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Myocardial IschaemiaNational Audit ProjectMyocardial IschaemiaNational Audit ProjectMyocardial Ischaemia NationalAudit ProjectHow the NHS cares for patients with heart attackAnnual Public Report April 2011 - March 2012

This report is written for the public to show the performance ofhospitals, ambulance services and Cardiac Networks in England,Wales and Belfast against national standards for the care ofpatients with heart attack in 2011/12.Authors:Report prepared by Ms Lucia Gavalova, MINAP Project Managerand Dr Clive Weston, MINAP Clinical DirectorWith assistance from:Dr John Birkhead, Former MINAP Clinical DirectorMrs Lynne Walker, NICOR Programme managerProfessor Adam Timmis, Chairman MINAP Academic GroupDr David Cunningham, NICOR Senior Strategist for NationalCardiac AuditsMr Ronald van Leeven, MINAP Project co-ordinatorMrs Sirkka Thomas, MINAP patient/carer representativeMr Alan Keys, MINAP patient representativeDr Darragh O’Neill, NICOR Information AnalystDr Emmanuel Lazaridis, Senior Information AnalystDr Nick West, Consultant Cardiologist, Papworth Hospital &Deputy Chair of BCS Working Group on Acute Cardiac CareDr Alexander Lyon, Consultant Cardiologist, RoyalBrompton HospitalElectronic copies of this report can be found at:www.ucl.ac.uk/nicorFor further information about this report, contact:Myocardial Ischaemia National Audit ProjectNational Institute for Cardiovascular Outcomes ResearchInstitute of Cardiovascular ScienceUniversity College London170 Tottenham Court RoadLondon W1T 7HATel: 0203 108 3926Email: l.gavalova@ucl.ac.ukAcknowledgementsThe MINAP team would like to thank all the hospitals andambulance services that have collected data.This report was completed in close collaboration with theNICOR Technical Team (formerly known as CentralCardiac Audit Database). Sue Manuel has again beenespecially involved.MINAP is commissioned and funded by the HealthcareQuality Improvement Partnership (HQIP). For moreinformation, please visit www.hqip.org.uk.Hospital or ambulance service dataIf you require further information on the performance ofyour local hospital or ambulance service, please contact the¬ relevant hospital or ambulance service, details of whichare available at NHS Choices http://www.nhs.uk/Pages/HomePage.aspxThe content of this report may not be published or usedcommercially without permission.Report published on 15 November 2012.University College London (media enquiries)Media Relations Manager David WestonTel: 020 3108 1056Out of hours: 07917 271 364Email: d.weston@ucl.ac.ukNICOR is a partnership of clinicians, IT experts, statisticians, academicsand managers which manages six cardiovascular clinical audits andseveral new technology registries. Its mission is to provide informationto improve heart disease patients’ quality of care, outcomes and help toreduce inequity in care.The Healthcare Quality Improvement Partnership (HQIP) is led bya consortium of the Academy of Medical Royal Colleges, the RoyalCollege of Nursing and National Voices. Its aim is to promote qualityimprovement, and in particular to increase the impact of clinical audit inEngland and Wales. HQIP hosts the contract to manage and develop theNational Clinical Audit and Patient Outcomes Programme (NCAPOP). Theprogramme comprises 40 clinical audits that cover care provided to peoplewith a wide range of medical, surgical and mental health conditionsFounded in 1826, UCL was the first English university established afterOxford and Cambridge, the first to admit students regardless of race, class,religion or gender, and the first to provide systematic teaching of law,architecture and medicine. We are among the world’s top universities, asreflected by performance in a range of international rankings and tables.Designed and published by:| www.padcreative.co.uk

Myocardial Ischaemia National Audit ProjectHow the NHS cares for patients with heart attackAnnual Public Report | April 2011 - March 2012MINAP Eleventh Public Report 20123

ContentsForeword 5By the Interim National Clinical Director forCardiovascular Disease (England)Executive Summary 6Part One: Introduction 81. Background to heart attacks 81.1 STEMI and nSTEMI 81.2 Aims of management 81.3 Reperfusion therapy 92. Background to MINAP 92.1 A look back 92.2 Organisation of MINAP 102.3 How the data are collected 102.4 Security and patient confidentiality 112.5 Case ascertainment 112.6 Data quality 122.7 Improving our IT platform 122.8 Improving analysis 123. Improving quality, improving outcome 133.1 Use of primary PCI 133.2 From coronary care to cardiac care 133.3 nSTEMI and access to angiography 143.4 Of broken hearts and octopus pots 144. MINAP: a patient’s perspective 16Part Two: Analyses 181. Characteristics of patients with heart attack 18in 2011/122. Hospitals that perform primary PCI 202.1 Door-to-balloon time 202.2 Call-to-balloon time 213. Hospitals using thrombolytic treatment 223.1 Door-to-needle time 223.2 Call-to-needle time 223.3 Future of thrombolysis and its use in the 22rural areas3.4 PCI post thrombolysis 234. Patients that received no reperfusion 235. Ambulance service performance 246. Use of secondary prevention medication 247. Cardiac Networks 248. Care for patients with nSTEMI 269. Change in mortality of heart attack patients 2710. Results by hospitals, ambulance services 28and Cardiac NetworksTable 1 Primary PCI in hospitals in 28England, Wales and BelfastTable 2 Thrombolytic treatment in hospitals 34in EnglandTable 3 Thrombolytic treatment in hospitals 42in Wales and BelfastTable 4 Reperfusion treatment in England 44Table 5 Reperfusion treatment in Wales 52and BelfastTable 6 Ambulance services in England, 53Wales and BelfastTable 7 Secondary prevention medication 54in hospitals in England, Wales and BelfastTable 8 Cardiac Networks in England, Wales 66and BelfastTable 9 Care of patients with non-ST-elevation 70infarction (nSTEMI) in EnglandTable 10 Care of patients with non-ST- 80elevation infarction (nSTEMI) in Wales and Belfast11. Difference in performance between 82England and WalesPart Three: Case Studies 83How hospitals, ambulance services andCardiac Networks have used MINAP data toimprove patient carePart Four: Research use of MINAP data 96Part Five: Conclusions/Recommendations 100Part Six: Appendices 1011. MINAP Steering Group 1012. MAG Membership 1013. Glossary 1024. MINAP Publications 1045. Contacts for information on heart and heart 106related conditions4 MINAP How the NHS cares for patients with heart attack

ForewordThe annual MINAP Report, now in its 12th year, has becomean eagerly awaited document by clinicians and healthcaremanagers. In the early years it reported predominantlyon patients suffering ST-elevation myocardial infarction(STEMI) and the use of thrombolysis as the preferredreperfusion therapy at the time. More recently its scopeextended to collecting data on other acute coronarysyndromes (ACS), and it has tracked considerable changesin the management of patients over time; the shift toprimary Percutaneous Coronary Intervention (PCI) forSTEMI (now the reperfusion modality in around 95%of cases), earlier and more frequent use of coronaryangiography for nSTEMI, and the prescription of provensecondary prevention medication (over 95% of cases). TheMINAP database now contains data on more than 1 millionACS admissions, making it one of the largest sources ofsuch registry data in the world. MINAP, and its long history,is a testament to the huge efforts of all those responsible:staff and hospitals collecting the data, data managersand analysts, researchers and publishers. All should becongratulated and thanked because this is an immenselyvaluable resource for measuring - and informingimprovements to - performance and outcomes.The management of patients with ACS has advanced greatly overthe last decade, with a welcome improvement in survival, butthere is more to be done. Over a quarter of patients with STEMIdo not receive reperfusion therapy, and whilst for many there willbe good clinical reasons for this, there are regional variationswhich suggest that some people are not getting as good a serviceas others. We need to find out more about the reasons for thesevariations and tackle any inequalities. We know also that outcomesare improved for patients with STEMI if they are admitted directlyto a Heart Attack Centre, and yet around 20% of cases still presentto non-interventional hospitals and have to be transferred, delayingcoronary reperfusion. Cardiac Networks have done much to helpdrive improved performance and outcomes, and work will continuewithin the Strategic Clinical Networks recently announced by theNHS Commissioning Board.Improving outcomes that are important to patients and the publichas never been more central to NHS performance, and if outcomesare to be improved they must be measured. There can be fewmore valuable sources of information on those with acute coronarysyndromes than this excellent MINAP Report.Professor Huon H GrayInterim National Clinical Director for Cardiovascular Disease,Department of Health (England)Consultant Cardiologist, Southampton University Hospital.MINAP Eleventh Public Report 20125

Executive SummaryThe Myocardial Ischaemia National Audit Project (MINAP)is a national clinical audit of the management of heartattack. It supplies participating hospitals and ambulanceservices with a record of their management and comparesthis with nationally and internationally agreed standards.MINAP provides comparative data to help clinicians andmanagers monitor and improve the quality and outcomesof their local services.This is the eleventh annual MINAP Public Report. It presentsanalyses from all hospitals and ambulance services, inEngland, Wales and Belfast, that provided care for patients withsuspected heart attack between April 2011 and March 2012(2011/12). For the first time we present data on primary PCIwithin 120 minutes of calling for help. The report also presentssome data from previous years. Its purpose is to inform thepublic about the quality of local care for heart attack patients.Heart attack is common and remains a major cause ofdeath and ill health. Importantly, prompt and appropriatetreatment reduces the likelihood of death and recurrent heartattack. Good treatment, coupled with cardiac rehabilitation,promotes optimal recovery. Heart attack, or myocardialinfarction, is part of the spectrum of conditions known asacute coronary syndromes (ACS). This term includes both STelevationmyocardial infarction (STEMI), for which emergencyreperfusion treatment with primary percutaneous coronaryintervention (PCI) or thrombolytic drugs is beneficial, and non-ST-elevation myocardial infarction (nSTEMI), which representsthe majority and for which a different approach is required.This year, in England 95% of patients who received anyreperfusion treatment received primary PCI compared to82% in 2010/11. In Wales the increase was from 30% to50%. In the Belfast hospitals the percentage of patients whoreceived primary PCI remains unchanged at 99%.This year 92% of eligible patients in England, 81% in Walesand 89% in Belfast were treated with primary PCI within 90minutes of arrival at the Heart Attack Centre.83% of eligible patients in England, 78% in Wales and 88%in Belfast were treated with primary PCI within 150 minutesof calling for professional help.This year for the first time we report on patients whoreceived primary PCI within 120 minutes from callingfor help as follows: in England 62%, in Wales 59% and inBelfast 84%.Access to primary PCI is becoming more uniform. Thepercentage of patients in English Cardiac Networks thatreceived primary PCI ranged between 41% and 99%; intwo Cardiac Networks fewer than 50% of patients receivedprimary PCI compared to 6 in 2010/11. In the two WelshCardiac Networks 6% and 64% of their patients receivedprimary PCI.79% of patients that were treated with primary PCI wereadmitted directly to a Heart Attack Centre in England, 86%in Wales and 79% in the Belfast hospitals.Initial treatment of patients with STEMIHigh quality care for STEMI includes early diagnosis and rapidtreatment to re-open the blocked coronary artery responsiblefor the heart attack. Two forms of treatment are available.The great majority of patients now receive primary PCI, wherethe artery is re-opened mechanically using a balloon catheterinserted into the blocked artery and a stent is deployed withinthe artery. Thrombolytic treatment, where the clot is dissolvedby a drug given by ambulance or hospital staff, is alsoavailable. Delay to providing either treatment is associatedwith poorer outcomes.Patients who received primary PCI for STEMIPrimary PCI is the preferred treatment if it can be providedpromptly. Most patients who are recognised as having a heartattack characterised by ST-elevation are taken by ambulancedirectly to the catheter laboratory of the nearest Heart AttackCentre, often bypassing smaller hospitals and the Accidentand Emergency (A&E) department.6 MINAP How the NHS cares for patients with heart attack

