute event (i.e. those with evidence to suggest a persisting narrowing of a coronary artery), should be advised to have a coronary angiogram within 96 hours of admission. Other international guidelines have encouraged even earlier angiography, if only to reduce the overall length of stay in hospital. This year we present preliminary data on length of stay for patients with both STEMI and nSTEMI (section xx), and some limited information on delays from admission to angiography for patients with nSTEMI (section xx). The percentage of patients with a final diagnosis of nSTEMI (broadly reflecting the NICE classification of moderate severity) who have angiography during the admission has increased from about 35% in 2003 to about 74% in 2012/13. This reflects as significant a change in management for nSTEMI as does the development of primary PCI for STEMI – albeit occurring over a longer period. However, angiography is not appropriate for all patients with nSTEMI and those at the very highest risk were not included in trials that demonstrated the benefit of routine angiography. Clinical judgement (as well as patient choice) needs to be exercised in such cases. So, there is no nationally agreed standard (against which to audit) for the proportion of patients that should undergo angiography. 24 Gale CP, Manda SO, Weston CF, Birkhead JS, Batin PD, Hall AS. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database. Heart. 2009;95:221-7. MINAP Twelfth Public Report 2013

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4. Patient perspective Patient involvement in different areas of healthcare is not a new concept. In fact, since 2010 commissioners have been required to explain how they have acted upon feedback from patients and the public. For example, Patient Participation Groups within Clinical Commissioning Groups are involved in the development, planning and provision of services. Through this public report, MINAP offers patients and the public information on their local health services, allowing comparisons with other local hospitals and against overall national performance figures. In order to reach out to more patients and the public, MINAP published its first patient friendly version of the main report in January 2013, and will continue to do so if required. A Patient version of the MINAP annual report is also available on the NICOR website http://www.ucl.ac.uk/nicor In this section Alan Keys, a patient representative, who is also a member of the MINAP Steering Group, discusses the importance of patient participation which is, as he points out, not without challenges. 4.1 Alan Keys, President of the Cardiovascular Care Partnership The Francis Report and Keogh Review have highlighted shortcomings and a failure to care properly for patients in some areas of the NHS. Budgetary restraint raises concerns that such troubles may not be behind us in a minority of hospitals. Therefore, vigilance remains essential. Much has been said about the need for transparency, which needs to be supported by changes in culture to overcome the blockages to communication that are characteristic of this large, hierarchical organisation. The best performers already

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recognise that this is one way to nurture the teamwork and innovation that are so essential to maintaining and improving the quality of care. What is beyond doubt is that patients need to report their experiences and play their part to ensure that high standards are maintained. In the worst cases patient information was ignored. So is there any reason for optimism about the future? Where are the opportunities for improvement? Despite the cuts in the clinical networks in England, I think the new arrangements for patient involvement at GP practice and Clinical Commissioning Group level offer the prospect of greater influence. It will require greater assertiveness from patients and more imagination and enthusiasm in primary care than we sometimes see. I shall concentrate on one specific area – data. Coming from a commercial background I have been taken aback by inadequacies in NHS data, though this is now being progressively tackled. Is there something amiss in a society where business, quite properly, has good data contributing to generation of profits but the data which measures mortality and damage to quality of life has been so deficient or often ignored? Has it too often been seen as data, not people? One impression from the Keogh Review was that hospitals were slow to recognise higher mortality rates and do something to correct them. There seems to have been a disconnection between managers and clinicians in improving outcomes, which I have seen elsewhere, including in cardiac care. The good news is that my Clinical Commissioning Group is energetic in securing quality data to monitor performance with no signs of complacency whatever. I believe that is likely to be true of most with Francis and Keogh providing the spur to that extra vigilance. Access to data for patients and patient representative groups has been, and remains, poor. Therefore, it is very pleasing to recognise the initiative to produce the MINAP and Heart Failure reports in a patient-friendly format, and the intention to move to reporting risk adjusted measures of outcome as well as performance. There is a monitoring role for patient groups nationally and locally, which has often been beyond the competence and capacity of such groups. With the introduction of patient participation groups and Healthwatch there should be more capacity, but training in accessing, understanding and organising data remains an issue to tackle. We need to remember that we may soon have data on primary care performance, for which patient monitoring may be even more vital.

