Growth of primary PCI for the treatment of heart attack patients in England 2008-2011: the role of...

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

NHSNHS Improvement

Growth of Primary PCI for the treatmentof heart attack patients in England2008-2011: the role of NHS Improvementand the Cardiac Networks

Heart

January 2012

Summary

Treatment of ST segment elevation MI: thrombolysis vs PPCI

The National Infarct Angioplasty Project (NIAP)

The need for ‘a faster pace of change’

Roll of NHS Improvement and the Cardiac Networks in the roll-out of PPCI

Results (1) - The national picture

Results (2) - PPCI roll-out by network

Outcomes - are we making a difference?

Rehabilitation

Patient and carer perspectives

Unfinished business:a. patients who cannot receive PPCIb. patients who do not receive reperfusion therapy

Conclusions

Contents

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Primary percutaneous coronary intervention (PPCI)is the optimum reperfusion treatment for patientspresenting with ST segment elevation myocardialinfarction (STEMI). During the third quarter of2008, just 46% of those STEMI patients inEngland who received reperfusion treatment werebeing treated by PPCI while the remaining 54%were treated with thrombolysis. By the secondquarter of 2011, 94% of patients were treatedwith PPCI. This document describes the role ofNHS Improvement and the Cardiac Networks inachieving this rapid change in clinical practice.

Summary

www.improvement.nhs.uk/heart

Growth of Primary PCI for the treatment of heart attack patients in England2008-2011: the role of NHS Improvement and the Cardiac Networks

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ST segment elevation myocardial infarction(STEMI) is caused by acute thrombotic occlusion ofone of the major epicardial coronary arteries. Theaim of treatment is to re-open the occludedcoronary artery as quickly as possible in order tominimise the damage to heart muscle. Normalblood flow can be re-established eitherpharmacologically (with thrombolytic drugs) ormechanically (with percutaneous coronaryintervention (PCI)).

Thrombolysis in the UKFollowing the publication of the ISIS-2 study (1),the use of thrombolysis in England spread rapidlyin the late 1980s and 1990s. Streptokinase wasthe initial agent, followed by the fibrin-specificagents including rtPA, reteplase and tenecteplase.All agents reduce mortality. With the publicationof the National Service Framework for Cardiologyin 2000 (2), there was a new focus on theperformance of thrombolysis. National targetswere set to ensure patients received treatmentwithout undue delay. These included targets forthe ‘door-to-needle’ time, this being the timeinterval between the arrival of the patient at thedoor of the Accident & Emergency Departmentand the initiation of thrombolysis. Latterly thistarget time was set at 30 minutes. These timeswere recorded and entered into a nationaldatabase (Myocardial Ischaemia National AuditProject) which was them published annually (3).Other data collected included the percentage ofMI patients treated with aspirin, the percentagetreated with beta blockers and the percentagetreated with statins. The setting of standards, andthe subsequent collection and publication of datafor individual hospitals, brought about a markedimprovement in the treatment of STEMI patientsbetween 2000 and 2006. The awareness thatearly administration of thrombolysis wasassociated with better outcomes led to theorganisation of pre-hospital thrombolysis (PHT)

Treatment of ST segment elevationmyocardial infarction (STEMI) in England


services throughout England. The paramedicambulance personnel were trained in ECGinterpretation and guidelines were drawn up forthe administration of fibrinolytic agents inambulances en-route to the nearest hospital. In2009-10, of the 8,166 patients who were treatedwith thrombolysis, 1,706 (21%) receivedthrombolysis in an ambulance (pre-hospitalthrombolysis) while 6,460 received thrombolysis inhospital (3).