Patients who received thrombolytic treatmentfor STEMIAs the number of patients having primary PCI has increased,the number having thrombolytic treatment, either before or onarrival at hospital, has fallen.54% of eligible patients received thrombolytic treatmentwithin 60 minutes of calling for professional help inEngland; 48% in Wales. Thrombolytic treatment is not usedin the Belfast hospitals.70% of patients who received thrombolytic treatment orhad no reperfusion treatment had, or were later referredfor, coronary angiography in England; 88% in Wales and74% in Belfast.Thrombolytic treatment given by paramedicsbefore the patient reaches hospitalFor many ambulance services, the focus has shifted fromprovision of early pre-hospital thrombolytic treatment toidentifying those patients with a heart attack who mightbenefit from primary PCI, and transferring these patientsrapidly to a Heart Attack Centre. This means that for manyambulance services the number of patients receiving prehospitalthrombolytic treatment has declined.210 patients received pre-hospital thrombolytic treatmentin England in 2011/12 compared to 824 in 2010/11, adecrease of 75%. In Wales 154 patients received prehospitalthrombolytic treatment compared to 219 in2010/11. Pre-hospital thrombolytic treatment is not usedin Belfast.care units and are not always cared for by cardiologists.However, specialist involvement has been shown to leadto better outcomes. The performance of angiography andcoronary intervention soon, and within the first 2-4 days (seeFigure 17), is an important facet of treatment for the majorityof these patients. Ideally, admission should be to a cardiacfacility where nursing staff have cardiac nursing expertise andthere is easy access to cardiological advice. This year:51% of nSTEMI patients were admitted to a cardiac unit orward in England, 64% in Wales and 87% in Belfast.93% of nSTEMI patients were seen by a cardiologist ormember of their team in England, 81% in Wales and 100%in Belfast. However the Welsh data are incomplete as 3/18hospitals did not enter data on their nSTEMI patients.Prescription of secondary prevention medicationTaking secondary prevention drugs after the acute event(for both STEMI and nSTEMI patients) reduces the risk ofdeath and further heart attack. The proportion of patientsin England, Wales and Belfast who are suitable for suchtreatment and in whom secondary prevention medication isprescribed on discharge from hospital continues at over 95%for each of the five drug classes monitored.Falling mortalityThere has been a year on year fall in the percentage ofpatients with STEMI and nSTEMI who die within 30 days ofadmission to hospital (Figure 19 and 20).Patients that received no reperfusion treatmentSome patients arriving at hospital with evidence of STEMIreceive neither primary PCI nor thrombolytic treatment – noreperfusion therapy is provided – often because they presentto hospital too late to benefit from such treatments, or duringemergency coronary angiography they are found to havecoronary arteries that do not require intervention.In England 30% of patients with STEMI received noreperfusion compared with 31% in 2010/11. In Wales 27% ofpatients with STEMI received no reperfusion compared with31% in 2010/11 and in Belfast 29% of patients with STEMIreceived no reperfusion compared with 30% in 2010/11.Care of patients with nSTEMIPatients with nSTEMI have a lower early risk of deathwithin the first month, but appear to be at similar or evengreater long-term risk than patients with STEMI. Perhapsbecause they do not require very rapid emergency treatment(reperfusion therapy), they are not always admitted to cardiacMINAP Eleventh Public Report 20127

Part One: Introduction1. Background to heart attacksThe term ‘heart attack’, while used widely in discussionsbetween clinicians and their patients, and therefore in thispublic report, is too imprecise to define the condition thatis the subject of this national clinical audit. The preferredterm is Acute Coronary Syndrome (ACS). This covers thesymptoms and clinical features that occur when there isan abrupt reduction in the blood supply to a segment ofheart muscle. Usually this is a consequence of a slowlyprogressive build-up of fibro-fatty material (atheroma)within the wall of the coronary artery, occurring over yearsand often without symptoms, followed by sudden disruptionof the internal artery wall. This readily causes blood to clotwithin the artery – a coronary thrombosis – and leads toa state of myocardial ischaemia, in which the demands ofthe affected heart muscle for oxygen-rich blood exceed thesupply of such blood down the clot-containing artery.If ischaemia is sufficiently prolonged or complete, death ofheart muscle results. This is myocardial infarction and isconfirmed if evidence of heart muscle cell death is found onblood testing. Such evidence may take some hours to appearand, to be most effective, treatment must start before theresults of such tests are available. Ischaemia is suggestedby characteristic symptoms (for example central chestdiscomfort, sweating, breathlessness) and abrupt changesin blood pressure, heart rate and heart rhythm (sometimesleading to collapse or sudden death). Ischaemia often can bedetected as electrical alterations on the electrocardiogram(ECG). When symptoms start it is uncertain whether theischaemia will be transient, and of no long-term consequence,or whether it will be prolonged and progress to infarction andconsequent failure of the heart to pump strongly. Rather thanwaiting to find out, all patients require urgent treatment toreverse ischaemia and prevent, or limit, infarction.Heart attack can occur at any age, but it is very rare toexperience one before middle age – consistently, most patientsin MINAP have been older than 65 years. This is because thedeposition of atheroma (see above) in the walls of coronaryarteries takes place over many years. Advanced investigationscan demonstrate coronary atheroma in many people in their30s and 40s who have no symptoms, yet who eventually suffera sudden coronary thrombosis many years later.A variety of genetic and potentially modifiable lifestyle factorsincrease the likelihood that a person will develop atheromaand later heart attack. The most easily recognised of theseinclude higher levels of blood lipids (e.g. cholesterol), blood1. http://www.bhf.org.uk/heart-health/prevention/risk-factors.aspx2. www.nice.org.uk/guidance/CG94glucose (i.e. diabetes) and blood pressure (hypertension), afamily history of premature coronary disease, a sedentarylifestyle with limited physical exercise, and cigarette smoking 1 .Many of these risk factors may be found in one individual,where they appear substantially to magnify the likelihood ofsuffering heart attack, or other vascular disorders. Someof them can be altered with a reduction in the chances ofheart attack and stroke – even in those who have alreadyexperienced such an event – forming part of the rationalefor both secondary preventive drug therapy and cardiacrehabilitation programmes.1.1 STEMI and nSTEMIBased upon the ECG, patients with characteristic symptomsare categorised into those with, and those without, ST segmentelevation – leading to the final diagnosis of those with STelevationmyocardial infarction (STEMI) and those with non-ST-elevation myocardial infarction (nSTEMI). A typical ECGshowing STEMI can be found accompanying the case studyfrom St George’s Hospital, London, later in this report (see partthree, case study 11). ST-elevation usually indicates completeblockage of a coronary artery and warrants specific immediatetreatment to re-open the artery – see ‘reperfusion therapy’below. The absence of ST-elevation usually indicates that anycoronary thrombosis is only partially occluding the artery.Although patients with STEMI are at greater early risk, themedium to long-term outcome (in terms of recurrent heartattack or death) is similar, if not worse, for those with nSTEMI– who are generally an older group. Each year MINAP reportsmore patients with nSTEMI than STEMI. Within the last threeyears the National Institute for Health and Clinical Excellence(NICE) 2 has published guidelines for the management ofpatients with nSTEMI, as well as the supporting evidence uponwhich the guidelines are based.1.2 Aims of managementThe aims of management of acute coronary syndromeare presented in Figure 1 together with examples of someinterventions that have been shown to be associated withbetter outcomes for patients, and have therefore beenincluded in various guidelines. Not all patients require allthe interventions and some interventions are unsuitable –contraindicated – in some patients. Therefore, cliniciansinvolved in providing care do not blindly follow protocols oftreatment but must use their clinical judgement to determinewhen particular treatments should be used, and when bestavoided, in individual patients.For patients with symptoms of ACS presenting without STelevationthere appears to be a clinically important spectrumof risk. This allows patients to be identified who would benefitmost from a more interventional approach – in particularan early coronary angiogram. Risk can be predicted by8 MINAP How the NHS cares for patients with heart attack

considering such factors as the age of the patient, their bloodpressure and heart rate on admission to hospital and certainaspects of their ECG and blood analyses. The NICE guidelinesupports the use of risk scoring in nSTEMI and the MINAPdataset contains data fields to allow this risk stratification.Figure 1. Aims of management of Acute Coronary SyndromeAimsPrompt recognition ofsymptomsProvision of heartmonitoring & resuscitationRestoration of coronaryblood flowPrevention of furthercoronary thrombosisReduction & reversal ofischaemiaStabilisation of coronaryarteryOptimise healingPrevention of futuremyocardial infarctionEducation & support,promotion of healthylifestyles1.3 Reperfusion therapyExamples of interventionsPublic educationEducation of professionalsAmbulance ‘999’ responseHospital Cardiac Care UnitsReperfusion treatmentPrimary percutaneous coronaryinterventionThrombolytic therapyNitratesElective angioplasty/CoronaryArtery Bypass SurgeryAnticoagulantsAntiplatelet agentsReperfusion treatmentAnti-anginal drugse.g. beta blockers, nitratesStatinsAngiotensin Converting EnzymeinhibitorSecondary prevention drugsLifestyle changesHospital cardiac nurse specialistsCardiac Rehabilitation classesPatient support groupsPublic Health InitiativesThese are treatments given to restore coronary blood flow byre-opening the blocked coronary artery that is causing the ACS;thereby reducing the amount of heart damage. If reperfusion isto be of benefit it needs to happen as quickly as possible, beforeall the heart muscle at risk has been damaged. These therapiesare therefore used in the immediate management of those withSTEMI (see above). If patients delay too long after the start oftheir symptoms reperfusion therapy may be of no value andwould not then be advised.Two forms of treatment exist: primary percutaneous coronaryintervention (PCI) – where the coronary artery is openedmechanically using a balloon catheter and a stent is thenleft in the artery to prevent re-occlusion (see the figureaccompanying the case report from St George’s Hospital,London); and thrombolytic therapy – where the clot isdissolved by a drug. Thrombolytics are given by intravenousinjection and can therefore be delivered rapidly, preferablyeven before arriving at hospital. While the drug can be givenquickly, its effect on the blood clot is not immediate andvaries from person to person – in some failing to re-open theartery at all. Primary PCI requires specialised equipment andhighly-trained clinical staff within the hospital. Patients tendto wait longer for primary PCI than they would for thrombolytictreatment, but the final results are more reliable in terms ofcomplete restoration of coronary blood flow, see Figure 2.Figure 2. Reperfusion therapy in ST elevation myocardialinfarctionThrombolyticdrugsPrimaryangioplastyAdvantagesEstablished treatmentSimple administration(intravenously)Potentially available inall hospitalsPre-hospital useby ambulanceparamedicsSuccessful in at least95%Lower stroke riskAllows visualisation ofall coronary arteriesCardiologistnecessarily involved incare of all patientsRandomised trialssuggest primaryangioplasty moreeffective thanthrombolytic therapy2. Background to MINAP2.1 A look backDisadvantagesFails in at least 20%Risk of bleeding andstrokeNot available in allcentresTreatment must bedelayed until arrivalat hospitalRisk of bleedingBy the end of the 1980s large randomised trials, in carefullyselected groups of patients, confirmed the effectivenessof clinical treatments of heart attack, and provided robustevidence upon which to base recommendations for bestmanagement. In particular, the recognition that thombolyticdrugs had substantial benefits when given early after theonset of symptoms led to the realisation that it also matteredhow and when a treatment was given as well as whether itwas given. Measurable targets for treatment, such as doorto-needletime and call-to-needle time appeared in nationalguidelines, together with advice that hospitals “should provideaudit data of delays to treatment” (against agreed standards) 3 .Some cardiologists established the Myocardial InfarctionAudit Group and began, from 1992, to share their data, and3. Weston CFM, Penny WJ, Julian DG. Guidelines for the early management ofpatients with myocardial infarction. BMJ 1994;308:767-71.MINAP Eleventh Public Report 20129

demonstrated significant variations in practice 4 . At the sametime Government officials began to recognise the potentialgain to public health from the optimum management of heartattack. Setting, delivering and monitoring standards becamean imperative, resulting in much professional and publicengagement in describing both potential health outcomeindicators 5 and the standards of care expected by patientswith coronary disease, expressed within a National ServiceFramework (NSF) 6 . This mandated every acute hospital tomake available clinical audit data that was no more than 12months old and suggested that “where relevant” these shouldbe “derived from participation in national audits”.A Myocardial Infarction (later, ischaemia) National AuditProject (MINAP) was established in 1999. It was founded onthe following propositions:The audit should be a complete record of care ratherthan a snapshot – all (rather than a sample of) patientsbeing included.The audit should be prospective – information beingcollected as soon after treatment as possible.Participating hospitals should agree both commondefinitions of clinically important variables and commonstandards of good quality care against which to audittheir practice.Standards of care should be chosen that have a provenlink to improved outcome – i.e. those aspects of care beingaudited, whilst capable of being expressed as measuresof process or performance, should link directly to betterpatient outcomes.The practices of individual hospitals should be aggregatedinto a national figure – a hospital could audit against agreedstandards and compare against the national aggregate.Sufficient data should be recorded to allow for casemixadjustment and other techniques for investigatingdifferences in outcomes between hospitals.The dataset should be revised periodically to account for theintroduction of newer treatments.4. Birkhead JS. Thrombolytic treatment for myocardial infarction: an examinationof practice in 39 United Kingdom hospitals. Myocardial Infarction Audit Group.Heart 1997;78:28-335. Birkhead J, Goldacre M, Mason A, et al. Health Outcome Indicators: MyocardialInfarction. Oxford, Centre for Health Outcomes Development, 1999.6.National Service Framework for Coronary Heart Disease. Modern standardsand service models. Accessed on 25 June 2011 at www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf7. Birkhead JS. Responding to the requirements of the National ServiceFramework for coronary disease: a core data set for myocardial infarction. Heart2000;84:116-7.8. www.cabinetoffice.gov.uk/content/transparency- overview9. Godlee F. Publish your team’s performance. BMJ 2012;344:e459010. www.data.gov.uk/dataset/myocardial-ischaemia-national-audit-projectThe audit should maintain its credibility and validity by beingguided and supported by relevant professional bodies andpatient groups and be managed by a small project team.A publicly accessible report should be published annually.The standards presented in the NSF became the standardsagainst which care was compared and a core dataset wasprepared for participating hospitals 7 . Data collection began inOctober 2000 and by mid-2002 all acute hospitals in Englandand Wales were participating in the audit.Latterly, the government has championed ‘Transparency andOpen Data’ 8 , wishing to promote ready access to health data,and the Editor of the British Medical Journal has challengedthe British Cardiovascular Society, and others, to show clinicalleadership in “pushing for public access to performance dataof individual clinical teams”, asking “What are you doing?” 9One answer is that for the past eleven years an annual MINAPreport, of the performance of clinical teams within hospitalsagainst nationally agreed standards, has been produced forthe benefit of clinicians, hospital managers, the ‘healthcarecommunity’ and, importantly, patients and the general public.MINAP is one of the first national audits to have data availableon the data.gov.uk website as part of the Transparency Agenda 10 .2.2 Organisation of MINAPMINAP is one of 6 national cardiac clinical audits thatare managed by the National Institute for CardiovascularOutcomes Research (NICOR), which is part of the Institute ofCardiovascular Science at University College London (UCL).NICOR was established in 2006 by Prof Sir Bruce Keoghand is co-chaired by Prof Sir Roger Boyle and Prof JohnDeanfield. Its purpose is to provide information on quality andoutcome of care provided to people with heart disease andto provide technical infrastructure, project management andstatistical support for the national cardiac audits. NICOR isa collaborative partnership between various cardiovascularprofessional societies, the Department of Health in Englandand the Welsh Government.MINAP is overseen by a Steering Group representing keystakeholders, including professional bodies, nationalgovernment and patient representatives – in collaborationwith the British Cardiovascular Society (Appendix 1). It iscommissioned by the Healthcare Quality ImprovementPartnership (HQIP) – the organisation that holdscommissioning and funding responsibility for MINAP and othernational clinical audits. An academic group, which reports tothe Steering Group, has been established to facilitate researchuse of the data, see Part 4.2.3 How the data are collectedThe current dataset v9.1 contains 124 fields and includes preandin-hospital treatment, patient demographics and information10 MINAP How the NHS cares for patients with heart attack