Sometimes one simply needs to use data differently. I extracted the MINAP data for the hospitals serving my county to highlight comparative performance, which I circulated to all the relevant managers and clinicians. I repeated the exercise with the Heart Failure Report and shall repeat both this year. The data had not been used that way locally and it has generated activity where disparities were given prominence. Perhaps the well-organised data in these two reports offers a way for patient groups to dip their toes into the water of performance monitoring and more direct involvement in influencing both service provision and quality improvement. 4.2 Pete Glassock, the National Audit of Cardiac Rehabilitation Patient Representative My name is Pete Glassock I am 52 years old and suffered a heart attack in February 2013. I had 2 stents fitted that day. Approximately 2 months later I started the ‘rehab’ programme at Eastbourne DGH. This has been beneficial for me on a number of levels: it has decreased my anxiety levels and given me the confidence to get fitter and generally healthier.

What matters after a heart attack? That you can carry on living as full a life as possible and the rehab programme is a fantastic tool with which to start this.

Note from MINAP: This article demonstrates the importance of cardiac rehabilitation following a heart attack. Although MINAP collects information about referrals for ‘cardiac rehab’, the proportion of patients that actually start (and complete) a cardiac rehabilitation course is unknown in MINAP. Thus there are plans for MINAP and Cardiac Rehabilitation audits to collaborate to establish these rates to establish this rate. In 2012/13 81% of both STEMI and nSTEMI were referred for cardiac rehabilitation compared with 82% of STEMI and 79% of nSTEMI in 2011/12. Successful cardiac rehabilitation appears to positively affect a patient’s quality of life and experience of healthcare.

The educational talks after each session have been particularly useful, helping me to understand what happened, and why. They provide expert advice on diet and lifestyle. I spent the first 2 months following my heart attack resting, and my fitness levels had reached a very low level. The rehab program was exactly what I needed to regain my fitness, with the added bonus of being run by cardiac nurses. The improvements in my fitness levels since starting the rehab program have been dramatic. The recording of personal achievements during each class is a great way to track your progress, and encourage you to do even better – this is similar to the way MINAP data is used by hospitals to monitor performance and improve quality. The class consists of 10 minutes of aerobic warm up, followed by 10 x 2 minute sessions on various pieces of gym equipment, with exercises you can easily do at home. All of this has helped me enormously in feeling fitter, healthier and having a greater understanding of what happened to me and how best to avoid it happening again. The staff have been very encouraging and always found time for the many questions that I had. The rehab program has been exactly what I needed and I would like to take this opportunity to thank all the staff for their patience and expert advice.


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Part Two: Analyses

In 2012/13, 88.788 records in MINAP were submitted to the MINAP database and 80,974 were records of patients with a final diagnosis of myocardial infarction. Of these some 40% had STEMI. [Figure 4] MINAP recognises that not all patients having nSTEMI are entered into the database and we believe that the true ratio for nSTEMI to STEMI should be at least 3:1.

Figure 4. Frequency distribution of STEMI and nSTEMI in 2012/13 30

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Among those admitted with a first heart attack there appears to have been a levelling off in the prevalence of previously diagnosed hypertension for both men (approx. 44%) and women (approx. 55%) [Figure 5]. A similar levelling off has occurred in the prevalence (approx. 31% in men and 30% in women) of recognised and treated hyperlipidaemia predominantly cholesterol management with statin treatment (Figure 6). This may reflect more efficient recognition and treatment in primary care of those at risk. Figure 5. Hypertension in patients having first heart attack 70 65

The average age for patients having a heart attack in England, Wales and Belfast was 65 years of age for STEMI and 72 for nSTEMI patients.

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smoking tends to be more prevalent in women, but the relationship changes in older persons with smoking being more prevalent in men than in women after the age of 70 (Figure 8b). Figure 8a. Current smoking amongst patients admitted with first heart attack by age

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An increase over the years in the frequency of diabetes continues, with the prevalence being slightly greater in females (approx. 19%) than males (approx. 18 %), and being substantially greater than in the general population (Figure 7). Further analysis shows that the increase is limited to those having type 2 diabetes i.e. non-insulin dependent diabetes. 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.