Thrombolysis, however, has a number oflimitations as a treatment for ST elevation MI.First, some patients will have a contra-indicationto thrombolysis; this may account for as many as25% of patients (4). Second, the thrombolyticagent may fail to re-open the occluded artery inaround 25-35% of those presenting with STelevation MI (5). Third, even if the lytic agentsuccessfully re-opens the occluded artery, thevessel may re-occlude resulting in furthermyocardial infarction (6). Fourth, all thrombolyticagents carry a risk of haemorrhagic stroke, whichis often fatal. In routine clinical practice, the risk ofstroke and other bleeding complications may bevery much higher than in the younger and fitterpatients generally included in randomised clinicaltrials of new thrombolytic agents. This was onepossible explanation for the discrepancy betweenthe 13-15% mortality rate for myocardialinfarction in England around 2003-4 and the4-6% mortality rates being reported incontemporaneous clinical trials of new fibrinolyticdrugs which often excluded higher risk patients(patients over the aged of 70, patients withprevious myocardial infarction and patientspresenting in cardiogenic shock).


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Primary PCI for ST segment elevation MIThe first publications of PCI as a treatment for STsegment elevation myocardial infarction appearedin the 1990s. A metanalysis of the early studieswas published in 2003 (7). In a total of more than7,700 patients randomised to either PCI orthrombolysis, the rate of death was significantlylower in those who underwent PPCI (7% versus9%). PPCI also reduced the rates of non fatalre-infarction and, importantly, of stroke.

Timing of PPCIThe superiority of PPCI over thrombolysis isbeyond doubt if the delay to treatment is thesame for both treatments. However, PPCI usuallyinvolves a longer delay to treatment thanthrombolysis, particularly in areas with asuccessful pre-hospital thrombolysis programme.The issue, therefore, was as follows: - at whattime delay are the clear advantages of PPCI overthrombolysis lost? This has been the source ofmuch debate. Initial recommendations were thatPPCI should be carried out with a delay of nomore than 90 minutes (8). However, a recentreview of the data suggested that PPCI remainedthe optimal treatment for STEMI patients providedthe PCI-related delay (ie the delay from the timethe patient would have received lysis to the timeof the PCI procedure) does not exceed 120minutes (9). The evidence that PPCI could still bebeneficial even with a longer PCI-related delayopened up the possibility of treating a muchgreater proportion of the population, and not justthose living close to PPCI centres.


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By 2004, some areas of the United Kingdom,particularly the London area, were offering a 24/7PPCI service for patients with ST segmentelevation MI. Outside London, the service waspatchy and there were doubts about whether itwas possible to organise this type of service on anational level. The National Infarct AngioplastyProject (NIAP) was a feasibility study designed toexamine whether it was possible to set up PPCI asthe default treatment for STEMI patients in theUK. The project was co-sponsored by theDepartment of Health and the BritishCardiovascular Society. 2245 patients wererecruited in the 12 month period from April 2005to April 2006. The results, including one yearfollow-up data, were published in October 2008(10).

The National Infarct AngioplastyProject (NIAP)10


The key findings from NIAP were as follows:

1. PPCI was deliverable in a UK setting withinacceptable treatment times.

2. The shortest times to treatment were achievedthrough direct admission to the cardiac cathlab.

3. Longer times to treatment occurred if thepatients were first assessed in an Accident &Emergency Department or at a local (non PPCI)hospital.

4. Longer times to treatment were associatedwith a higher mortality rate.

5. Although PCCI was more expensive to deliverthan thrombolysis, PPCI was both clinicallyeffective and cost effective when deliveredwithin 120 minutes.

6. Although NIAP was not a randomised trial,PPCI was associated with few complications, alower recurrence rate of heart attack, a lowincidence of stroke and a low mortality rate, allof which compared favourably withthrombolysis data published in clinical trialsand registries.


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The final report of the National Infarct AngioplastyProject was published in October 2008 under thetitle ‘Treatment of Heart Attack NationalGuidance.’ In the foreword to the NIAPpublication, Ann Keen, Parliamentary UnderSecretary of State for Health commended thefeasibility project and said that a faster pace ofchange was needed with a rapid expansion ofPPCI throughout England. The NHS waschallenged with the task of rolling PPCI out tocover 95% of the population of England within aperiod of three years.