egarding previous medical history. The dataset is revised everytwo years to meet the requirements of users and to respond todevelopments in the management of ACS and is due for revisionin late 2012. The dataset is available on the MINAP web pages:http://www.ucl.ac.uk/nicor/audits/minap/dataset.Data are collected by nurses and clinical audit staff andentered in a dedicated data application (either on-line or webbased). Alternatively hospital personnel may collect datausing commercial software. The project uses a highly secureelectronic system of data entry, transmission and analysisdeveloped by the NICOR Technical Team. The audit has beenrunning continuously since 2000 and all hospitals in Englandand Wales that admit patients with ACS contribute data (exceptScarborough General Hospital and Kingston Hospital).Participating hospitals are requested to enter all patients withsuspected myocardial infarction. Approximately 91,000 recordsare uploaded annually and by August 2012 the databasecontained over 1 million records, making it the largestdatabase of its kind in the world.2.4 Security and patient confidentialityAll data uploaded by hospitals are encrypted on transmissionand stored encrypted on the NICOR servers. NICOR managesaccess control to the servers via user IDs and passwords. Allpatient identifiable data are pseudonymised by the NICORtechnical team before release to the project management teamvia a secure drop box on the NICOR server. Patient identifiabledata are only available for the purpose of record linkage. Dataheld within NICOR are managed within a secure environmentfor storage and processing provided by the UCL network andwithin the UCL information governance and security policy.NICOR is registered under the Data Protection Act. Additionally,NICOR - of which MINAP is part - has support under section251 of the National Health Service (NHS) Act 2006 (Ref: NIGB:ECC 1-06 (d)/2011).NICOR staff recognise that confidentiality is an obligation andregularly undergo information governance training to ensureunderstanding of the duty of confidentiality and how it relatesto patient data.2.5 Case ascertainmentIn practice MINAP records the great majority of patientshaving STEMI in England and Wales. However it is recognisedthat a small minority of hospitals do not enter all their nSTEMIpatients, mainly due to lack of resources, although in therecent year there has been an improvement in this area. Thetrue number of heart attacks is difficult to establish, as it isnot possible to compare MINAP data with Hospital EpisodeStatistics (HES), the only possible comparator, except inaggregate. Although HES reports approximately 105,000hospital admissions per year with myocardial infarction,it is not possible to separate this number into the clinicalcategories used within MINAP. MINAP records about 30,000STEMIs, but only about 50,000 nSTEMIs annually. Frominternal data we consider that approximately 80,000 nSTEMIsper year would be an appropriate number. However, withthe expanding analytical capacity within NICOR, there arenow plans to explore other ways of establishing the caseascertainment rate in MINAP and to provide a clearer pictureon the incidence of heart attacks in England and Wales.MINAP Eleventh Public Report 201211

Where all patients with acute coronary syndromes are admittedto the same ward or area patients can be readily identified. It ismuch harder where patients are not all cared for in one area, andare looked after in several wards. Under-reporting of nSTEMIpatients varies between hospitals and reflects variation in resourcesallocated to data collection.MINAP had 100% participation since 2002 until mid-2011 whenScarborough General Hospital stopped submitting data toMINAP altogether, whilst Kingston Hospital did not submit anydata from January 2012. Participation in MINAP also requiresparticipation in an annual data validation study, see below. Thefollowing hospitals were eligible but did not take part in the 2011data validation study:EnglandAddenbrooke’s HospitalHexham General HospitalHinchingbrooke HospitalKingston HospitalMilton Keynes General HospitalScarborough General HospitalScunthorpe General Hospital2.6 Data qualityAssessment of data completion is presently based on patients withnSTEMI. The completeness of 20 key fields is continually monitoredand is available to hospitals in an online view that is refreshed daily.Currently these fields continue to be 99% complete.MINAP also performs an annual data validation study to assessthe agreement of data held on the NICOR servers. Hospitals arerequired to re-enter data from case notes in 20 key fields (differentfields to the data completeness fields, with some overlap) in 20randomly selected nSTEMI records in an online data validationtool. Agreement between the original and re-entered data isassessed for each variable and each record. Reports showingthe agreement of each variable compared to national aggregatedata are sent to hospitals to allow them to identify areas forimprovement. 95% of eligible hospitals in England, 69% in Walesand 2 hospitals in Northern Ireland participated in this year’s datavalidation study. The median score for 2011 was 95.5% (IQR 89.5-98) maintaining the high standards of 2010.The MINAP data application contains error-checking routines,including range and consistency checks, designed to minimisecommon errors. MINAP provides detailed guidelines for data entryand provides a dedicated helpdesk to support problems regardingclinical definitions and data entry in a variety of clinical scenarios.2.7 Improving our IT platformWalesMorriston HospitalNeath Port Talbot HospitalPrince Philip HospitalPrincess of Wales HospitalRoyal Glamorgan HospitalWest Wales General HospitalYsbyty GwyneddEarlier this year NICOR began a major project to upgrade itsdata collection and management systems. The current LotusNotes software has become increasingly unwieldy as theMINAP database has grownin size (greater than 1 millionrecords) and complexity. Anew platform will substantiallyimprove NICOR’s ability to derivehigh-quality analyses from theMINAP database to inform localhospitals, ambulance trusts andpatients regarding the provisionof cardiac care.The first step in this projectinvolved a transfer of all datafrom the NHS Information Centrefor Health and Social Care ontosecure NICOR servers. Thisinvolved re-issuing a new userID to every database user. Themigration was not easy, and it led tosome delays in accessing the MINAPdatabase. Despite these difficulties,participating hospitals submitted their dataon time, making possible the timely publicationof this report. We would like to thank everyone fortheir effort and patience during the migration.The second phase involves development of a new IT platform,which will be rolled out in stages throughout 2013, with theMINAP audit transferred in July/August.2.8 Improving analysisThe processes that NICOR uses for analysing MINAP data havealso undergone substantial changes this year. Until recentlyNICOR data were analysed using software and ad hoc analyticcodes that were neither consistent nor easy to manage. Inpreparation for the incorporation of analytic technologies intothe new NICOR system, code that was written in SPSS and Excelspreadsheets (for analyses presented in this annual report)was migrated to a standard cross-audit analytic platform basedon the R statistical processing language - precise details areavailable from NICOR).Migration of MINAP to the new platform for statistical analysisbegan in July 2012 and continues, with an intended completiondate of June 2013.The results presented in this annual report were generatedusing some, but not all, elements of the new platform. Becausethe new analytic platform is still under development, withincremental improvements expected over the next few months,the results presented in this report should be consideredpreliminary and subject to change. Any substantive differencesthat follow improvements in filtering and more sophisticatedstatistical modelling of the data will be highlighted in next year’sannual report.12 MINAP How the NHS cares for patients with heart attack

3. Improving quality,improving outcome3.1 Use of primary PCIPerhaps the most important, andcertainly the most high profile,change in the management ofheart attack during the twelveyears of MINAP has been theimplementation of a policy to provideprimary PCI, rather than thrombolytictherapy, in cases of STEMI (see Figure10). The advantage of timely primaryPCI over thrombolysis has beendescribed above – though there is stillan important role for thrombolysis inthose rural areas where travel times tohospitals that provide primary PCI arelong enough to negate the advantage ofthe procedure.This rapid change largely has been driven bylocal clinicians and promoted by members ofthe British Cardiovascular Interventional Societyand Cardiac Networks in response to a governmentchallenge to ‘roll-out’ a primary PCI national service.Consecutive annual MINAP reports have recorded thechanges and a final NHS report on the ‘roll-out’ project waspublished in 2012 11 . The policy has had major knock-on effectson the organisation of hospital-based cardiac services, requiringthe continuous availability of expert teams of clinicians and‘High Tech’ equipment. This has led to centralisation of services.Substantial numbers of district general hospitals no longeradmit patients with STEMI. Rather, it is recommended that suchpatients are taken directly to a smaller number of Heart AttackCentres, serving large populations – for example the two HeartAttack Centres in Manchester serve 3 million people – and anetwork of smaller feeder hospitals. In some networks patientsare ‘repatriated’ from the Heart Attack Centre to their localhospital following primary PCI, but often patients are dischargeddirectly home after a stay in hospital of as little as 3 days.National and international guidance 12 13 recommend that in theemergency treatment of patients with STEMI, primary PCI shouldbe performed as soon as possible: within 90 minutes of arrivalat hospital (door-to-balloon time) and within 150 minutes of apatient’s call for help (call-to-balloon time). Results are presentedagainst these best practice standards, and against a morestringent ‘aspirational’ call-to-balloon target of 120 minutes, inTable 1 in the Results section.The call-to-balloon time reflects the interval from a call forprofessional help to the time that the primary PCI procedure isperformed. To reliably achieve this within 120 minutes, or even150 minutes, requires significant coordination between ambulanceand hospital services. Ideally, ambulance crews make anaccurate diagnosis, through expert assessment of the patient andinterpretation of their ECG, before taking the patient directly to thenearest Heart Attack Centre. At the hospital the provision of timelyprimary PCI is complex and involves close collaboration betweenambulance, portering, nursing, medical, and radiographic teams.This is particularly important during ‘out of hours’ working. Thepercentage of patients with an admission diagnosis of STEMIwho receive primary PCI within 90 minutes of arrival at theHeart Attack Centre has increased from 52% in 2003/4 to 92% in2011/12 and is a reflection of this close collaboration [Figure 11].In particular direct transfer of the patient from ambulance to thecatheter lab without involvement of other hospitals, departmentsor wards has reduced delays. However, it remains the case thatassessment at a local non-interventional hospital is associatedwith added delay and prolonged call-to-balloon times. In someareas a new metric has been introduced to record this addeddelay and promote the shortest possible safe assessment andstabilisation period in the initial receiving local hospital – theDoor-In-Door-Out interval (DIDO) (see part three, case study 8).3.2 From coronary care to cardiac careChanging demographics of the UK population, coupled withreorganisation of acute services to deliver primary PCI acrossCardiac Networks, has caused a significant change in theacute cardiology workload for all acute hospitals; more elderlypeople are being admitted with more complex cardiac problems.This prompted the British Cardiovascular Society (BCS) – theprofessional body associated with MINAP – to set up a WorkingGroup on Acute Cardiac Care in 2010. The Group examined thechanging nature of acute cardiac care in the UK and how, whereand by whom it should best be delivered. The final report waspublished on the BCS website last autumn 14 and reviewed in aneditorial in Heart 15 .Briefly, the report calls for enhanced access to specialisedcardiac care, in dedicated acute cardiac care units, for allpatients presenting with any acute cardiovascular condition.11. NHS Improvement. Growth of primary PCI for the treatment of heart attackpatients in England 2008-2011: the role of NHS Improvement and the CardiacNetworks. January 2012. Available at: http://www.improvement.nhs.uk/LinkClick.aspx?fileticket=PWttejHG45M%3D&tabid=63 (accessed 6 Aug 2012).12. The Task Force on the Management of ST-segment elevation acutemyocardial infarction of the European Society of Cardiology, (2012) ESCguidelines for the management of acute myocardial infarction in patientspresenting with ST-segment elevation. Eur Heart J doi:10.1093/eurheartj/ehs21513. Antman EM, Hand M, Armstrong PW et al. (2008) 2007 focused update of theACC/AHA 2004 Guidelines for the Management of Patients With ST-ElevationMyocardial Infarction. J Am Coll Cardiol 2008; 51: 210–247.14. From Coronary Care Unit to Acute Cardiac Care Unit – the evolving role ofspecialist cardiac care. Recommendations of the British Cardiovascular SocietyWorking Group on Acute Cardiac Care. Accessible at http://www.bcs.com/documents/9A6_BCS_Report_on_Coronary_Care_Units.pdf15. Walker DM, West NEJ, Ray SG. From coronary care unit to acute cardiac careunit: the evolving role of specialist cardiac care. Heart 2012; 98: 350-2.MINAP Eleventh Public Report 201213

