Coronary heart disease (CHD) is the leading cause of death in the UK. The main symptoms of CHD are angina (chest pain), myocardial infarction (heart attack) and heart failure. The National Institute for Health and Care Excellence (NICE) has published a series of formal guidelines for how to manage these conditions.
To determine whether a heart attack has occurred, an electrocardiogram (ECG) and blood test are carried out. If a myocardial infarction is confirmed, analysis of the ECG will lead to two possible diagnoses: ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (nSTEMI). This distinction is important since the guidelines vary for the management of these conditions.
Cardiac rehabilitation is a programme of exercise and education sessions, which aims to improve wellbeing after a cardiac event and reduce the risk of further cardiac events. It has been shown to reduce cardiovascular mortality and hospital readmissions in patients with coronary heart disease.
Here we look at data from the Myocardial Ischaemia National Audit Project to understand whether heart attack patients are receiving the recommended treatment within the time-frames set out in the NICE Quality Standards. We also use data from the National Audit of Cardiac Rehabilitation to look at uptake of cardiac rehabilitation services.
Patients with nSTEMI (who lack the ST elevation on an ECG that is demonstrative of a complete occlusion of a coronary artery) generally do not require urgent reperfusion therapy. With adequate monitoring and drug treatments their symptoms often improve. However, the NICE quality standard states that all patients with nSTEMI should have diagnostic coronary angiography within 72 hours of first admission to hospital, in order to gauge the extent of coronary disease. Follow-on PCI can be performed at the time of the angiogram, if necessary.
Recorded delays from admission to angiography for nSTEMI patients have not improved over time in England, Wales and Northern Ireland. In 2019/20, 55% of patients with nSTEMI who underwent angiography did so within 72 hours, the same proportion of patients as in 2010/11. This demonstrates an area for significant quality improvement, although there is considerable variation between hospitals.
Recognising the need to improve this aspect of care, NHS England introduced a Best Practice Tariff metric, through which participating hospitals receive a higher reimbursement where at least 60% of all nSTEMI patients receive angiography within 72 hours.
For patients with STEMI, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy (reopening of blocked coronary artery). This is carried out as an emergency treatment, which must be performed as soon as possible after diagnosis to prevent, or reduce, damage to heart muscle and subsequent heart failure. The target is to provide primary PCI within 90 minutes of a patient's arrival at hospital (door to balloon, or DtB) and within 150 minutes of a patient's call for help (call to balloon, or CtB).
Between 2004/05 and 2013/14, there was a significant increase in the proportion of STEMI patients receiving primary PCI within 90 minutes of arrival at a heart attack centre in England, Wales and Northern Ireland, from 52% to 92%. In 2014/15 the proportion receiving primary PCI within 90 minutes of arrival fell slightly to 89%, and since then there has been no substantial change in DtB. The median DtB has varied very little over the last 10 years, and was 40 minutes in 2019/20 (data not shown).
Whilst DtB has remained stable in recent years, the percentage of patients receiving primary PCI within 150 minutes of calling for help (CtB) has decreased over the last six years, falling in 2019/20 to the lowest level for the last decade. The median CtB time increased from 110 minutes in 2013/14 to 126 minutes in 2019/20 (data not shown). The maintenance of in-hospital Dtb performance together with the increase in CtB time suggests that increasing delays to treatment are being incurred prior to the patient arriving at the heart attack centre. NHS England proposed a target for CtB, which stated that, by 2020, 90% of eligible heart attack patients should receive primary PCI within 150 minutes of calling for help. As of the 2019/20 report, hospitals in England are further away from this target than ever.
NICE recommends that all eligible patients should be offered cardiac rehabilitation after a cardiac event. In 2017/18, the percentage of patients accessing cardiac rehabilitation was highest in Wales (61%), compared to 50% in England and 49% in Northern Ireland. Data for Scotland is not currently published, however the National Audit of Cardiac Rehabilitation state that they continue to work towards inclusion in the audit. Between 2005/06 and 2017/18, the largest increase in uptake was seen in Northern Ireland (from 25% to 49%), followed by Wales (from 41% to 61%).
Uptake in England increased overall from 46% in 2005/06 to 52% in 2015/16, but has since decreased slightly to 50% in 2017/18. In the Long Term Plan, NHS England introduced a goal to increase the proportion of patients accessing cardiac rehabilitation to 85% by 2028. To meet this target, uptake will have to increase considerably.
Many cardiac rehabilitation services were reduced or suspended as part of the Covid-19 pandemic response. As such, the National Audit of Cardiac Rehabilitation report did not publish uptake figures for 2018/19 and instead focused on ‘waiting times and quality of service provision’.
The Covid-19 pandemic has had a significant impact on cardiac rehabilitation programmes; almost 80% had some or all of their team redeployed between January and December 2020. 12% of cardiac rehabilitation programmes ceased to run due to full redeployment of staff. The 2021 National Audit of Cardiac Rehabilitation states that this has increased health inequalities; there was an 11% relative drop in ethnic minority participation in cardiac rehabilitation in 2020 compared to 2019.