The need for ‘a faster pace of change’

Following the announcement that PPCI would berolled out to cover 95% of the population over aperiod of three years, there was discussion as tohow this might be achieved. It was clear that anyPPCI service had to operate 24 hours a day, sevendays a week. It was equally clear that for allhospitals providing a PCI service to move to a 24/7PPCI service would be difficult and hugelyinefficient. The task of developing a roll-outstrategy for England was given to the 28 cardiacnetworks (or cardiac and stroke networks) whowork closely with NHS Improvement, the aims ofwhich are “to achieve sustainable effectivepathways, to share improvement resources andlearning, to ensure value for money and toimprove the efficiency and quality of NHSservices.”

Different cardiac networks faced differentchallenges. In some rural areas, with longertransport times, decisions had to be made aboutwhether all patients should be transferred for PPCIor whether a pre-hospital thrombolysis serviceshould continue for those patients more than 90-100 minutes drive from the PPCI centre. In othernetworks, there were issues about whether somesmaller hospitals should provide a limited hoursPPCI service (9am to 5pm, Monday to Friday) without of hours patients travelling to the moredistant centres or whether all PPCI patients shouldbe transferred directly to the 24/7 centre. Someissues were common to all networks. All networkshad to develop pathways for patient referral andtransfer to ensure the shortest possible call-to-balloon and door-to-balloon times. All networkshad to resolve local issues relating to 24 / 7staffing of the service by medical, nursing,technical and radiography staff. All had to reachagreement with the non-PPCI hospitals in thenetwork about whether those patients treated byPPCI should spend their entire hospital stay in thePPCI centre or whether they should be transferredto their local hospital after their PPCI procedure.Different networks reached different solutions.

Role of NHS Improvement and the CardiacNetworks in the roll-out of PPCI


To assist each network in developing a localimplementation plan, resources were provided byNHS Improvement. NHS Improvement hosted anumber of national meetings including bi-annualmeetings that brought together the clinical leadsof the 28 networks. The purpose of thesemeetings was to reflect on progress and to sharesuccessful experiences. NHS Improvement alsopublished two documents to aid the networks indeveloping their strategy. A Guide toImplementing Primary Angioplasty was publishedin June 2008 and National Roll-out of Primary PCIfor patients with ST segment elevation myocardialinfarction: an interim report was published inSeptember 2009. In addition, NHS Improvementprovided bespoke advice to individual networks asrequested and provided expert opinion to localnetwork meetings when invited to do so. In thisway, each network developed its own localimplementation plan, tailored to its pre-existinginfrastructure, to allow them to commission thisnew service (PPCI) in line with national strategy.


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Figure 1 summarises the increase in PPCI, and theconsequent fall in the use of thrombolysis, inEngland between the second quarter of 2008 andthe second quarter of 2011. The numbers arepercentages of all those patients with ST segmentelevation myocardial infarction who underwentreperfusion treatment. Patients who did notreceive reperfusion treatment, for whateverreason, are not included.

During the third quarter of 2008, around the timeof the publication of the NIAP report, 45.8% ofthose STEMI patients who received reperfusiontreatment were being treated by PPCI. Theremaining patients (54.2%) were treated withthrombolysis, either in-hospital or pre-hospital. Bythe second quarter of 2011, a dramatic shifttowards PPCI had occurred with 93.8% ofpatients now being treated with PPCI.

Results (1) - The national picture

International comparisons are difficult because ofdifferences in the completeness of data collectionin different countries. However, an analysis of PPCIrates in Western Europe published in theEuropean Heart Journal showed that the UnitedKingdom, in 2007-8, was lagging behind manyEuropean countries in the development of PPCIservices (figure 2) (11). Figure 4 shows the samedata with the rates for PPCI in England for thesecond quarter of 2011 superimposed. Whilst thisis not a valid comparison, since the data shownfor the European countries are mostly from2007-8, the rate of growth of PPCI in Englandbetween 2008 and 2011 was almost certainlyhigher than in most European counties.