Whilst traditionally, the coronary care unit has been thedomain of patients presenting with acute STEMI, with suchpatients now being concentrated in primary PCI (Heart AttackCentres), a unique opportunity has arisen to extend andexpand specialist cardiac care to patients with other acutecardiac complaints who have also been shown to benefit fromcare by cardiology teams. In particular, there is an imperativeto use such a system to provide uniformly high standard careto those with nSTEMI.Crucial to the report was acquisition of reliable data to providethe evidence to support such recommendations. Data fromMINAP regarding management of over 80,000 cases of nSTEMIbetween 2008 and 2009 was used to illustrate the potentialbenefits of dedicated cardiological care in these patients.nSTEMI care may be delivered by general physicians orcardiologists, depending on local protocols or arrangements.MINAP data indicates that those patients admitted under thecare of a cardiologist or to a cardiology unit (encompassingboth coronary care units and dedicated cardiology beds) weremore likely to receive appropriate secondary preventativecardiac medications and were more likely to be referred on forcoronary angiography and subsequent revascularisation. Mostimportantly, those patients under the care of cardiologists in adesignated cardiac unit had significantly lower hospital lengthof stay and were less likely to die within 30 days after their heartattack. The arguments, therefore, for dedicated cardiologicalcare for nSTEMI patients can clearly be made in terms of qualityof care, financial expediency and clinical governance.The Working Group’s report has already been influentialin assisting Trusts where coronary care units had beenthreatened with downgrading or reassignment, and continuesto influence Cardiac Networks across the country in terms ofprovision of equity of evidence-based acute cardiac care.3.3 nSTEMI and access to angiographyThe absence of ST-elevation on the presenting ECG ofthe patient with ACS (nSTEMI) is thought to indicatethat any coronary thrombosis is not totally blocking theaffected coronary artery. As such, immediate coronaryangiography with a view to proceeding straight to PCI orimmediate administration of a powerful thrombolytic drug,is not warranted. Often the event can be managed with acombination of drug treatments.However, some patients with nSTEMI either do not ‘settle’,and continue to suffer ischaemic pain, or initially appear tostabilise but soon afterwards have a further heart attack.Rather than waiting for this to happen patients can beassessed within hours of admission to hospital using a variety16. Gale CP, Manda SO, Weston CF, Birkhead JS, Batin PD, Hall AS. Evaluation ofrisk scores for risk stratification of acute coronary syndromes in the MyocardialInfarction National Audit Project (MINAP) database. Heart. 2009;95:221-7.of validated risk scores 16 . For those of at least moderate risk,a policy of routine early angiography (and revascularisationwhere possible) appears to prevent more heart attacks andreadmissions to hospital than medical treatment alone.The 2009 NICE Guideline, that used MINAP data to model theimplications of its recommendations, suggested that ACSpatients at moderate risk, and those in whom it is possibleto demonstrate residual ischaemia on testing after the acuteevent (evidence of persisting narrowing of a coronary artery),should be advised to have a coronary angiogram within 96hours of admission. Other international guidelines haveencouraged even earlier angiography, if only to reduce theoverall length of stay in hospital.The percentage of patients with a final diagnosis of nSTEMI(broadly reflecting the NICE classification of moderate severity)who have angiography during the admission has increasedfrom just over 30% in 2003 to 76% in 2011/12 – as significanta change in management as the development of primary PCIfor STEMI. However, angiography is not appropriate for allpatients with nSTEMI and those at the very highest risk werenot included in trials that demonstrated the benefit of routineangiography. So, there is no nationally agreed standard for theproportion of patients that should undergo angiography.3.4 Of broken hearts and octopus potsWith increasing use of coronary angiography during the earlymanagement of heart attack it has become apparent thatabout 2% of patients admitted to hospital with features ofacute myocardial infarction have a condition called TakotsuboCardiomyopathy – also known as Stress Cardiomyopathy,Apical Ballooning Syndrome and Broken Heart Syndrome. This14 MINAP How the NHS cares for patients with heart attack

is an acute heart failure syndrome in patients with acute chestpain and ECG changes. It seems likely that between 2000 and3000 cases occur each year in the UK.The typical patient is a post-menopausal woman (who makeup about 90% of all cases) who, within minutes or hoursof extreme physical or emotional stress (hence the use of‘Broken Heart syndrome’), develops acute cardiac chest pain,breathlessness, and features of heightened sympatheticnervous activity (racing heart, headache, sweatiness). The ECGduring the acute episode usually shows ST-elevation and/or Twave inversion, consistent with, but in these particular casesnot caused by, coronary artery obstruction. The corrected QTinterval is frequently prolonged, sometimes to levels that mightprovoke sudden cardiac arrest (>500ms). Often evidence of heartmuscle damage is revealed – serum cardiac enzymes, such astroponin, are elevated, though not to the higher levels seen withmyocardial infarction due to coronary disease.Patients with such symptoms and ECG changes are usuallytaken straight to the angiography laboratory as part of aprimary PCI service (where the majority will be shown to havesuffered coronary thrombosis and obstruction). However,in Takotsubo Cardiomyopathy the coronary arteries areeither completely normal, or have non-obstructive coronarydisease which cannot account for the abnormal contractilefunction of the heart shown using echocardiography orventriculography. For while the coronary arteries appearnormal or mildly affected, the entire left ventricular apex ishypo- or akinetic – contracting poorly or not at all – and thisdysfunction frequently extends symmetrically upwards toinvolve the mid-ventricular muscle while the upper portionscontinue to contract vigorously. This gives a characteristicpicture (see Figure 3) of ‘virtual’ apical ballooning on cardiacimaging, and instead of having an inverted conical shape theleft ventricle takes on an appearance that is similar to theJapanese fisherman’s octopus pot, the tako tsubo. Atypicalpatterns are also recognised, with basal hypocontractility andapical preservation (inverted Takotsubo), and a mid-ventricularvariant. Crucially this ventricular contractile dysfunctioncannot be explained by a problem in a single coronary artery; itextends beyond a single coronary artery territory.A number of cardiac complications have been recognisedduring the early phase, and these relate directly to the severityof the acute heart failure syndrome. These include atrial andventricular arrhythmias, pericarditis, pulmonary oedema,cardiogenic shock, cardiac rupture, cardiac arrest and thereis a recognised mortality of 2% during the acute phase.Apical thrombus is detected in 5-7% cases with associatedthromboembolic complications. That being said, in many casesthe heart recovers good function within weeks and months.A role for MINAPThere is a lot to learn about this condition, not least theprecise cause and the best treatment. Using new fields addedto the MINAP dataset it should be possible to determine thefrequency of the condition in the UK, the types of individuals itaffects, their long-term prognoses and, through observation,associations of treatments in hospital and at discharge withlong-term outcome.Figure 3: Left venticulogram-showing the left ventricle of the heart in a contracted (right ) and relaxed (left) state inTakotsubo CardiomyopathyMINAP Eleventh Public Report 201215

4. MINAP: a patient’s perspectiveSirkka ThomasCardiac nurse, health visitor, cardiac carer and patient,member of the Patient Panel for the London CardiovascularProject 2012 and member of Patient Panel for the HealthcareQuality Improvement Partnership.Some medical experts might disagree but I believe thatstress, physical and mental, started me on my nSTEMI PatientJourney three years ago. My problems began with a latemorning fire alarm and evacuation from the 17th floor of anoffice block in London’s Victoria. Ironically the occasion, onNovember 12, 2009, was a Cardiology meeting. At that timeI was a carer for my husband who has heart failure and anImplantable Cardiac Defibrillator. After physically supportingmy husband downstairs, with occupants of the buildingcharging past us, he collapsed in distress halfway down. I, too,felt most unwell. We later learned it was only a fire drill!In the evening I experienced chest pains, which I thought mighthave been muscular due to the strain which I had been under.The following day, I visited my GP. I was sweating and short ofbreath and the doctor phoned my husband to say I was havinga heart attack. At 5.45pm I was in an ambulance where thecrew diagnosed an irregular heart beat and took me to the A&Edepartment at my local general hospital.That happened on a Friday evening, which I discovered wasthe worst time to have a cardiac episode. I was seen by juniordoctors and a gastroenterology consultant and spent the nightin an Assessment Unit. I was not transferred to a CardiacCare Unit until 6pm the next day and did not see a CardiologyConsultant until the Monday morning (16th). He booked mefor an angiogram, to be done at a specialist centre to whereI was transferred. Once there I received the diagnosis ofnSTEMI, and had my angiogram, a week after my admissionto the original hospital. After further tests, including anechocardiogram, I was discharged. I was told that my hearthad to be monitored because I was having periods when myheart was beating slowly.However, the tale of my journey is not meant to be a complaintabout treatment. It is a statement of the facts that MINAP hashighlighted. For example, MINAP figures show that in 2008/9only 46% of nSTEMI patients were admitted to a Cardiac Ward/Unit. In 2010/11 this figure had only risen to 50%. In 2008/980% of such patients were seen by a cardiologist, with thefigure improving to 91% in 2010/11: Still not the perfect 100%.These figures also raise the problem experienced in all areas ofmedical treatment: specialised care for all weekend admissions.The first-half of my journey had been a strenuous one butthe second-half went more positively, thanks to excellentmonitoring and superb backing from consultants and GPs.I was followed-up throughout 2010. Then, early in 2011 I wasexperiencing dizziness and fainting. I was developing problemswith the electrical circuits of my heart and my consultantcardiologist advised that I should have a pacemaker. Lifehas improved for me. I no longer suffer from dizziness andfainting. And I have had one exceptional tonic from my serviceon the Patients’ Panel of the London Cardiovascular Projectwhich was implemented in March 2012. The non-ST-elevationacute coronary syndrome policy (nSTEACS) policy states thatpatients will be diagnosed and their risk will be identifiedearly, with “high risk” patients being offered angiographywithin 24 hours of admission. If a patient is triaged in ahospital that cannot provide this investigation within thetimeframe, the patient will be transferred to a hospital thatcan. MINAP will help to audit the provision of this standard ofcardiac care.So, my journey was really necessary and I hope it can help toprovide success for others, both patients and professionals, ontheir journeys.For more information about implementing the high risknSTEACS pathway across London refer to part three, casestudy 3.16 MINAP How the NHS cares for patients with heart attack

Alan KeysMINAP Steering Group patient representativeI first became a patient representative in Sussex in 2004,initially with the local Primary Care Trust, then the SussexHeart Network, leading on to a variety of other roles relating tocardiac care and more general health care.As I became more involved I was taken aback by the paucityof good, reliable data available in the NHS, compared to myexperience in the private sector. It was evident that decisionmaking was being hampered by such deficiencies.I also found myself in meetings with cardiologists and otherhealth professionals arguing passionately about which careoptions were best for patients. The views may have differed butthe motivation around patient outcomes was always central.It was soon apparent that cardiac care had the benefit of qualitydata, which was often lacking elsewhere, although the qualityof inputting was variable. Access to good data became useful tome as the move to primary PCI was debated and implemented.Here was the tool that enabled us all to assess how well the jobwas being done by local and national comparison.One also sees the culture of clinical audit influencingimprovement in the Enhancing Quality project in the NorthWest and South East. It operates across a number ofdisciplines, including some cardiovascular care. After someinitial scepticism the potential and immediate benefits of theproject are being recognised and I hope that will spread toother areas.We should also be aware of the probable impact of the newcommissioning structure on clinical audit. There can belittle doubt that Clinical Commissioning Groups (CCGs) willrequire reliable data to assess acute providers, communityservices, etc., but the NHS Commissioning Board and theCCGs themselves will require measurement of primary careperformance to assess how well 90% of patient contacts withthe NHS are being managed and which models of care workbest at GP level.In cardiac care we have a cohort of people who are motivatedto perform to a high standard. I know that MINAP data hasbeen the spur to improve data input quality, thus enablingvalid comparisons to be made, leading to direct improvementsin performance. Would we, for instance, have seen directadmittance to cath labs become accepted practice so quicklywithout the influence of comparative clinical data? Wouldthere be confidence in the evidence to support the decisionsmade over primary PCI without MINAP?From the patient perspective I would like to see door-to-balloontimes monitored against a standard of 60 minutes, as well as 90minutes. Last year Papworth was quoting 98% achievement of90 minutes and an average of 37 minutes in the MINAP report.With the upward drift of call-to-door times this is the onlyway I see 120 minutes call-to-balloon becoming the norm as,ideally, it should. MINAP may also show in due course that theimplications of longer call-to-door times require further thoughtto raise overall performance, although one must accept thatgeography is a major determinant as well.I know others, with far deeper knowledge than I, have ideas onhow to take clinical audit further for cardiac care, but we shouldrecognise the influence of the MINAP approach and its potentialelsewhere. The recent introduction of similar audit of strokecare (SINAP) was overdue but welcome. I have already seenurgent responses to poor SINAP data. Together they will help todrive the quality of cardiovascular and cerebrovascular care.MINAP Eleventh Public Report 201217