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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 60 years of age having a first heart attack. The smoking rate has been decreasing over the years in all age groups (Figure 8a). The proportion of current smokers experiencing a first heart attack has been nearly the same between men and women under the age of 50 over the years. In the 50 to 70 year cohort

National and international guidance25 recommend that in the emergency treatment of patients with STEMI, primary PCI should be performed within 90 minutes of arrival at the primary PCI centre (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 2. The sooner a patient receives this treatment, the better the outcome. The results in this table show that most of the hospitals are now achieving the call-to-balloon-time (CTB) within 150 minutes. European guidelines propose a CTB within 120 minutes26 and this is also presented in the Table 2. MINAP Twelfth Public Report 2013

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definitions and analyses of hospital performance between MINAP and the British Cardiovascular Intervention Society national audit for PCI.

The use of primary PCI continued to increase in 2012/13 (Figure 9). This year in England, 97% of patients were so treated compared to 95 % in 2011/12. In Wales 72% patients had primary PCI compared to 50% in 2011/12. In Belfast all patients recorded in MINAP received primary PCI. The overall median time from arrival at hospital to primary PCI was 40 minutes in 2012/13. Interestingly for patients that were transferred for an intervention, the median time from arrival at hospital to primary PCI was 37 minutes. This could be that whilst a patient is in the ambulance on the way to the heart attack centre, the centre has some time to prepare the lab and the team together.

Figure 9. Use of reperfusion treatment for patients with a final diagnosis of STEMI (Primary PCI continues to make up more than 97% of reperfusion treatment.) In−house pPCI

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This year, 84 hospitals in England performed primary PCI, 3 hospitals in Wales and 2 hospitals in Belfast. These hospitals may provide this service only for their own patients, or may do so for groups of other hospitals. 64 hospitals in England reported that they were performing primary PCI on a routine basis, 51 provided the service throughout a 24 hour period. A small number (2) shared a night time rota on an alternating basis. An additional two hospitals started to provide a ‘24/7’ service after April 2012. In Wales two hospitals performed primary PCI with 24 hour availability. In Belfast, two hospitals performed primary PCI with 24 hour availability.

40 30 20 10 0 2003−4

In reporting on the use of primary PCI in the management of patients with STEMI, increasingly there is alignment of

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26 The Task Force on the Management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology, (2012) ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J doi:10.1093/eurheartj/ehs215

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2.1 Door-to-balloon time The proportion of patients receiving primary PCI within the 90 minute continues to rise. In England this year, 92% of 18,577 eligible patients were treated with primary PCI within 90 minutes of arrival at the heart attack centre similarly as in 2011/12. In Wales 85% of 808 eligible patients were treated within 90 minutes compared to 80% of 518 in 2011/12. In Belfast 85% of 199 eligible patients were treated within 90 minutes compared to 89% of 137 in 2011/12. Figure 10. Call-to-balloon distributions for direct admission by ambulance service compared with median call−to−door time CTB Distributions for Direct Admission by Ambulance Service Compared with Median Call−to−Door Time 240

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The percentage of patients with an admission diagnosis of STEMI who receive primary PCI within 90 minutes of arrival at a Heart Attack Centre has increased from 52% in 2004/5 to 92% in 2012/13 and is a reflection of close collaboration between ambulance services, emergency departments and admitting hospitals. In particular direct transfer of the patient from ambulance to the catheter lab without involvement of other departments or wards has reduced delays. In the last year there was an increase in direct admissions from 17,454 in 2011/12 to 18,192 in England (an increase of 4%). In Wales there was an increase in direct admissions from 915 in 2011/12 to 993 in 2012/13 (8%).There was also an increase in direct admissions in Belfast from 119 in 2011/12 to 163 in 2012/13. In Northern Ireland routine use of primary PCI 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 PCI is occasionally available in some hospitals. The Northern Ireland Cardiac Network is currently developing a national strategy for the management of STEMI. Other hospitals in Northern Ireland have now started joining MINAP, although it will be another year or two before any meaningful analyses can be provided.

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The median time is 40 minutes; for 29% the interval is less than 30 minutes and for 77% the interval is less than 60 minutes.

