The National Institute for Health and Care Excellence (NICE) has published a series of formal guidelines to manage patients experiencing a myocardial infarction, both with ST-segment elevation (STEMI) and without ST-segment elevation (nSTEMI) showing on the electrocardiogram. Here we explore audit data to understand the extent to which patients receive recommended care processes, which should result in better health outcomes.
For adults with STEMI, primary percutaneous coronary intervention (PCI) is the reperfusion (re-opening the blocked coronary artery) treatment technique of choice. It is recommended that primary PCI should be performed within 90 minutes of arrival to hospital (door-to-balloon time) and within 150 minutes of a patient's call for help (call-to-balloon time). Results show that over time there has been an increase in the proportion of patients receiving primary PCI within 90 minutes of arrival at the heart attack centre. Call-to-balloon time can either be assessed against 150 minutes or 120 minutes (according to European guidelines-see Audit). Over time the proportion of patients admitted directly to a heart attack centre and receiving primary PCI within 150 minutes from the moment the patient made the call has stabilised around 90% but is just over 60% when assessed against the 120 minutes (data not presented-see Audit).
The graph captures how the use of angiography for patients with STEMI who do not receive primary PCI but instead received thrombolytic treatment or no reperfusion treatment, has changed over time. The use of thrombolysis in heart attack patients has been diminishing, even though it still remains the gold standard treatment for acute stroke patients (Audit). The small proportion of patients who do receive thrombolysis or for various reasons have not received reperfusion therapy, should receive angiography. We observe a gradual increase over time in the use angiography, from 31.9% in 2004/5 to 72.2% in 2013/14.
If ST is not elevated, nSTEMI patients may not require immediate reperfusion therapy, and the condition can be managed with medication; despite diagnostic difficulties, nSTEMI patients have a lower early risk of death. As a result, these patients often do not end up in specialist units or with the specialist's advice, even though their involvement is important (Audit), especially as for a proportion of nSTEMI patients there is a risk of deterioration and these should be assessed with validated instruments to determine whether they need a coronary angiogram within 96 hours of admission. Over time, we observe an increase in the proportion of patients with nSTEMI receiving angiography, from 22% in 2003/4 to 78.3% in 2013/14. We should note that many patients with nSTEMI who are treated outside of cardiac care units may be omitted from the Audit and the quality of care they receive is therefore not known.
The 2013/14 Audit report also included information on patient outcomes. Overall unadjusted 30 day mortality over 3 years (2011-2014) was 8.1% (7.2% for patients admitted directly to primary PCI interventional centre and 14.3% for patients admitted to primary PCI non-interventional centre) compared with 12.4% in 2003/4.
About this data
For details and other care processes where data was not available over time or difficult to reproduce, see the most recent audit report.