Figure 1: PPCI and Lysis - England

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The trend line in figure 1, showing a steady rise inPPCI over the period of three years, might suggestthat the national roll-out of PPCI proceeded at aconstant pace throughout England. This was notthe case. Some areas, notably the London cardiacnetworks, were already delivering close to 100%PPCI prior to 2008. Most other areas had a lysis-based strategy with only occasional ad-hoc PPCI.

The challenges faced by the 28 cardiac networkswere very different, and depended on pre-existinginfrastructure, pre-existing clinical practice andlocal geography. As a result, PPCI services wereplanned and developed at very different rates upand down the country. Kent, for example, had notertiary centre. Historically, patients from Kentrequiring emergency out-of-hours PCI weretransferred to a London centre. The developmentof a 24/7 PPCI service for Kent, therefore, requiredthe cooperation and collaboration ofinterventional cardiologists from different NHStrusts to decide on an appropriate site for thesingle 24/7 centre. At a time when providerhospitals, and the cardiologists they employ, findthemselves increasingly in competition with eachother, the ‘honest broker’ role of the cardiacnetwork in hosting these discussions was of greatimportance. In Kent, the decision was tocommission a single 24/7 PPCI centre in Ashford.The Kent 24/7 PPCI service started in April 2010;as the graph of PPCI activity for Kent shows, (page23), this resulted in an almost instantaneousswitch from lysis to PPCI for the population ofKent.

Results (2) - PPCI roll-out by network

In other cardiac networks, the changeover wasmore gradual. East Midlands is one of the largestcardiac networks in the country, covering apopulation of around three million. The networkincludes two cardiac surgical centres (Leicesterand Nottingham) and a number of large districthospitals (Derby, Lincoln, Northampton andKettering), many of which were already providinga daytime PCI service. The cardiac network, onbehalf of the SHA, undertook a majorconsultation exercise which included:

• Service models developed by the network• Pre-qualification questionnaires sent to potentialproviders

• Accreditation documentation requested fromproviders

• Accreditation documentation evaluated by agroup appointed by the network

• Service assessment reviews undertaken bynetwork (including external clinicians andpatients).

A report and recommendations were thenproduced for the PCTs and the commissioners.The report was accepted and implemented. Theactivity graph for East Midlands (page 19) showsthat the rate of change, as different centres cameon-line at different times, was very different toKent. Nevertheless, by the second quarter of2011, PPCI had become the dominant reperfusionstrategy for STEMI patients in East Midlands.

The next few pages describe the development ofPPCI services across the 28 cardiac networks inEngland. For each network, the centres in whichPPCI is performed are listed, the roll-out strategy issummarised and the graph shows the % ofpatients treated with PPCI and thrombolysis(expressed as a % of all those receivingreperfusion treatment) by quarter from the secondquarter of 2008 to the second quarter of 2011.



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Anglia Stroke and Heart Network

Population2.3 million

Hospitals providing 24/7 PPCINorfolk and Norwich Hospital, NorwichPapworth Hospital, Cambridge

Hospitals providing limited hours PPCINone

Neighbouring centres where PPCI patientsmay be treatedBasildon Hospital, Basildon

Comments100% population coverage achieved

Anglia

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Hospitals providing 24/7 PPCIMusgrove Park Hospital, TauntonBristol Royal infirmary, BristolSouthampton General Hospital, Southampton

Hospitals providing limited hours PPCIRoyal United Hospital Bath, BathCheltenham General Hospital, CheltenhamThe Great Western Hospital, Swindon

Neighbouring centres where PPCI patientsmay be treatedJohn Radcliffe Hospital, OxfordRoyal Berkshire Hospital, ReadingRoyal Bournemouth General Hospital, Bournemouth


Avon, Gloucestershire, Somerset and Wiltshire

Avon, Gloucestershire, Somerset andWiltshire Cardiac and Stroke Network

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Bedfordshire and Hertfordshire Heart and Stroke Network


Hospitals providing 24/7 PPCINone

Hospitals providing limited hours PPCILister Hospital, StevenageWatford General Hospital, Watford