2.2 Call-to-balloon time As explained above, this reflects the interval from a call for professional help to the time that the primary PCI procedure is performed. It is largely a shared responsibility of the relevant ambulance service and the admitting hospital. Usually all patients with a diagnosis of STEMI confirmed by a paramedic crew are taken directly 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 England, 82% of all eligible patients were treated within 150 minutes (and 60% within 120 minutes) of calling for professional help (the same as in 2011/12). In Wales 70% of patients were treated within 150 minutes (and 48% within 120 minutes) compared to 78% in 2011/12. In Belfast 89% of patients were treated within 150 minutes (and 80% within 120 minutes) which remains the same as in 2011/12. Hospital performance with respect to this standard is presented in Table 1. For comparison, Figure 11 demonstrates similar results derived from BCIS audit for PCI [NB: the reporting period in slightly different between the two audits and is likely account for the small difference in overall rate of call-toballoon within 150 minutes.

Figure 11: Call-to-balloon within 150 minutes from calling for professional help (Plot of 2012 data from the BCIS audit)

In England, 87% of patients taken directly to the Heart Attack Centre were treated with primary PCI within 150 minutes of calling for professional help compared to 56% of patients taken first to a local hospital and then transferred to a Heart Attack Centre. The equivalent figures for Wales were 76% for direct admissions and 18% for transfers and in Belfast 90% for direct admissions whilst 86% of patients were transferred to the Heart Attack Centre after prior assessment.


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The proportion of patients admitted directly to a Heart Attack Centre who received primary PCI within 150 minutes of a call for professional help suffered a slight reduction in 2012/13 compared to 2011/13 (Figure 12). 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. Figure 12. Percentage of patients with an admission diagnosis of STEMI having primary PCI within either 120 (CTB120) or 150 (CTB150) minutes from the time of calling for professional help and admitted directly or transferred to a Heart Attack Centre 100 90

3.1 Door-to-needle time In England, 56% of eligible patients received thrombolytic treatment within 30 minutes of arrival at hospital compared to 61% in 2011/12. In Wales 49% of eligible patients received treatment with 30 minutes compared to 62% in 2011/12. The median door-to-needle time was 28 minutes in 2012/13. 3.2 Call-to-needle time In England, 48% of eligible patients receiving thrombolytic treatment did so within 60 minutes of calling for professional help compared to 55% in 2011/12. In Wales 45% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help compared to 48% in 2011/12. Median call to needle time is 65 minutes. 3.3 Future of thrombolysis and its use in rural areas

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Years CTB150 with direct admission to Heart Attack Centre CTB120 with direct admission to Heart Attack Centre CTB150 involving transfer to Heart Attack Centre CTB120 involving transfer to Heart Attack Centre

3. Hospitals using thrombolytic treatment The use of thrombolytic treatment in the management of heart attack has been declining over a number of years. At present, only 5% of patients with STEMI (Figure 14) receive thrombolytic treatment. This occurs mainly in those few areas where timely access to primary PCI in a Heart Attack Centre is not available. While thrombolysis is becoming the gold standard in early treatment for acute stroke, its use in heart attack is diminishing. The previous national standard for thrombolytic treatment was that it should be given within 60 minutes of a call for professional help – the call-to-needle time. This is a joint responsibility of acute hospital trusts and ambulance services. Table 3 shows hospital thrombolytic treatment statistics for 2011/12 and 2012/13 for England and Wales. The Belfast hospitals did not report use of any thrombolytic treatment in 2012/13.

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The apparent reduction in performance with respect to the delivery of thrombolysis, with fewer patients receiving treatment within the national door-to-needle and call-toneedle standards, largely reflects the shift in emphasis from thrombolysis to primary PCI. Those remaining patients receiving thrombolysis are likely to be those in whom there is diagnostic uncertainty, those who present when the local Heart Attack Centre is busy performing primary PCI for another patient, and those who live in more rural areas where there is no ready access to primary PCI. For the foreseeable future there will still be a place for thrombolysis treatment in rural areas. There are particular challenges to maintaining a rapid, efficient and safe response to a small number of patients – if a treatment is not delivered frequently it is likely to be delivered with extra caution and therefore more slowly; thus the increasing delays can be a reflection of loss of practice in administering the drug. The delivery of this treatment before arrival at hospital – prehospital thrombolysis – is one way of trying to reduce delay. While air ambulance helicopters have been used to transport patients from remote areas to Heart Attack Centres (see the case study in Appendices), their use is limited, and there are circumstances in which such flights are not feasible (e.g. adverse weather and night flying restrictions). However, even after thrombolytic treatment is given there is a need to be ready to transfer patients to a Heart Attack Centre (often many miles away), for emergency ‘rescue PCI’ in cases where thrombolysis proves ineffective, or for semiurgent elective angiography and PCI – the recommended management following successful thrombolysis. Such transfers require a significant amount of planning by ambulance services, and divert ambulances from other emergency duties for prolonged periods.