Part Two: Analyses1. Characteristics of patients with heart attackin 2011/12In 2011/12, 90,905 records in England and Wales weresubmitted to the MINAP database and 79,433 were recordsof patients with a final diagnosis of myocardial infarction.Of these some 41% had STEMI. [Fig 4] MINAP recognisesthat not all patients having nSTEMI are entered into thedatabase and we believe that the true ratio for nSTEMI toSTEMI should be at least 2:1.Figure 5. Frequency distribution of STEMI and nSTEMI in2011/12302520%15105Figure 4. Heart attacks recorded in MINAP in 2011/1279433 admissionswith heart attack090STEMInSTEMIAge19907 (65%)had pPCIin-house32439 (41%)STE MI1625 (5%) hadthrombolytictreatment46994 (59%)nSTEMI8986 (29%) hadno reperfusiontreatment371 (1%)treatment optionnot clearAmong those admitted with a first heart attack there appearsto have been a levelling off in the prevalence of previouslydiagnosed hypertension for both females (approx. 54%)and males (approx. 43%) [Figure 6]. A similar levelling offhas occurred in the prevalence (approx. 30%) of recognisedand treated hyperlipdaemia (predominantly cholesterolmanagement with statin treatment) [Figure 7]. This may reflectmore efficient recognition and treatment in primary care ofthose at risk.15502 (78%) wereadmitted via theemergency servicesor self-presentation4037 (20%) wereadmitted viatransfer for aspecific treatment368 (2%) wereadmitted viaanother orunknown method398 (24%) hadthrombolytictreatment in anambulance1196 (74%) hadthrombolytictreatment inhospital31 (2%) hadthrombolytictreatment inunknown locationFigure 6. Hypertension in patients having first heart attack7065605550%4540353025202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12The average age for patients having a first heart attack inEngland and Wales was 68 years; for men 65 years and forwomen 73 years. Heart attack is more common in men, withtwo men having a heart attack for every woman. STEMI tendsto present in younger age groups than nSTEMI. The averageage for a first STEMI is 65 years, while that of nSTEMI is 70years. Overall more than 49% of all heart attacks recordedin MINAP were in people over 70 years of age. While cases ofSTEMI appear to be equally distributed around the age-range60-69 years, for nSTEMI the majority present older than thisage [Figure 5].FemalesMalesYears18 MINAP How the NHS cares for patients with heart attack

Figure 7. Patients admitted with a first heart attack alreadyreceiving treatment for hyperlipidaemia at admissionFigure 9. Proportion of patients admitted with heart attackwho currently smoke353070Females%2520%6050401530102002003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12Years1002003-4 2004-5 2005-6 2006-7 2007-82008-9 2009-10 2010-11 2011-12Hyperlipidaemia having treatmentAn increase over the years in the frequency of diabetescontinues, with the prevalence being slightly greater infemales (approx. 19%) than males (approx. 17%), and beingsubstantially greater than in the general population. Furtheranalysis shows that the increase is limited to those having type2 diabetes (non-insulin dependent diabetes) [Figure 8]. It is notclear to what extent this represents a real increase, or whetherthis in part reflects improved recognition of type 2 diabetes inprimary care.%7060504030Males20-54 yrs65-74 yrs55-64 yrs>75 yrsYearsFigure 8. Frequency of diabetes in patients having firstheart attack2010%20191817161502003-4 2004-5 2005-6 2006-7 2007-820-54 yrs65-74 yrs55-64 yrs>75 yrsYears2008-9 2009-10 2010-11 2011-1214131211102003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12YearsFemalesMalesCigarette smoking remains a major contributor to heartattacks in younger people, being a risk factor present in morethan half of men and women under 55 years of age having afirst heart attack. While the smoking rate in these youngermales and females has been steadily decreasing [(Figure 9)],now the frequency of smoking in the under 55 year groups isalmost as great in women as in men, and is actually greater inwomen aged 55-64 years than in men of that age.MINAP Eleventh Public Report 201219

2. Hospitals that perform primary PCINational and international guidance 17 recommend that inthe emergency treatment of patients with STEMI, primaryPCI should be performed within 90 minutes of arrival at theprimary PCI centre (door-to-balloon time) and within 150minutes of a patient’s call for help (call-to-balloon time).Results are presented against these best practice standardsin Table 1. The sooner a patient receives this treatment,the better the outcome. The results in this table show thatmost of the hospitals are now achieving the call-to-balloontime(CTB) within 150 minutes. European guidelines for2012 propose a CTB within 120 minutes 18 and this is alsopresented in the Table 1.The use of primary PCI continued to increase in 2011/12(Figure 10). This year in England, 19,226 patients were sotreated compared to 16,037 in 2010/11, an increase of 20%. InWales 528 patients were treated compared to 303 in 2010/11,an increase of 74%. In Belfast 153 patients were treatedin 2011/12 compared to 173 in 2010/11, a decrease by 12%.Of patients who received reperfusion treatment in 2011/12,95% of patients in England, 50% in Wales and 99% in Belfastreceived primary PCI. The overall median time from arrival athospital to primary PCI was 42 minutes in 2011/12. In 28% ofrecords this interval was less than 30 minutes and for 72% theinterval was less than 60 minutes.This year, 76 hospitals in England performed primary PCI, inWales 3 hospitals and 1 hospital in Belfast performed primaryPCI routinely. These hospitals may provide this service only fortheir own patients, or may do so for groups of other hospitals.Of 76 hospitals in England reporting that they were performingprimary PCI on a routine basis, 52 provided the servicethroughout the 24 hour period. A small number shared a nighttime rota on an alternating basis.The percentage of patients with an admission diagnosis ofSTEMI who receive primary PCI within 90 minutes of arrivalat a Heart Attack Centre has increased from 52% in 2003/4to 92% in 2011/12 and is a reflection of close collaborationbetween ambulance services, emergency departments andadmitting hospitals. [Figure 11]. In particular direct transferof the patient from ambulance to the catheter lab withoutinvolvement of other departments or wards has reduceddelays. In the last year there was an increase in directadmissions from 10,921 in 2010/11 to 13, 444 in 2011/12 inEngland. In Wales from 221 in 2010/11 to 397 in 2011/12. Therewas a slight increase in direct admissions in Belfast from 91 to95 in 2011/12.In Northern Ireland routine use of primary PCI is presentlylimited to the Belfast area. Outside Belfast thrombolytictreatment is understood to be the primary reperfusiontreatment of choice for STEMI, though primary PCI isoccasionally available in some hospitals. The Northern IrelandCardiac Network is currently developing a national strategyfor the management of STEMI. We look forward to the otherhospitals in Northern Ireland joining MINAP before long.Figure 10. Use of reperfusion treatment for patients with afinal diagnosis of STEMI. Primary PCI makes up more than95% of reperfusion treatment%10090807060504030201002003-42004-5In-hospital lysis2005-6Pre-hospital lysisPrimary PCI2.1. Door to balloon time2006-7The proportion of patients receiving primary PCI within the 90minute standard has continued to rise [Figure 11]. In Englandthis year, 92% of 17,965 eligible patients were treated withprimary PCI within 90 minutes of arrival at the Heart AttackCentre compared to 90% of 14,666 in 2010/11. In Wales81% of 503 eligible patients were treated within 90 minutescompared to 68% of 283 in 2010/11. In Belfast 89% of 137eligible patients were treated within 90 minutes compared to87% of 160 in 2010/11.2007-8Years2008-92009-102010-112011-1217. http://www.improvement.nhs.uk/heart/?TabId=6618. The Task Force on the Management of ST-segment elevation acutemyocardial infarction of the European Society of Cardiology, (2012) ESCguidelines for the management of acute myocardial infarction in patientspresenting with ST-segment elevation. Eur Heart J doi:10.1093/eurheartj/ehs21520 MINAP How the NHS cares for patients with heart attack

Figure 11. Percentage of patients with an admission diagnosisof STEMI having primary PCI within 90 minutes of arrival at theHeart Attack Centre in England Wales and Belfast%100908070605040302010052.22004-553.42005-672.42006-7The median time is 42 minutes in 2011/12; for 28% theinterval is less than 30 minutes and for 72% the interval isless than 60 minutes.79.22007-8Years84.32008-9882009-1089.92010-1191.62011-122.2 Call to balloon timeAs explained above, this reflects the interval from a call forprofessional help to the time that the primary PCI procedure isperformed. It is largely a shared responsibility of the relevantambulance service and the admitting hospital. Usually allpatients with a diagnosis of STEMI confirmed by a paramediccrew are taken directly to a Heart Attack Centre. This howeveris not always possible, particularly where there is diagnosticuncertainty, or in remoter parts of the country.In England, 83% of all eligible patients were treated within150 minutes of calling for professional help compared to 81%in 2010/11. In Wales 78% of patients were treated within 150minutes compared to 75% in 2010/11. In Belfast 88% of patientswere treated within 150 minutes compared to 91% in 2010/11.This year for the first time we report on the proportionof patients who received primary PCI within 120 minutesof calling for help. In England, 62% of patients receivedprimary PCI within 120 minutes of calling for professionalhelp compared to 59% in 2010/11. Similar improvement wasobserved in Wales where 59% in 2011/12 and 46% in 2010/11,and in Belfast where 84% compared to 72% in 2010/11,reached call-to-balloon within 120 minutesIn England, 89% of patients taken directly to the Heart AttackCentre were treated with primary PCI within 150 minutes ofMINAP Eleventh Public Report 201221

calling for professional help compared to 51% of patientstaken first to a local hospital and then transferred to a HeartAttack Centre. The equivalent figures for Wales were 79% fordirect admissions and 73% for transfers and in Belfast 88%for direct admissions and only a small number of patientstransferred to the Heart Attack Centre after prior assessment.The proportion of patients admitted directly to a Heart AttackCentre who received primary PCI within 150 minutes of a callfor professional help continues to improve [Figure 12]. There isa limit to how rapidly ambulance services can assess patientsand transfer them safely to hospital. The scope for furtherimprovement in this interval may be limited.Figure 12. Percentage of patients with an admissiondiagnosis of STEMI having primary PCI within either 120(CTB120) or 150 (CTB150) minutes from the time of callingfor professional help admitted directly or transferred to theHeart Attack Centre10090807060%504030201002006-7 2007-82008-9 2009-10 2010-11 2011-12YearsCTB150 with direct admission to the Heart Attack CentreCTB150 involving transfer to the Heart Attack CentreCTB120 with direct admission to the Heart Attack CentreCTB120 involving transfer to the Heart Attack Centre3. Hospitals using thrombolytic treatmentThrombolytic treatment is now used infrequently in themanagement of heart attack. At present only 5% of all patientswith STEMI [Figure 4] – less than 10% of those eligible forreperfusion treatment [Figure 10] – receive thrombolytictreatment, and this occurs mainly in a few areas where timelyaccess to a Heart Attack Centre is not yet available. Whilethrombolysis is becoming the gold standard early treatmentfor acute stroke, its use in heart attack is diminishing.The national standard for thrombolytic treatment is that it isgiven within 60 minutes of a call for professional help – thecall-to-needle time. This is a joint responsibility of acutehospitals and ambulance services. The aim is for at least68% of cases to achieve this standard in England, and 70% inWales, though the reported figures are prone to wide variation– a few delayed treatments being very influential when thetotal number still receiving thrombolysis is small.Tables 2 and 3 show hospital thrombolytic treatment analysesfor 2010/11 and 2011/12 for England and Wales respectively.The Belfast hospitals did not report use of any thrombolytictreatment in 2011/12.3.1 Door to needle timeIn England, 61% of eligible patients received thrombolytictreatment within 30 minutes of arrival at hospital comparedto 76% in 2010/11. In Wales 62% of eligible patients receivedtreatment with 30 minutes compared to 63% in 2010/11.3.2 Call to needle timeIn England 54% of eligible patients receiving thrombolytictreatment did so within 60 minutes of calling for professionalhelp compared to 69% in 2010/11. In Wales 48% of eligiblepatients received thrombolytic treatment within 60 minutes ofcalling for professional help compared to 53% in 2010/11.3.3 Future of thrombolysis and its use in the rural areasThe apparent reduction in performance with respect tothe delivery of thrombolysis, with fewer patients receivingtreatment within the national door-to-needle and call-toneedlestandards, largely reflects the shift in emphasisfrom thrombolysis to primary PCI. Those remaining patientsreceiving thrombolysis are likely to be those in whom thereis diagnostic uncertainty, those who present when the localHeart Attack Centre is busy performing primary PCI foranother patient, and those who live in more rural areas wherethere is no ready access to primary PCI.While air ambulance helicopters have been used to transportpatients from remote areas to Heart Attack Centres, theiruse is limited, and there are circumstances in which suchflights are not feasible (e.g. adverse weather and night flyingrestrictions). For the foreseeable future there will still be aplace for thrombolytic treatment in rural areas. There areparticular challenges to maintaining a rapid, efficient andsafe response to a small number of patients – if a treatmentis not delivered frequently it is likely to be delivered withextra caution and therefore more slowly. The delivery ofthis treatment before arrival at hospital – pre-hospitalthrombolysis – is one way of trying to reduce delay (see partthree, case study 7).However, even after thrombolytic treatment is given there is aneed to be ready to transfer patients to a Heart Attack Centre(often many miles away), for emergency ‘rescue angioplasty’in cases where thrombolysis proves ineffective, or for semiurgentelective angiography and PCI – the recommendedmanagement following successful thrombolysis. Such22 MINAP How the NHS cares for patients with heart attack