Neighbouring centres where PPCI patientsmay be treatedPapworth Hospital, CambridgeHarefield Hospital, Middlesex


Bedfordshire and Hertfordshire

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Hospitals providing 24/7 PPCI• Heart of England NHS Foundation Trust• Birmingham Heartlands Hospital, Birmingham(Covering Good Hope Hospital and Solihull Hospital)

• University Hospitals Birmingham NHS Foundation Trust• Queen Elizabeth Hospital, Birmingham

• Sandwell and West Birmingham Hospitals NHS Trust –• Sandwell District Hospital, West Bromwich• City Hospital, Dudley Road, Birmingham

(Out of hours one on call team – attending the trust wherethe patient presents)


Neighbouring centres where PPCI patientsmay be treatedNew Cross Hospital, WolverhamptonUniversity Hospital, Coventry


Birmingham, Sandwell and Solihull

Birmingham, Sandwell and Solihull Cardiac and Stroke Network

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Population1 million

Hospitals providing 24/7 PPCINew Cross Hospital, Wolverhampton


Neighbouring centres where PPCI patientsmay be treatedBirmingham Hospitals


Black Country

Black Country Cardiovascular Network

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Cheshire and Merseyside Cardiac Network


Hospitals providing 24/7 PPCILiverpool Heart and Chest Hospital, Liverpool


Neighbouring centres where PPCI patientsmay be treatedNone


Cheshire and Merseyside

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Hospitals providing 24/7 PPCIUniversity Hospitals Coventry and Warwickshire NHS Trust


Neighbouring centres where PPCI patientsmay be treatedBirmingham Heartlands Hospital, Birmingham


Coventry and Warwickshire

Coventry and Warwickshire Cardiovascular Network

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Dorset Cardiac and Stroke Network



Hospitals providing limited hours PPCIDorset County Hospital, Dorchester

Neighbouring centres where PPCI patientsmay be treatedSouthampton General Hospital, SouthamptonRoyal Devon and Exeter Hospital, ExeterMusgrove Park Hospital, Taunton

CommentsDaytime PPCI provided at Dorset and Bournemouth withthrombolysis for out-of-hours presenters

Dorset

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Hospitals providing 24/7 PPCIGlenfield Hospital, LeicesterRoyal Derby Hospital, DerbyKettering General Hospital, KetteringNorthampton General Hospital, NorthamptonNottingham City Hospital, Nottingham

Hospitals providing limited hours PPCIUnited Lincolnshire Hospitals NHS Trust, Lincoln

Neighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldJohn Radcliffe Hospital, OxfordWalsgrave Hospital, Coventry

CommentsRural population of Lincolnshire will receive PPCI inspring 2012

East Midlands

East Midlands Cardiac and Stroke Network

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Essex Cardiac and Stroke Network


Hospitals providing 24/7 PPCIEssex Cardiothoracic Centre, Basildon


Neighbouring centres where PPCI patientsmay be treatedBart’s and the London NHS Trust, LondonHarefield Hospital, Middlesex


Essex

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Hospitals providing 24/7 PPCIManchester Royal Infirmary, ManchesterWythenshawe Hospital, Manchester


Neighbouring centres where PPCI patientsmay be treatedUniversity Hospital of North Staffordshire, Stoke on Trent


Greater Manchester and Cheshire

Greater Manchester and Cheshire Cardiac and Stroke Network

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Herefordshire and Worcestershire Cardiac and Stroke Network



Hospitals providing limited hours PPCIWorcester Royal Hospital, Worcester


CommentsExtended daytime PPCI at Worcester Royal Infirmaryworking towards 24/7.