Figure 14. Proportion of STEMI patients by reperfusion treatment, including those that did not receive any form of reperfusion

3.4 PCI post thrombolysis All patients with STEMI receiving primary PCI will necessarily undergo coronary angiography – the diagnostic investigation that produces images of the coronary arteries and allows identification of the ‘culprit’ artery responsible for the heart attack – the target for the PCI. Angiography, with a view to performing PCI (even coronary artery bypass grafting heart surgery) is also recommended in those patients who have received thrombolysis, and in those patients who have presented with evidence of STEMI yet for various reasons (often because they present too late to benefit) do not receive immediate reperfusion therapy.

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Figure 13. Use of angiography for patients having STEMI who do not receive primary PCI, but instead received thrombolytic treatment or had no reperfusion treatment

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The use of angiography for patients with STEMI who did not receive primary PCI, but instead received thrombolytic treatment or who had no reperfusion treatment, has steadily risen, from approximately 55% in 2007/8 to nearly 70% in 2012/13 (Figure 13).

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4. Patients that receive no reperfusion While there has been a major shift in the preferred reperfusion therapy – from thrombolysis to primary PCI – there remains a substantial proportion of patients who have a final diagnosis of STEMI yet who do not receive reperfusion therapy at all; the proportion appears to hover around 26% across the past decade.

The commonest reason why no reperfusion treatment is given is that a patient presents too late for treatment. Typically reperfusion is not given more than 12 hours after onset of symptoms, because the benefits of getting it after 12 hours is limited. In a small number of cases severe comorbidity, such as advanced malignancy or severe dementia, may make reperfusion treatment inappropriate. In other cases the perceived risk of bleeding induced by thrombolysis, or by some of the medication given during PCI, is judged too high to allow such treatment. Largely these are matters for clinical judgement by individual clinicians when they first assess the patient. However, the performance of angiography before an intended primary PCI may demonstrate features that indicate that PCI is not required (for example in cases of Takotsubo Cardiomyopathy, see section 1.3 in part one of this report) or is not feasible. This 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. That being said, those who undergo timely emergency angiography in readiness for primary PCI, yet who do not proceed to PCI will appear as ‘no reperfusion’ in the annual report.


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5. Ambulance service performance Ambulance services collaborate closely with receiving hospitals and networks to improve care. For many services, the focus has shifted from provision of pre-hospital thrombolytic treatment to identifying those patients with heart attack who might benefit from primary PCI, and transferring them rapidly to a Heart Attack Centre. So, for many ambulance services, the number of patients receiving prehospital thrombolytic treatment has declined. Nevertheless, ambulance personnel continue to provide the essential earliest phase of cardiac care for patients with heart attack including resuscitation from sudden cardiac arrest, pain relief, (and where appropriate) oxygen therapy, drugs such as aspirin and clopidogrel, performance of diagnostic ECG and continuing cardiac monitoring. They are largely responsible for the early recognition of an ACS, its initial diagnosis and decisions as to which receiving hospital to alert. Their role in providing professional reassurance to patients and their relatives should not be underestimated. Table 4 shows ambulance service performance in England and Wales. In England in 2012/13, 218 patients received prehospital thrombolytic treatment compared to 381 in 2011/12. In Wales 88 patients received pre-hospital thrombolytic treatment compared to 158 in 2011/12.

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Because the response of the ambulance service influences the call-to-balloon time of patients receiving primary PCI, table 4 also contains information on call-to-balloon time for each ambulance Trust.

