Further evidence of effective treatment for Heart Attack
Published: 27 Jun 2017
The latest Myocardial Ischaemia National Audit Project (MINAP) report, published today, contains information about the care provided to 85,000 people with heart attack by 13 ambulance services and 212 hospitals in England, Wales and Northern Ireland. It demonstrates sustained high quality care in key indicators for heart attack patients, identifies areas for further improvement and continued vigilance, and also highlights the serious impact of smoking on the age of onset of heart attack.
Commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme, the MINAP report analysed care between April 2015 and March 2016. Participation of nearly all acute hospitals allows us to provide a reliable representation of the treatment of heart attack across the country, enabling clinicians, clinical leaders/managers and commissioners to assure the quality of care provided, and to plan and implement quality improvement initiatives that should improve the experience of patients and lead to better outcomes.
Treatment for Heart Attack
Immediate Primary PCI (Percutaneous Coronary Intervention) at a specialised interventional hospital is established as best practice for re-opening the blocked arteries that cause heart attack. Almost every patient (99%) in England and Northern Ireland who receives reperfusion therapy are now offered primary PCI. This was similar last year in England, but represents an increase (from 92%) in Northern Ireland. In Wales the rate of primary PCI is 86%, up from 80% in 2015, as more centres establish PCI capability.
Over the last decade there has been a significant improvement in the timeliness of such treatment. A key performance measure, the ‘call-to-balloon’ time (CTB), is the interval between the call for professional help (ambulance) and the start of primary PCI treatment. In 2015/16, 80% of patients were receiving primary PCI in hospital within 150 minutes of alerting the emergency services, with a little over half getting the treatment within 120 minutes. The MINAP audit found that 90% of patients are treated with primary PCI within 90 minutes of arrival at hospital – the equivalent figure being 52% in 2004/05.
However, there has been a slight lengthening of the median CTB time over the last 5 years. Given that median in-hospital treatment times have improved over this period, it follows that lengthening of the time spent outside hospital following a call for help has resulted in increasing CTB. The median call to door time has increased, year-on-year, by 10 minutes between 2010/11 and 2015/16.
Dr Clive Weston (Consultant Cardiologist & MINAP clinical lead) said:
“MINAP provides tangible evidence of hospital performance across key measures in the treatment for heart attack. For those requiring reperfusion, hospitals are consistently providing rapid treatment once the patient arrives at hospital. The small increase in the overall time to treatment appears to reflect a longer interval between a call for help and arrival at hospital. This may reflect a “roll-out” of primary PCI services during the last few years to more rural areas, with corresponding increased distance and transport times between home and hospital. It might also reflect changes in the categorisation of urgent 999 ambulance calls from people reporting symptoms of possible heart attack. Leaders of Ambulance Trusts should continue to monitor the effect of new types of response to emergency calls to ensure an efficient use of their resources and the provision of appropriate and equitable care to all that require their services, while assuring the timeliness of care for patients with heart attack.”
For those patients whose heart attacks do not require immediate PCI, there has been a steady improvement in care. In line with key recommendations, 96% of patients are assessed by a cardiologist compared with 90% in 2011; 57% are now admitted to a cardiac ward compared with 49% in 2011, and 84% of patients have access to a diagnostic coronary angiogram (compared with 68% in 2011) to determine whether PCI or cardiac surgery is required.
However, the delay from admission to angiography in these patients has not improved. For those admitted directly to hospitals that are capable of providing on-site angiography, 17.5% received an angiogram within 24 hours; 53% within 72 hours; 66.3% within 96 hours. In 2010/11 the equivalent figures were 21% within 24 hours, 55% within 72 hours and 67% within 96 hours.
Dr Weston commented: “Centres have an opportunity to provide more timely treatment, which may lead to shorter lengths of stay, reducing the burden on the health system. Recognising the need to improve this aspect of care, NHS England is introducing a Best Practice Tariff for angiography in this type of heart attack in the 2016-17 financial year. Participating hospitals will receive a higher reimbursement for service where at least 60% of all patients receive angiography within 72 hours.
Recommendations from the Report
The Myocardial Ischaemia National Audit Project (MINAP) measures the performance of hospitals that treat heart attack in the UK against best practice. The 15th annual report covers 94,800 patient episodes, of which 85,123 had a final diagnosis of heart attack (myocardial infarction).
The MINAP provides valuable information on the performance of hospitals on an individual level while also having the scope to illustrate performance trends on a national scale. This wealth of data allows Medical Directors to identify areas for improvement, to effect change within their trust; while giving direction to commissioners and policy makers to implement initiatives on a regional or national scale, leading to better patient outcomes.
We should seek to continue an open dialogue with the general public, to increase the awareness of the risk factors for heart attack, and most importantly, to increase recognition of the early symptoms of heart attack so that care can be given sooner and a better outcome achieved.