Pre hospital thrombolysis with immediate transport to aPCI centre will be the treatment of choice for areas withlong travel times

Herefordshire and Worcestershire

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Hospitals providing 24/7 PPCIWilliam Harvey Hospital, Ashford


Neighbouring centres where PPCI patientsmay be treatedGuys and St Thomas’s, LondonKing’s College Hospital, London


Kent

Kent Cardiovascular Network

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Cardiac and Stroke Networks in Lancashire and Cumbria


Hospitals providing 24/7 PPCIVictoria Hospital, Blackpool



CommentsCumbria will continue with thrombolysis because of thelong travel times from this area pending the developmentof a PCI/PPCI centre at Carlisle.

Lancashire and Cumbria

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Hospitals providing 24/7 PPCICastle Hill Hospital, Hull


Neighbouring centres where PPCI patientsmay be treatedLeeds General Infirmary, LeedsJames Cook University Hospital, Middlesbrough


North & East Yorkshire and Northern Lincolnshire

North & East Yorkshire and NorthernLincolnshire Cardiac and Stroke Network

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North Central London Cardiac and Stroke Network


Hospitals providing 24/7 PPCIRoyal Free Hospital, LondonThe Heart Hospital, London


Neighbouring centres where PPCI patientsmay be treatedAny other London hospital


North Central London

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Hospitals providing 24/7 PPCIBarts and the London Hospital


Neighbouring centres where PPCI patientsmay be treatedEssex Cardiothoracic Centre, Basildon


North East London

North East London Cardiovascular and Stroke Network

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North Trent Cardiac Network


Hospitals providing 24/7 PPCINorthern General Hospital, Sheffield




North Trent

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Hospitals providing 24/7 PPCIHammersmith Hospital, LondonHarefield Hospital, Middlesex


Neighbouring centres where PPCI patientsmay be treatedSt George’s Hospital, LondonBart’s and the London, LondonLondon Chest Hospital, LondonThe Heart Hospital, London


North West London

North West London Cardiac and Stroke Network

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North of England Cardiovascular Network


Hospitals providing 24/7 PPCIJames Cook University Hospital, MiddlesbroughFreeman Hospital, Newcastle


Neighbouring centres where PPCI patientsmay be treatedLeeds General Infirmary, Leeds


North of England

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Hospitals providing 24/7 PPCIDerriford Hospital, PlymouthRoyal Devon and Exeter Hospital, ExeterSouth Devon Healthcare Trust, Torbay


Neighbouring centres where PPCI patients may be treatedNone


Peninsula

Peninsula Heart and Stroke Network

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Shropshire and Staffordshire Heart and Stroke Network


Hospitals providing 24/7 PPCIUniversity Hospital of North Staffordshire, Stoke on Trent


Neighbouring centres where PPCI patientsmay be treatedNew Cross Hospital, WolverhamptonHeart of England NHS Foundations Trust


Shropshire and Staffordshire

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Hospitals providing 24/7 PPCIJohn Radcliffe Hospital, OxfordSouthampton General Hospital, SouthamptonRoyal Berkshire Hospital, ReadingNorth Hampshire Hospital, Basingstoke

Hospitals providing limited hours PPCIWycombe General Hospital, High WycombeQueen Alexandra Hospital, Portsmouth

Neighbouring centres where PPCI patients may be treatedHarefield Hospital, MiddlesexFrimley Park Hospital, Surrey

Comments97% population coverage achievedThrombolysis out of hours on the Isle of Wight

South Central

South Central Vascular Networks

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South East London Cardiac and Stroke Network


Hospitals providing 24/7 PPCIGuy’s and St Thomas’s Hospital, LondonKings College Hospital, London




South East London

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Hospitals providing 24/7 PPCISt George’s Hospital, London




South West London

South West London Cardiac and Stroke Network

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Surrey Heart and Stroke Network


Hospitals providing 24/7 PPCIFrimley Park Hospital, Frimley




Surrey

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Hospitals providing 24/7 PPCIRoyal Sussex County Hospital, BrightonEastbourne District General Hospital, EastbourneConquest Hospital, St Leonards on Sea

Hospitals providing limited hours PPCIWorthing Hospital, Worthing

Neighbouring centres where PPCI patientsmay be treatedSouthampton General Hospital, SouthamptonEast Surrey Hospital, RedhillWilliam Harvey Hospital, AshfordFrimley Park Hospital, Frimley