6. Use of secondary prevention medication Use of secondary prevention medication after the acute event is proven to improve outcomes for patients after either STEMI or nSTEMI. NICE guidance27 recommends that all eligible 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 • dual anti-platelet therapy. Additionally, MINAP collects data on other drugs which have been shown to have beneficial effects after heart attack, either in all patients or in specific subsets of patients. These include angiotensin receptor blockers, aldosterone antagonists, and thienopyridine inhibitors (clopidogrel and prasugrel). A recent


MINAP 2013 Public Report Part 1 and 2.indd 26

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Table 6 shows the percentage of patients prescribed secondary prevention medication on discharge by hospital in England and Wales in 2012/13. Importantly, for each hospital those patients surviving to be discharged home from that hospital are included but not those transferred to another hospital and those patients in whom such drugs were contraindicated. 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 and Clopidogrel/thienopyridine inhibitors. 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 [Figure 15]. In England prescription of aspirin was 99%, beta blockers 97%, statins 98%, ACE inhibitors 95% and Clopidogrel/thienopyridine inhibitors 96%. In Wales prescription of aspirin was 98%, beta blockers 95%, statins 95%, ACE inhibitors 89% and Clopidogrel/thienopyridine inhibitors 93%. In the Belfast hospitals prescription of aspirin was 100%, beta blockers 99%, statins 99%, ACE inhibitors 99% and Clopidogrel/thienopyridine inhibitors 99%. There is good evidence that composite measures of hospital performance correlate with outcomes.28 Patients are likely to do better if they receive all, rather than some, aspects of care, in a timely manner. So, for the first time, we have presented the use of secondary prevention medicines within a bundle of care. That is, rather than just reporting the percentage use of each individual drug in the group of patients who were eligible for and willing to receive it, we also report the proportion of patients discharged from hospital who received all drugs (from the possible combination of aspirin, beta blockers, statins ACE inhibitors/angiotensin receptor blockers and Clopidogrel/thienopyridine inhibitors) for which they were eligible. In the future other components of ‘evidence-based’ care will be included in similar care-bundles to produce composite measures of performance.

Table 6 shows the percentage of patients receiving their prescribed secondary prevention medication on discharge by hospital in England, Wales and Belfast over the last two years. The proportion of patients who received all the secondary prevention medications for which they were eligible was 89% in England in 2011/12 and 90% in 2012/13. In Wales the proportions were 83% and 81% respectively, and in Belfast they were 98% and 97%. There appears to be a substantial variation in treatment patterns across the hospitals, but some of this may be due to differential recording of eligibility criteria. Some support for this possibility can be seen in the wide range of values across hospitals in the proportion of patients who were recorded as not eligible to receive any secondary prevention medication. Whereas the overall proportion of such patients in England and Wales is 2%, some hospitals with large numbers of patients unusually report proportions of patients ineligible for any secondary prevention medication above 10%.

Figure 15. Use of secondary prevention medication All heart attacks, (transfers, deaths, contraindicated and patient refused are all excluded). 100

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revision of the dataset will allow recording of use of a newer antiplatelet agent, ticagrelor. However it is likely to be another two years before sufficient data is available to provide reliable reports on the use of this drug.

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27 http://guidance.nice.org.uk/CG48/QuickRefGuide/pdf/English 28 Simms AD, Baxter PD, Cattle BA, et al. An assessment of composite measures of hospital performance and associated mortality for patients with acute myocardial infarction. Analysis of individual hospital performance and outcome for the National Institute for Cardiovascular Outcomes Research (NICOR) European Heart Journal: Acute Cardiovascular Care 2013; 2: 9-18 MINAP Twelfth Public Report 2013

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7. Care for patients with nSTEMI Figure 16. Distribution of time to angiography from arrival at hospital for direct admission patients with a diagnosis of nSTEMI DTA Distributions for Direct Admissions

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Figure 17. Use of angiography for patients with diagnosis of nSTEMI who were directly admitted to the angiography capable hospital

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Table 7 shows the percentage of nSTEMI patients that were 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 2011/12 and 2012/13. In England in 2012/13 53% of nSTEMI patients were admitted to a cardiac care unit or ward compared with 50% in 2011/12. In Wales 60% of patients were admitted to a cardiac unit or ward compared to 65% in 2011/12. In the Belfast hospitals, 93% of patients were admitted to a cardiac unit or ward compared to 87% in 2011/12. 7.2 Cardiological care during admission

