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.
For patients with STEMI, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy (reopening of a 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 (known as ‘door to balloon’, or DtB) and within 150 minutes of a patient's call for help (known as ‘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%. Since then, there has been a slight decrease to 88% in 2017/18. Overall, the median DtB time in 2017/18 was 41 minutes in England, 42 minutes in Wales and 31 minutes in Northern Ireland (data not shown).
Meanwhile, the percentage of patients treated within 150 minutes of calling for help fell from 75% in 2015/16 to 71% in 2017/18 (data not shown). The maintenance of in-hospital performance together with an 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 has proposed a target for CtB, which states that, by 2020, 90% of eligible heart attack patients should receive primary PCI within 150 minutes of calling for help.
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, diagnostic coronary angiography is recommended 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 2017/18, 19% of patients with nSTEMI who underwent angiography did so within 24 hours, 57% within 72 hours and 70% within 96 hours. This compares to 21% within 24 hours, 55% within 72 hours and 67% within 96 hours in 2010/11. This demonstrates an area for significant quality improvement.
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.
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 from 44% in 2006-07 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.