Sussex

Sussex Heart Network

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West Yorkshire Cardiovascular Network


Hospitals providing 24/7 PPCILeeds General infirmary, Leeds


Neighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldCastle Hill Hospital, HullJames Cook University Hospital, Middlesbrough


West Yorkshire

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Figure 2 shows the 30 day mortality for allpatients having ST segment elevation myocardialinfarction. Mortality data are obtained from theNHS Central Register by the Central Cardiac AuditDatabase (CCAD) and are published in the annualMINAP Public Report. The graph demonstratesthat 30 day mortality for STEMI has fallen fromaround 12.4% in 2003-4 to around 8.6% in2010-11. It is clear that many different factorswill have contributed to the falling mortality butthe switch to PPCI is likely to have been a majorfactor from the time of recruitment to the NIAPstudy in 2005, publication of the NIAP study in2008 and the NHS Improvement led roll-outprogramme between 2008 and 2011.

Outcomes - are we making a difference?

Figure 2: 30 day mortality (with 95% confidence limits) for allpatients with STEMI (Source MINAP Public report September 2011)



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Primary PCI is a major step forward in themanagement of patients with ST segmentelevation MI. However, the speed of treatmentcan leave patients bewildered and confused aboutexactly what has happened to them (12). Patientsmay see their heart attack as an acute event fromwhich they have been cured. Access to cardiacrehabilitation services is key in allowing patients,and their carers, to understand that they shouldreturn to a fully productive life but to understandalso that coronary artery disease is a chroniccondition and that lifestyle modification (smokingcessation etc) and compliance with prescribedmedication will greatly reduce the risk of furtheradverse events. This is dealt with in more detail inthe NHS Improvement web-based documententitled ‘Primary Angioplasty and HealthInformation Provision’ (13). A vital part of eachnetwork’s pathway, therefore, was to ensure thatall PPCI patients were offered timely access tocardiac rehabilitation services. Full descriptions ofthe role of cardiac rehabilitation are availableelsewhere (14).

Rehabilitation



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a. Patients who cannot receive PPCIA small proportion of patients, probably around5%, will be unable to reach a PPCI centre withinthe appropriate time period for PPCI. This willapply to those patients living in more rural areasof England where the journey time to a PPCIcentre exceeds 90-100 minutes. It is importantthat these patients receive the ‘next best’treatment. This should comprise earlyadministration of fibrinolysis, either pre-hospital orin-hospital. Current guidelines suggest that thesepatients should have immediate ‘rescue’ PCI iftheir symptoms and ST segments have failed toresolve. This will apply to around 30% of patients.Even if they are pain-free with resolving ECGchanges, these patients are at high risk of re-infarction and should have angiography, withfollow-on PCI if required, within 24 hours.

Unfinished business

One option, therefore, for these patients is torecommend pre-hospital thrombolysis followed byimmediate transfer to a 24/7 PPCI centre.

b. Patients who do not receive reperfusiontherapySome patients who are initially thought to behaving an ST segment elevation MI do not receiveeither PPCI or thrombolysis. Figure 3 shows theproportion of patients in this category anddemonstrates a small rise in the numbers fromaround 25% in 2008 to almost 30% in 2011.Furthermore, the proportion of STEMI patientswho do not receive reperfusion therapy showsmarked variability between networks. Figure 4shows the percentage of STEMI patients receivingno reperfusion therapy for the 28 networks duringthe second quarter of 2011; the rate variesbetween 6% and 33%. What is not clear iswhether it was clinically appropriate that thosepatients did not receive reperfusion therapy orwhether there were missed opportunities for PPCIor lysis.