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29 Birkhead JS, Weston C, Lowe D on behalf of the MINAP Steering Group. Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales 2004-2005. BMJ 2006;332:1306-8

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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 cardiac care unit are, in many cases, omitted. 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. 7.1 Admission to cardiac unit/ward

100

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The earliest MINAP reports focussed upon the early provision of reperfusion treatment to those patients presenting with STEMI. Patients with 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 cardiac care units, nor always cared for by cardiologists. However, specialist involvement is important in determining the likelihood of receiving ‘evidence-based’ treatments such as coronary angiography and revascularisation29. It is recognised that performance of angiography and coronary intervention is an important facet of treatment for most patients (see below). Ideally admission should be to a cardiac facility (where nursing staff have expertise in cardiac nursing and there is easy access to cardiological advice).


In England in 2012/13, 94% of nSTEMI patients were seen by a cardiologist, or member of the cardiologist’s team, compared to 93% in 2011/12. In Wales 83% of nSTEMI patients were seen by a cardiologist or member of their team compared to 80% in 2011/12. In the Belfast hospitals almost all nSTEMI patients were seen by a cardiologist or member of their team in both years.

7.3 Angiography in nSTEMI The frequency with which patients are referred for angiography for nSTEMI also continues to increase – from about half (47%) in 2007/8 to nearly three quarters (74%) in 2012/13 (Figure 17). Table 7 shows the percentage of nSTEMI that were referred for angiography by hospital in 2011/12 and 2012/13. In 2012/13 73% of nSTEMI patients in England were referred for angiography after nSTEMI compared to 70% in 2011/12. In Wales 80% were referred in 2012/13 and 74% in 2011/12. In Belfast 93% were referred in 2012/13 and 91% in 2011/12. In a small number of cases, patients are discharged with arrangements to return for angiography later. This year we continue to report on the interval between admission and performance of angiography. While immediate angiography is not warranted in the vast majority of patients with nSTEMI, early angiography is recommended for those at moderate to high risk. The maximum acceptable delay from admission to angiogram has been variously defined. For example, the European Society of Cardiology suggests a 72 hour maximum, while NICE suggests a 96 hour maximum.

Figure 16 shows a general improvement over the last few years. Between 2011/12 and 2012/13 the proportion of patients receiving angiography continues to be at 21% within 24 hours, a slight decrease from 56% to 55% within 72 hours and also a slight decrease (from 69% to 68%) within 96 hours was observed. 32% of patients with nSTEMI who receive an angiogram do so after the maximum recommended time interval (i.e. 96 hours) compared to 31% in 2011/12. It is important to note that these analyses on the intervals from admission to angiography have been calculated only for those patients who are directly admitted to the hospital where angiography is performed. We have this year excluded those patients that were transferred to the angiography-capable hospital from another hospital. In order to capture the entire patient’s care pathway it is necessary to link records from both hospitals that cared for such patients – this requires careful assessment of the available data to ensure that linkage only captures the specific episode of care that is being measured. We will be considering this possibility in future work.


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8. Access to primary PCI It is now generally agreed (e.g. NICE clinical guideline 167)30 that patients with ST segment elevation on their ECG in the early stage of heart attack (STEMI) should be offered specific treatment to restore blood flow in the occluded coronary artery and, most importantly, that this happens very quickly. Previous national and international guidelines have recommended a delay to treatment of no more than 150 minutes from the time of call for professional help. More recent guidelines have defined even more ambitious thresholds, such as an overall delay from symptom onset to angioplasty balloon deployment of 180 minutes or less and an interval from first medical contact (i.e. the first ECG) to angioplasty wire passage into the blocked coronary artery of no more than 90 minutes (or even 60 minutes in those patients presenting early with potentially large infarctions)31.