transfers require a significant amount of planning byambulance services, and divert an ambulance from otheremergency duties for prolonged periods.3.4 PCI post thrombolysisAll patients with STEMI receiving primary PCI will necessarilyundergo coronary angiography – the diagnostic investigationthat produces images of the coronary arteries and allowsidentification of the ‘culprit’ artery responsible for the heartattack and the target for the PCI. Angiography, with a viewto performing PCI (even coronary artery bypass graftingheart surgery) is also recommended in those patients whohave received thrombolysis. It is also recommended in thosepatients who have presented with evidence of STEMI yet forvarious reasons (often because they present too late to benefit)do not receive immediate reperfusion therapy.The use of angiography for patients with STEMI who didnot receive primary PCI, but instead received thrombolytictreatment or who had no reperfusion treatment, has steadilyrisen, from 53% in 2007/8 to 72% this year [Figure 13]Figure 13. Use of angiography for patients having STEMI whodo not receive primary PCI, but instead received thrombolytictreatment or had no reperfusion treatment (England, Walesand Belfast)%100908070605040302010024.32003-434.62004-538.82005-647.24. Patients that received no reperfusion2006-7While there has been a major shift in the preferred reperfusiontherapy – from thrombolysis to primary PCI – there remains asubstantial proportion of patients who have a final diagnosis ofSTEMI yet who do not receive reperfusion therapy at all; 30% in2011/12, compared to 31% in 2010/11 (Figure 14).52.52007-8Years58.32008-966.42009-1071.4 72.12010-112011-12Figure 14. Use of reperfusion treatment for patients with afinal diagnosis of STEMI, including those that received noreperfusion treatment%10090807060504030201002003-42004-5In-hospital lysis2005-6Pre-hospital lysisPrimary angioplastyNo reperfusion2006-7The commonest reason why no reperfusion treatment is given isthat the patient presents too late for treatment, which typicallyis not given more than 12 hours after onset of symptomsbecause of limited benefit by this time. In a small numberof cases severe co-morbidity, such as advanced malignancyor severe dementia, may make reperfusion treatmentinappropriate. In some cases the perceived risk of bleedinginduced by thrombolysis, or by some of the medication givenduring primary PCI, is judged too high to allow such treatment.Largely these are matters for clinical judgement by individualclinicians when they first assess the patient.However, the performance of angiography before an intendedprimary PCI may demonstrate features that indicate thatPCI is not required (for example in cases of TakotsuboCardiomyopathy, see section 3.4) or is not feasible. This canonly be determined by angiography. Thus, angiography allowstreatment to be offered only to those for whom benefit canbe expected, and enables clinicians to exclude those wherebenefit is not anticipated. That being said, those who undergotimely emergency angiography in readiness for primary PCI,yet who do not proceed to PCI, will appear as ‘no reperfusion’in this report.2007-8Years2008-92009-102010-112011-12MINAP Eleventh Public Report 201223

5. Ambulance service performanceAmbulance services collaborate closely with receivinghospitals and networks to improve care. For many, the focushas shifted from provision of pre-hospital thrombolytictreatment to identifying those patients with heart attack whomight benefit from primary PCI, and transferring them rapidlyto a Heart Attack Centre. So, for many ambulance services,the number of patients receiving pre-hospital thrombolytictreatment has declined. Nevertheless, ambulance personnelcontinue to provide the essential earliest phase of cardiac carefor patients with heart attack including resuscitation fromsudden cardiac arrest, pain relief, (and where appropriate)oxygen therapy, drugs such as aspirin and clopidogrel,performance of diagnostic ECG and continuing cardiacmonitoring. They are largely responsible for the earlyrecognition of an ACS, its initial diagnosis and decisions asto which receiving hospital to alert. Their role in providingprofessional reassurance to patients and their relatives shouldnot be underestimated (see part three, case study 4).Table 6 shows ambulance service performance in Englandand Wales. In England in 2011/12, 210 patients received prehospitalthrombolytic treatment compared to 824 in 2010/11.In Wales 154 patients received pre-hospital thrombolytictreatment compared to 219 in 2010/11.Because the response of the ambulance service influences thecall to balloon time of patients receiving primary PCI, Table6 also contains information on call-to-balloon time for eachambulance Trust.6. Use of secondary prevention medicationUse of secondary prevention medication after the acute eventis proven to improve outcomes for patients. These benefitsapply after both STEMI and nSTEMI.NICE guidance 19 recommends that all eligible patients whohave had an acute heart attack should be offered treatmentwith a combination of the following drugs:ACE inhibitoraspirinbeta blockerstatin.Table 7 shows the percentage of patients prescribed secondaryprevention medication on discharge by hospital in England,Wales and Belfast in 2011/12. For each hospital thosepatients surviving to be discharged home from that hospitalare included but those transferred to another hospital andthose patients in whom such drugs were contraindicated are19. http://guidance.nice.org.uk/CG48/QuickRefGuide/pdf/Englishexcluded. Historically, we have used the NSF audit standardof 80% for aspirin, beta blockers and statins treatment. Thereare no national standards for the prescription of ACE inhibitorsand Clopidogrel/ thienopyridine inhibitors.Use of secondary prevention medication at dischargefrom hospital is very satisfactory, continuing to exceedthe national standards, and there is little room for furtherimprovement [Figure 15]. In England prescription of aspirinwas 99%, beta blockers 96%, statins 97%, ACE inhibitors95% and Clopidogrel/thienopyridine inhibitors 96%. In Walesprescription of aspirin was 99%, beta blockers 96%, statins96%, ACE inhibitors 90% and Clopidogrel/thienopyridineinhibitors 95%. In the Belfast hospitals prescription of aspirinwas 100%, beta blockers 100%, statins 99%, ACE inhibitors98% and Clopidogrel/thienopyridine inhibitors 99%.Figure 15. Use of secondary prevention medicationAll heart attacks, (transfers, deaths, contraindicated andpatient refused are all excluded).100908070%605040302003-4 2004-5 2005-6 2006-7 2007-8MINAP will revise its dataset at the end of 2012 to include theuse of newer antiplatelet medication; however it is likely to beanother two years before sufficient data is available to providereliable reports.7. Cardiac NetworksYearsClopidogrel/thienopyridine inhibitorsAspirinBeta Blocker2008-9 2009-10 2010-11 2011-12StatinACEI/ARBCardiac Networks (also known as ‘heart and stroke networks’since they also now facilitate improvements in stroke care)are local NHS organisations that seek to improve the waythat services are planned and delivered. Bringing togetherclinicians, managers, commissioners and patients, and awareof the entire ‘cardiac pathway’, the networks can provide apowerful voice in the local health economy to enable frontlinestaff to secure the changes needed to deliver best care.They provide a forum through which the public can influencetheir services. Some Cardiac Networks have patient carerrepresentatives providing a voice among the professionals.24 MINAP How the NHS cares for patients with heart attack

Table 8 shows the performance of the call-to-needle and callto-balloontargets and the percentage of patients that receivedpre-hospital thrombolytic treatment,in-hospital thrombolytictreatment and primary PCI by Cardiac Network. The twoCardiac Networks in Wales are shown separately.There are 28 Cardiac and Stroke Networks in England and twoin Wales. The purpose of the analyses at this level, amongstothers, is to highlight issues relating to equality of access tooptimal patient care. Figure 16 shows the rate of primary PCIsperformed within each Cardiac Network (based on postcode ofpatient’s residence). It is important to note that some patientsare now treated across their network’s boundaries – if theirnearest Heart Attack Centre lies outside this boundary.Countrywide access to primary PCI remains incomplete,although the picture is changing rapidly. The percentage ofpatients in English Cardiac Networks that received primary PCIranged between 42-99% and in 2 Cardiac Networks less than50% of their patients received primary PCI. In Wales primary PCIservices are currently only routinely available at the South WalesCardiac Network (Rhwydwaith y Galon De Cymru).Figure 16 (right). Number of primary PCIs permillion population by Cardiac Network0 100 150 200 250 300 350 400 450 >500MINAP Eleventh Public Report 201225

8. Care for patients with nSTEMIThe earliest MINAP reports focussed upon the early provisionof reperfusion treatment to those patients presentingwith STEMI. Patients with nSTEMI have a lower early riskof death and, perhaps because they do not require veryrapid emergency treatment (reperfusion therapy), theyare not always admitted to cardiac care units, nor alwayscared for by cardiologists. However, specialist involvementis important in determining the likelihood of receiving‘evidence-based’ treatments such as coronary angiographyand revascularisation 20 . It is recognised that performanceof angiography and coronary intervention is an importantfacet of treatment for most patients (see below). Ideallyadmission should be to a cardiac facility (where nursing staffhave expertise in cardiac nursing and there is easy access tocardiological expertise).As mentioned above the numbers of nSTEMI reported in MINAPare incomplete, and in particular it is likely that patients whoare not admitted to a cardiac care unit are omitted. The qualityof care for patients not entered into MINAP remains unknown.In addition the variable nature of recording nSTEMI betweenhospitals may distort some analyses.Table 9 shows the percentage of nSTEMI patients that wereadmitted to a cardiac unit or ward and the percentage ofnSTEMI patients seen by a cardiologist or member of theirteam, by hospital, in 2010/11 and 2011/12. Similar analyses forhospitals in Wales and Belfast are shown in Table 10. In Englandin 2011/12 51% of nSTEMI patients were admitted to a cardiaccare unit or ward compared with 50% in 2010/11. In Wales 64%of patients were admitted to a cardiac unit or ward compared to59% in 2010/11. In the Belfast hospitals, 87% of patients wereadmitted to a cardiac unit or ward compared to 81% in 2010/11.In England in 2011/12, 93% of nSTEMI patients were seen by acardiologist, or member of the cardiologist’s team, comparedto 91% in 2010/11. In Wales 81% of nSTEMI patients wereseen by a cardiologist or member of their team comparedto 84% in 2010/11. In the Belfast hospitals 100% of nSTEMIpatients were seen by a cardiologist or member of their teamcompared to 99% in 2010/11.The frequency with which patients are referred for angiographyfor nSTEMI also continues to increase – from 53% in 2007/8to 76% in 2011/12 [Figure 18]. Tables 9 and 10 show thepercentage of nSTEMI that were referred for angiography byhospital in 2010/11 and 2011/12. In 2011/12, 69% of nSTEMIpatients in England were referred for angiography afternSTEMI, and 63% in 2010/11. In Wales 74% were referred in2011/12, and 71% in 2010/11. In Belfast 91% were referred in2011/12 and 82% in 2010/11.Figure 17. Time to angiography from arrival at hospital forpatients with a diagnosis of nSTEMIFigure 18. Use of angiography for patients with a diagnosis ofnSTEMI%%100908070605040302010010080604020030.22003-40-24 hrs24-48 hrs48-72 hrs40.32004-52010-11 2011-1244.12005-646.12006-772-96 hrs>96 hrs48.52007-8Years52.42008-962.72009-1070.62010-1175.72011-1220. Birkhead JS, Weston C, Lowe D on behalf of the MINAP Steering Group. Impactof specialty of admitting physician and type of hospital on care and outcome formyocardial infarction in England and Wales 2004-2005. BMJ 2006;332:1306-826 MINAP How the NHS cares for patients with heart attack

This year we report on the interval between admission andperformance of angiography. While immediate angiographyis not warranted in the vast majority of patients with nSTEMI,early angiography is recommended for those at moderate tohigh risk. The maximum acceptable delay from admission toangiogram has been variously defined. So, for example theEuropean Society of Cardiology suggests a 72 hour maximum,while NICE suggests a 96 hour maximum. Figure 17 shows ageneral improvement over the last year. Between 2010/11 and2011/12 the proportion of patients receiving angiography within24 hours of admission increased from 21% to 22%; within72 hours from 55% to 58%; and within 96 hours from 67%to 71%. However, 29% of patients with nSTEMI who receivean angiogram do so after the maximum recommended timeinterval (i.e. 96 hours) compared to 33% in 2010/11.Figure 20. 30 day mortality (with 95% confidence limitsaround the point estimate within each year) for nSTEMI%141210864209. Change in mortality of heart attack patients2003-42004-52005-6Figure 19. 30 day mortality (with 95% confidence limitsaround the point estimate within each year) for all patientshaving STEMI1412Over the last 8 years there have been gradual reduction in thereported death rates for patients within the MINAP dataset,both those with a final diagnosis of STEMI (Figure 19) andnSTEMI (Figure 20).10%864202003-42004-52005-62006-72006-72007-8Year2007-82008-92009-102010-112011-122008-92009-102010-112011-12YearMINAP Eleventh Public Report 201227