There are a number of entirely justifiable clinicalreasons why patients who have a final diagnosisof ST elevation MI might not receive reperfusiontherapy. Two ongoing audits should help inclarifying whether the differences betweennetworks are attributable to differences in clinicalpractice or to differences in data collection andcoding and whether the decision not to givereperfusion treatment to this group of patientswas clinically appropriate or not. These comprise:

• An audit at network level of all ‘PPCIpathway activations’. This audit is summarisedin figure 5. The audit will capture the reasonswhy patients may present as a probable STEMI,and hence be referred to as ‘pathwayactivations’, but not ultimately receive asuccessful PPCI procedure

• A retrospective audit of patients who have adischarge diagnosis of ST elevation MI fromMINAP but who did not receive PPCI or lysis.

Figure 3: Percentage of patients not receiving reperfusion therapy

Figure 4: Variation between networks in % of patients receivingno reperfusion therapy: Data second quarter of 2011

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Primary PCI is the optimum reperfusion strategyfor patients with ST elevation MI. The number ofpatients treated in this way in England rosesteadily between 2004 and 2008, but in an ad-hoc way. The National Infarct Angioplasty Project,co-sponsored by the British Cardiovascular Societyand the Department of Health, followed by thePPCI roll-out programme between 2008 and2011, organised by NHS Improvement and the 28cardiac networks in England, achieved a change inclinical practice that was both swift and consistentacross the country. This change in practice hasbrought about immediate benefits for patients interms of a reduction in deaths and shortenedhospital stays. At a time when individual hospitalsmay be competing for patients with neighbouringhospitals, the role of the cardiac networks hasbeen pivotal in ensuring that the patient pathwaysdeveloped have been safe and sustainable.

Conclusion

Networks can have a major role in thedevelopment of other services for patients,particularly specialist services that will not beprovided by every hospital but will require closecooperation between hospitals with rapid andsafe inter-hospital transfer of patients in order tooptimise their care.

Figure 5: PPCI pathway



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1. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial ofintravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acutemyocardial infarction: ISIS-2. Lancet 1988; ii: 349-360

2. Coronary heart disease: national service framework for coronary heart disease - modern standards andservice models. Department of Health Publcation, 2000.

3. How the NHS cares for patients with heart attack. Ninth public report 2010. Prepared on behalf of theMINAP steering group. www.rcplondon.ac.uk/clinical-standards/organisation/partnership/Pages/MINAP-.aspx

4. Juliard J-M, Himbert D, Golmard J-L, et al. Can we provide reperfusion therapy to all unselected patientsadmitted with acute myocardial infarction? J Am Coll Cardiol 1997;30:157-164

5. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, orboth on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. NEngl J Med 1993;329:1615-1622

6. Gibson CM, Karha J, Murphy SA, et al. Early and long-term clinical outcomes associated withreinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials. J AmColl Cardiol 2003;42:7-16

7. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acutemyocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20.

8. Task Force on the management of ST-segment elevation acute myocardial infarction of the EuropeanSociety of Cardiology. Management of acute myocardial infarction in patients presenting with persistentST-segment elevation. The: Eur Heart J (2008) 29 (23): 2909-2945.

9. Terkelsen CJ, Chritiansen EH, Sorensen JT, at al. Primary PCI as the preferred reperfusion therapy inSTEMI: it is a matter of time. Heart 2009;95:362-369 doi:10.1136/hrt.2007.139493

10. Treatment of Heart Attack. National Guidance. Final Report of the National Infarct Angioplasty Project(NIAP). (2008)

11. European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for STelevation acute myocardial infarction in Europe: description of the current situation in 30 countries. EurHeart J 2010;31:943-957

12. Astin F, Closs SJ, McLenachan J, Hunter S and Priestley C. Primary angioplasty for heart attack:mismatch between expectations and reality? Journal of Advanced Nursing 65(1), 72–83doi: 10.1111/j.1365-2648.2008.04836.x

13. NHS Improvement. Primary Angioplasty and Health Information Provision.

14. NICE Clinical Guideline 48 MI:Secondary Prevention

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Carol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: [email protected]

Sheelagh MachinDirector, Heart, NHS Improvementemail: [email protected]

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