Figure 18a. Number of primary PCIs per million population by Local Area Team for 2011/12

As discussed in section 4, the rate of patients that receive no reperfusion has hovered around 25% over the last few years. The proportion of all heart attack patients in MINAP that received primary PCI in 2012/13 was 72% in England and in Wales the rate was 55%. There remains limited treatment for patients in some regions, particularly those within rural areas. For these there may still be a role for thrombolytic treatment given by paramedics in the attending ambulance32. Unlike many planned (elective) interventions, in the emergency treatment of heart attack, a patient is normally unable to exercise choice as to the admitting hospital. The attending ambulance will convey the patient with suspected heart attack to the nearest hospital admitting this type of patient. However, wherever a patient is – whether a place of residence, work, visiting – they should have an equal opportunity to receive the best treatment. Considering the provision of primary PCI at the Local Area Team level in England the percentage of patients that received primary PCI ranged between 55% and 83%. In the two Welsh cardiac networks 8% (North Wales Cardiac Network) and 71% (South Wales Cardiac Network) of their patients received primary PCI. See Figures 18a and 18b. The darker the shade, the higher rate (in cases per million population) of primary PCIs performed in the region.

30 NICE. Myocardial infarction with ST-segment-elevation. NICE Clinical Guideline 167. July 2013 http://www.nice.org.uk/nicemedia/live/14208/64410/64410.pdf 31 Steg PG, James SK, Atar D, et al. European Society of Cardiology Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. Eur Heart J 2012;33:2569-619. 32 Gershlick AH, Banning AP, Myat A, et al. Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention? Lancet 2013;382:624-32.

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Figure 18b. Number of primary PCIs per million population by Local Area Team for 2012/13

Primary PCI requires a skilled clinician. In common with other technical skills, expertise develops with increasing experience, and with plentiful opportunities to practise the technique. There has been much debate as to the number of procedures that should be performed in order to maintain this expertise. Some have pointed out that a larger secondary care (District General hospital) centre with an active elective coronary intervention programme can provide primary PCI facilities for its local population and deliver as good results as a larger Heart Attack Centre33. Others have argued for centralised services, pointing to the need for continuous availability of primary PCI. In any case, since the implementation of primary PCI in 2005/06, the number of hospitals performing this life saving procedure has risen.

9. Length of stay The length of time that a patient stays in hospital following a heart attack depends on a number of factors. One of these factors is whether a patient stayed at more than one hospital during the course of care. We restricted our analyses of length of

stay to patients with direct admissions to the local district hospital or Heart Attack Centre, and excluded patients who transferred between hospitals, in order to permit an objective comparison. Another factor appears to be the type of heart attack a patient suffered. Those with nSTEMI are likely to spend significantly longer than patients with STEMI. In 2012/13 the median length of stay for patients with nSTEMI was five days (IQR 3-10 days) in England, six days (IQR 3-12 days) in Wales and five days (IQR 3-9 days) in Belfast. We report a shorter length of stay in STEMI patients whose median length of hospital stay was three days in all three regions (IQR 2-5 days in England; IQR 2-6 days in Wales and IQR 2-4 days in Belfast). The prolonged admission in nSTEMI might partly reflect the urgency with which primary PCI is provided in STEMI compared with the (generally) slower provision of angiography in nSTEMI, but also characteristic of the patients. Those presenting with nSTEMI tend to be older and have more associated health issues that might affect rapid discharge home. 33 http://bjcardio.co.uk/2013/03/primary-angioplasty-for-acute-stemi-insecondary-care-feasibility-outcomes-and-potential-advantages/ MINAP Twelfth Public Report 2013

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32 MINAP

10. Results by hospitals, ambulance services and Local Area Teams/Welsh Cardiac Networks The following notes should be read before attempting to interpret the data in this section: Denominators are represented by the notation ‘N’. Numerators are represented by the notation ‘n’. Statistics are not presented for units with fewer than 20 records eligible for a specific analysis. Median call-to-needle, door-to-needle, call-to-balloon and door-to-balloon statistics are not reported for units with fewer than three records eligible for the specific analysis. Each table includes a statement of the inclusion and exclusion criteria used in presentation as well as an explanation of the table’s contents.

Table 1: Reperfusion treatment of patients with STEMI The following table gives, for all patients with discharge diagnosis of STEMI who received reperfusion therapy, the proportion treated with primary PCI compared with thrombolytic treatment . Statistical Disclosure Control: The total number of records for hospitals with fewer than 20 records has been replaced with the notation ‘