28 MINAP10. Results by hospitals, ambulance services and cardiac networks - percentages are not shown for less than 20 casesTable 1: Primary PCI in hospitals in England, Wales and BelfastPrimary PCI within 90 minutes of arrival reflects the ability of hospital to provide treatment in a timely manner. Primary PCI within 150 minutes of calling for help reflects hospital performanceand that of the emergency services in identifying STEMI and taking the patient to the Heart Attack Centre (which may not be the closest hospital). Not all patients are taken directly to a HeartAttack Centre, especially where is a diagnostic uncertainity. This inevitably takes longer than direct transfer, but cannot be avoided in some cases.Primary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentrePrimary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentreYear 2010/11 2011/12n % n % n % n % n % % n % n % n % n % n % %England: Overall 14722 90% 12955 81% 10921 87% 2062 48% 12955 59% 79% 17965 92% 15922 83% 13444 89% 2540 51% 15922 62% 79%Barts and the London, London 484 96% 418 80% 330 95% 88 25% 418 57% 68% 595 98% 491 84% 407 96% 84 25% 491 65% 69%Basildon Hospital, Basildon 607 97% 587 84% 457 90% 130 62% 587 58% 77% 649 97% 623 85% 497 88% 126 75% 623 57% 79%Basingstoke and North HampshireHospital, BasingstokeBirmingham City Hospital,BirminghamBirmingham Heartlands Hospital,BirminghamBlackpool Victoria Hospital,Blackpool104 94% 85 95% 85 95% 0 85 87% 100% 88 99% 76 96% 74 96% 2 76 89% 97%67 78% 52 88% 52 88% 0 52 56% 100% 99 78% 79 86% 79 86% 0 79 65% 100%262 84% 249 85% 205 90% 44 61% 249 51% 82% 224 82% 213 83% 184 89% 29 45% 213 50% 84%154 87% 140 95% 139 96% 1 140 73% 99% 505 93% 438 80% 369 86% 69 48% 438 54% 76%Bradford Royal Infirmary, Bradford 0 0 0 0 0 100% 3 3 3 0 3 100%Bristol Royal Infirmary, Bristol 558 90% 527 74% 414 82% 114 46% 527 46% 75% 589 92% 575 73% 431 85% 144 38% 575 51% 74%Castle Hill Hospital, Hull 348 89% 300 89% 279 94% 21 24% 300 78% 84% 469 94% 390 91% 380 93% 10 390 75% 85%Cheltenham General Hospital,Cheltenham74 93% 73 86% 72 86% 1 73 78% 99% 64 81% 63 83% 61 82% 2 63 73% 97%

Conquest Hospital, St Leonards onSeaCroydon University Hospital,Croydon63 90% 56 80% 54 83% 2 56 61% 95% 87 90% 84 86% 73 92% 11 84 70% 85%1 0 0 0 0 0 0 0 0 0 100%Darent Valley Hospital, Dartford 6 3 3 0 3 100% 12 7 7 0 7 100%Derriford Hospital, Plymouth 138 80% 136 77% 136 77% 0 136 55% 100% 161 80% 145 86% 145 86% 0 145 52% 100%Dorset County Hospital, Dorchester 26 88% 25 80% 25 80% 0 25 60% 100% 29 97% 28 96% 27 96% 1 28 79% 97%East Surrey Hospital, Redhill 52 94% 50 90% 49 90% 1 50 68% 98% 11 7 7 0 7 100%Eastbourne DGH, Eastbourne 39 62% 32 69% 32 69% 0 32 41% 100% 66 89% 58 86% 51 92% 7 58 69% 88%Freeman Hospital, Newcastle 766 98% 656 91% 529 98% 127 62% 656 83% 70% 832 98% 713 94% 631 98% 83 59% 713 87% 76%Frenchay Hospital, Bristol 2 2 2 0 2 100% 1 0 0 0 0Frimley Park Hospital, Frimley 140 76% 123 80% 94 86% 29 62% 123 54% 75% 249 92% 203 92% 188 92% 15 203 76% 83%Glenfield Hospital, Leicester 267 84% 232 85% 227 87% 5 232 64% 92% 349 89% 307 86% 306 86% 1 307 64% 97%Hammersmith Hospital, London 329 89% 293 74% 184 90% 109 48% 293 58% 65% 342 89% 306 77% 253 83% 53 49% 306 57% 77%Harefield Hospital 467 81% 421 86% 361 93% 76 58% 421 71% 84% 800 95% 775 91% 553 98% 239 75% 775 68% 69%James Cook University Hospital,Middlesborough550 95% 471 87% 413 92% 58 45% 471 72% 78% 607 93% 520 91% 437 95% 83 70% 520 77% 78%John Radcliffe Hospital, Oxford 348 93% 329 79% 240 93% 89 40% 329 61% 72% 344 96% 315 86% 264 94% 52 44% 315 71% 80%Kettering General Hospital,Kettering102 83% 93 87% 92 88% 1 93 60% 99% 259 89% 230 88% 227 89% 3 230 70% 95%King's College Hospital, London 336 66% 262 70% 252 72% 10 262 43% 96% 302 86% 279 75% 247 78% 33 52% 279 41% 88%Leeds General Infirmary, Leeds 1034 84% 823 64% 650 76% 173 21% 823 35% 68% 1058 88% 880 66% 668 82% 212 17% 880 43% 65%Lincoln County Hospital, Lincoln 11 11 11 0 11 100% 70 90% 64 89% 64 89% 0 64 75% 97%Lister Hospital, Stevenage 78 94% 69 93% 63 95% 6 69 87% 87% 90 97% 82 98% 79 97% 3 82 88% 93%MINAP29Liverpool Heart and Chest Hospital,LiverpoolManchester Royal Infirmary,ManchesterMedway Maritime Hospital,Gillingham677 97% 605 82% 362 98% 244 57% 605 65% 58% 798 98% 641 82% 429 98% 212 50% 641 66% 55%331 89% 253 74% 172 88% 81 43% 253 53% 55% 521 86% 435 64% 289 83% 146 26% 435 39% 57%10 10 10 0 10 100% 12 11 11 0 11 100%

30 MINAPPrimary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentrePrimary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentreYear 2010/11 2011/12n % n % n % n % n % % n % n % n % n % n % %Musgrove Park Hospital, Taunton 158 99% 147 98% 125 98% 22 100 147 88% 83% 174 100% 166 96% 149 97% 17 166 84% 90%New Cross Hospital, Wolverhampton 498 91% 383 81% 324 89% 59 36% 383 62% 72% 476 88% 376 81% 338 88% 38 16% 376 58% 77%Norfolk and Norwich UniversityHospital, NorwichNorthampton General Hospital,NorthamptonNorthern General Hospital,Sheffield402 96% 389 86% 357 89% 32 53% 389 58% 91% 413 96% 400 90% 373 91% 27 78% 400 62% 92%36 92% 28 96% 28 96% 0 28 79% 100% 20 90% 14 14 0 14 100%607 88% 573 75% 578 75% 4 573 48% 99% 595 87% 546 74% 393 84% 153 48% 546 48% 69%Northwick Park Hospital, Harrow 3 3 3 0 3 100% 2 0 0 0 0 100%Nottingham City Hospital,Nottingham189 96% 177 86% 166 90% 11 177 74% 92% 355 96% 320 82% 304 84% 16 320 70% 93%Papworth Hospital, Cambridge 420 98% 410 76% 295 90% 115 39% 410 47% 71% 441 97% 425 70% 346 79% 80 30% 425 45% 81%Pinderfields General Hospital,WakefieldQueen Alexandra Hospital,PortsmouthQueen Elizabeth Hospital,Birmingham0 0 0 0 0 1 1 1 0 1 100%193 88% 177 81% 138 91% 39 44% 177 54% 78% 372 79% 330 77% 242 82% 88 64% 330 53% 72%124 68% 110 74% 107 76% 3 110 45% 93% 221 92% 205 92% 205 92% 0 205 73% 100%Royal Berkshire Hospital, Reading 147 96% 134 95% 134 95% 0 134 89% 100% 166 92% 146 96% 146 96% 0 146 90% 100%Royal Blackburn Hospital,BlackburnRoyal Bournemouth GeneralHospital, Bournemouth0 0 0 0 0 5 1 1 0 1 100%72 92% 68 96% 63 95% 5 68 76% 93% 70 79% 64 80% 63 81% 1 64 62% 98%Royal Brompton Hospital, London 1 1 0 1 1 11 11 5 6 11 38%Royal Cornwall Hospital, Truro 33 97% 33 94% 32 94% 1 33 67% 97% 185 88% 177 82% 175 82% 2 177 52% 99%

Royal Derby Hospital, Derby 62 89% 55 87% 55 87% 0 55 67% 100% 165 90% 157 88% 157 88% 0 157 69% 100%Royal Devon & Exeter Hospital,Exeter176 91% 141 79% 141 79% 0 141 56% 97% 231 91% 200 83% 201 83% 0 200 56% 98%Royal Free Hospital, London 186 93% 184 91% 183 91% 1 184 67% 99% 172 98% 165 97% 140 98% 25 92% 165 70% 85%Royal Sussex County Hospital,Brighton191 94% 176 86% 175 87% 1 176 61% 99% 248 93% 238 88% 217 93% 21 43% 238 66% 89%Royal United Hospital Bath, Bath 52 92% 49 92% 48 92% 1 49 61% 98% 52 92% 50 92% 49 92% 1 50 70% 98%Russells Hall Hospital, Dudley 1 1 1 0 1 100% 0 0 0 0 0Salisbury District Hospital, Salisbury 0 0 0 0 0 1 0 0 0 0 100%Sandwell General Hospital, WestBromwichSouthampton General Hospital,Southampton95 77% 76 92% 76 92% 0 76 68% 100% 98 87% 81 90% 81 90% 0 81 69% 100%208 92% 185 89% 172 92% 13 185 62% 88% 251 93% 226 85% 204 92% 22 18% 226 61% 85%St George's Hospital, London 341 89% 306 90% 218 89% 88 91% 306 70% 70% 482 91% 451 92% 350 90% 101 96% 451 71% 77%St Peter's Hospital, Chertsey 27 96% 26 96% 26 96% 0 26 77% 100% 8 3 3 0 3 100%St Thomas' Hospital, London 131 82% 117 73% 86 83% 31 45% 117 52% 71% 93 94% 82 77% 63 90% 19 82 59% 73%Sunderland Royal Hospital,SunderlandThe Great Western Hospital,Swindon2 2 2 0 2 100% 4 2 2 0 2 100%33 97% 29 97% 29 97% 0 29 76% 100% 56 93% 52 94% 51 94% 1 52 83% 98%Torbay Hospital, Torquay 77 87% 70 93% 70 93% 0 70 81% 100% 97 89% 87 90% 87 90% 0 87 72% 100%Tunbridge Wells Hospital, TunbridgeWells3 3 3 0 3 100% 6 5 5 0 5 100%University College Hospital, London 168 93% 126 65% 88 85% 38 18% 126 36% 53% 154 97% 108 70% 74 95% 34 18% 108 57% 48%University Hospital Coventry,CoventryUniversity Hospital of NorthStaffordshire, Stoke-on-Trent330 88% 303 84% 292 85% 12 303 67% 96% 390 89% 354 86% 309 87% 46 76% 354 70% 85%341 89% 282 73% 225 85% 57 26% 282 48% 69% 440 88% 356 77% 314 85% 42 17% 356 55% 73%Watford General Hospital, Watford 48 90% 42 88% 42 88% 0 42 83% 100% 52 100% 52 98% 52 98% 0 52 87% 100%MINAPWexham Park Hospital, Slough 41 83% 39 95% 39 95% 0 39 85% 100% 36 89% 30 97% 30 97% 0 30 93% 100%William Harvey Hospital, Ashford 519 88% 427 75% 377 74% 50 80% 427 40% 76% 511 90% 488 85% 369 85% 119 87% 488 46% 75%31

32 MINAPPrimary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentrePrimary PCIwithin 90minutes ofarrival at HeartAttack CentrePrimary PCIwithin 150minutes ofcalling for helpPrimary PCIwithin 150minutes ofcalling for helpfor patientswith directadmission toHeart AttackCentrePrimary PCIwithin 150minutes ofcalling for helpfor patientstransferred toHeart AttackCentrePrimary PCIwithin 120minutes ofcalling for help% of patientswith directadmission toHeart AttackCentreYear 2010/11 2011/12n % n % n % n % n % % n % n % n % n % n % %Worcestershire Royal Hospital,Worcester11 11 10 1 11 93% 75 83% 67 78% 63 76% 4 67 55% 92%Worthing Hospital, Worthing 22 77% 19 19 0 19 100% 24 79% 17 17 0 17 100%Wycombe Hospital, High Wycombe 30 93% 21 90% 21 90% 0 21 86% 100% 60 98% 45 84% 45 84% 0 45 73% 94%Wythenshawe Hospital, Manchester 313 92% 246 73% 179 87% 67 36% 246 46% 63% 467 94% 383 71% 365 77% 57 30% 383 51% 80%Belfast: Overall 160 87% 127 91% 91 89% 36 94% 127 72% 63% 137 89% 104 88% 95 88% 10 104 84% 79%Belfast City Hospital, Belfast 1 0 0 0 0 2 2 1 1 2 67%Royal Victoria Hospital, Belfast 159 87% 127 91% 91 89% 91 89% 127 72% 63% 135 89% 102 88% 94 88% 94 88% 102 83% 79%Wales: Overall 283 68% 224 75% 221 76% 3 224 46% 89% 503 81% 448 78% 397 79% 51 73% 448 59% 86%Glan Clwyd Hospital, Rhyl 4 3 3 3 3 100% 14 11 11 11 11 100%Morriston Hospital, Swansea 190 76% 158 79% 155 81% 155 81% 158 53% 89% 303 83% 282 76% 231 76% 231 76% 282 58% 81%University Hospital of Wales, Cardiff 89 52% 63 67% 63 67% 63 67% 63 32% 87% 186 77% 155 83% 155 83% 155 83% 155 63% 93%

“During times of financial constraint thereis a temptation to reduce investment in suchexercises, even though participation in clinicalaudit is mandated by the Department ofHealth and Welsh Government. Conversely, wewould argue that such conditions – a workingenvironment characterised by cost containmentand efficiency – increase, rather than decrease,the need for reliable contemporary knowledge ofhospital performance.”MINAPDr Clive WestonClinical Director of MINAP33

34 MINAPTable 2: Thrombolytic treatment in hospitals in EnglandThis table presents results for hospitals that administered thrombolytic treatment to patients with admission diagnosis of STEMI. ‘n’ represents number of all eligible patients for this typeof reperfusion.Thrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpYear 2010/11 2011/12n % n % n % n %England: Overall 1494 76% 1757 69% 428 61% 495 54%Addenbrooke's Hospital, Cambridge 0 0 1 1Airedale General Hospital, Steeton 1 4 2 1Alexandra Hospital, Redditch 25 96% 30 77% 6 4Arrowe Park Hospital, Wirral 18 17 0 0Barnsley Hospital, Barnsley 1 1 1 1Barts and the London, London 1 1 6 6Basildon Hospital, Basildon 1 25 80% 2 2Bassetlaw Hospital, Nottingham 0 3 0 1Bedford Hospital, Bedford 3 1 1 0Birmingham City Hospital, Birmingham 0 0 1 1Birmingham Heartlands Hospital, Birmingham 2 2 0 0Blackpool Victoria Hospital, Blackpool 6 3 5 7Bradford Royal Infirmary, Bradford 5 5 1 1Bristol Royal Infirmary, Bristol 0 0 2 2

Broomfield Hospital, Chelmsford 0 0 1 1Calderdale Royal Hospital, Halifax 2 1 2 1Castle Hill Hospital, Hull 1 0 0 0Cheltenham General Hospital, Cheltenham 0 2 0 0Chesterfield Royal Hospital, Chesterfield 6 9 2 2Chorley and South Ribble Hospital, Chorley 28 79% 19 5 5Colchester General Hospital, Colchester 1 1 0 0Conquest Hospital, St Leonards on Sea 8 7 2 0Countess of Chester Hospital, Chester 10 24 88% 3 9County Hospital Hereford, Hereford 35 80% 44 82% 14 24 92%Cumberland Infirmary, Carlisle 34 68% 50 74% 34 74% 55 73%Darent Valley Hospital, Dartford 2 3 0 0Dewsbury District Hospital, Dewsbury 5 5 4 2Diana, Princess of Wales Hospital, Grimsby 25 72% 31 74% 2 2Doncaster Royal Infirmary, Doncaster 1 1 0 0Dorset County Hospital, Dorchester 17 15 10 14East Surrey Hospital, Redhill 32 69% 16 1 1Eastbourne DGH, Eastbourne 12 5 4 5Epsom Hospital, Epsom 14 7 0 0Fairfield General Hospital, Bury 16 12 0 0Freeman Hospital, Newcastle 1 1 0 0Frenchay Hospital, Bristol 1 1 0 0MINAPFrimley Park Hospital, Frimley 0 1 0 035

36 MINAPThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpYear 2010/11 2011/12n % n % n % n %Furness General Hospital, Barrow-in-Furness 18 21 76% 8 4George Elliot Hospital, Nuneaton 1 1 1 0Glenfield Hospital, Leicester 2 52 90% 3 4Gloucestershire Royal Hospital, Gloucester 2 1 0 0Grantham and District Hospital, Grantham 23 100% 19 12 11Harefield Hospital 1 1 0 0Harrogate District Hospital, Harrogate 0 0 1 1Hillingdon Hospital, Uxbridge 1 1 0 0Hinchingbrooke Hospital, Huntingdon 2 2 0 0Horton General Hospital, Banbury 0 1 0 0Huddersfield Royal Infirmary, Huddersfield 1 1 1 1James Cook University Hospital, Middlesborough 1 1 0 0John Radcliffe Hospital, Oxford 1 1 0 0Kent and Canterbury Hospital, Canterbury 1 0 0 0Kettering General Hospital, Kettering 9 19 3 2King's College Hospital, London 3 3 0 0King's Mill Hospital, Nottingham 66 76% 75 73% 0 0Leeds General Infirmary, Leeds 5 5 3 2Leicester Royal Infirmary, Leicester 2 2 0 0

Leighton Hospital, Crewe 43 86% 49 73% 0 0Lincoln County Hospital, Lincoln 31 84% 51 71% 34 71% 42 50%Macclesfield District General Hospital, Macclesfield 19 17 1 1Maidstone Hospital, Maidstone 2 1 0 0Manchester Royal Infirmary, Manchester 2 2 4 4Medway Maritime Hospital, Gillingham 2 1 4 4Musgrove Park Hospital, Taunton 0 1 1 1New Cross Hospital, Wolverhampton 2 2 0 0Newark Hospital, Newark 3 3 0 0Norfolk and Norwich University Hospital, Norwich 0 7 1 1North Devon District Hospital, Barnstable 9 13 1 1North Manchester General Hospital, Manchester 3 2 0 0North Middlesex Hospital, London 1 1 1 0Northampton General Hospital, Northampton 11 29 93% 1 1Northern General Hospital, Sheffield 2 0 4 4Nottingham City Hospital, Nottingham 16 23 52% 1 1Papworth Hospital, Cambridge 0 8 1 2Peterborough City Hospital, Peterborough 0 2 0 3Pilgrim Hospital, Boston 40 88% 47 62% 34 68% 62 58%Pinderfields General Hospital, Wakefield 4 2 9 7Poole Hospital, Poole 21 67% 28 57% 36 61% 30 60%Princess Royal Hospital, Haywards Heath 4 4 0 0MINAPPrincess Royal Hospital, Telford 1 1 1 137

38 MINAPThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpYear 2010/11 2011/12n % n % n % n %Queen Alexandra Hospital, Portsmouth 28 75% 30 53% 1 1Queen Elizabeth Hospital, Birmingham 0 0 1 1Queen Elizabeth Hospital, King's Lynn 0 0 1 1Queen Elizabeth the Queen Mother Hospital, Margate 4 4 0 0Queen's Hospital, Burton-upon-Trent 3 3 0 0Queens Hospital, Romford 1 1 0 0Royal Albert Edward Infirmary, Wigan 84 94% 72 88% 4 3Royal Berkshire Hospital, Reading 1 1 0 0Royal Blackburn Hospital, Blackburn 98 81% 94 69% 18 16Royal Bolton Hospital, Bolton 66 85% 55 67% 3 3Royal Bournemouth General Hospital, Bournemouth 28 79% 35 80% 26 69% 41 63%Royal Cornwall Hospital, Truro 34 68% 82 67% 0 0Royal Derby Hospital, Derby 44 89% 74 69% 0 0Royal Devon & Exeter Hospital, Exeter 2 2 0 1Royal Free Hospital, London 0 0 2 2Royal Hampshire County Hospital, Winchester 0 0 1 1Royal Lancaster Infirmary, Lancaster 30 77% 29 55% 4 4Royal Liverpool University Hospital, Liverpool 0 0 2 1Royal Oldham Hospital, Oldham 20 70% 17 0 0

Royal Preston Hospital, Preston 48 77% 38 92% 6 6Royal Shrewsbury Hospital, Shrewsbury 5 3 1 2Royal Surrey County Hospital, Guildford 5 4 0 0Royal Sussex County Hospital, Brighton 0 2 0 1Royal United Hospital Bath, Bath 3 5 2 2Russells Hall Hospital, Dudley 0 0 1 0Salford Royal Hospital, Manchester 1 0 1 1Salisbury District Hospital, Salisbury 15 20 45% 0 0Sandwell General Hospital, West Bromwich 1 1 0 0Scarborough General Hospital, Scarborough 18 18 0 0Scunthorpe General Hospital, Scunthorpe 19 36 89% 1 1Skegness District Hospital, Skegness 6 0 3 0Southampton General Hospital, Southampton 0 0 1 1Southend University Hospital, Westcliffe on Sea 2 2 0 0Southport and Formby District General, Southport 7 7 0 0St George's Hospital, London 0 0 1 1St Mary's Hospital, Newport 12 25 84% 6 7St Peter's Hospital, Chertsey 20 90% 14 0 0St Richard's Hospital, Chichester 18 18 0 0Stepping Hill Hospital, Stockport 1 3 0 0Stoke Mandeville Hospital, Aylesbury 10 7 1 1Tameside General Hospital, Ashton Under Lyme 2 2 1 1MINAPThe Great Western Hospital, Swindon 3 6 2 239

40 MINAPThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpThrombolytic treatment within30 mins ofhospital arrivalThrombolytic treatment within60 mins ofcalling for helpYear 2010/11 2011/12n % n % n % n %The Ipswich Hospital, Ipswich 0 1 0 0Torbay Hospital, Torquay 16 24 58% 15 19University College Hospital, London 1 1 0 0University Hospital Aintree, Liverpool 5 2 1 1University Hospital Coventry, Coventry 4 3 1 1University Hospital Of North Durham, Durham 0 0 1 1University Hospital of North Staffordshire, Stoke-on-Trent 0 1 1 2University Hospital of North Tees, Stockton on Tees 1 1 0 0University Hospital Queen's Medical Centre, Nottingham 27 74% 33 48% 0 0Warrington Hospital, Warrington 4 4 0 0Warwick Hospital, Warwick 0 0 1 1West Cornwall Hospital, Penzance 5 0 0 0West Cumberland Hospital, Whitehaven 36 81% 41 78% 22 73% 21 67%West Suffolk Hospital, Bury St Edmunds 1 1 0 0Wexham Park Hospital, Slough 2 1 0 0Whiston Hospital, Prescott 2 1 0 0William Harvey Hospital, Ashford 5 4 2 3Worcestershire Royal Hospital, Worcester 29 83% 40 60% 15 6Worthing Hospital, Worthing 13 13 0 0

Wycombe Hospital, High Wycombe 11 10 0 0Wythenshawe Hospital, Manchester 2 2 0 0Yeovil District Hospital, Yeovil 2 2 0 0York District Hospital, York 2 1 0 0MINAP41

42 MINAPTable 3: Thrombolytic treatment in hospitals in Wales and BelfastThis table presents results for hospitals that administered thrombolytic treatment to patients with admission diagnosis of STEMI. ‘n’ represents number of all eligible patients for this typeof reperfusion.Thrombolytic treatmentwithin 30 mins ofhospital arrivalThrombolytic treatmentwithin 60 mins ofcalling for helpThrombolytic treatmentwithin 30 mins ofhospital arrivalThrombolytic treatmentwithin 60 mins ofcalling for helpYear 2010/11 2011/12n % n % n % n %Wales: Overall 301 63% 398 53% 258 62% 313 48%Bronglais General Hospital, Aberystwyth 15 14 3 4Glan Clwyd Hospital, Rhyl 30 97% 49 62% 28 71% 55 65%Llandough Hospital, Llandough 3 2 1 1Llandudno General Hospital, Llandudno 4 3 0 0Morriston Hospital, Swansea 1 1 3 4Neath Port Talbot Hospital, Neath 3 2 0 0Nevill Hall Hospital, Abergavenny 29 66% 28 46% 21 43% 35 46%Prince Charles Hospital, Merthyr Tydfil 23 61% 32 53% 12 22 45%Prince Philip Hospital, Llanelli 10 6 7 3Princess Of Wales Hospital, Bridgend 14 25 60% 9 11Royal Glamorgan, Llantrisant 4 7 11 6Royal Gwent Hospital, Newport 40 60% 62 52% 35 43% 45 42%University Hospital of Wales, Cardiff 5 32 88% 1 5West Wales General Hospital, Camarthen 30 70% 25 44% 18 14Withybush General Hospital, Haverfordwest 10 16 22 91% 18Wrexham Maelor Hospital, Wrexham 47 64% 50 54% 56 68% 60 47%Ysbyty Gwynedd, Bangor 33 45% 44 43% 31 61% 30 43%Belfast: Overall 2 1 0 1Mater Infirmorum Hospital, Belfast 2 1 0 0Royal Victoria Hospital, Belfast 0 0 0 1

“I know that MINAP data has been the spur toimprove data input quality, thus enabling validcomparisons to be made, leading to directimprovements in performance. Would we,for instance, have seen direct admittance tocath labs become accepted practice so quicklywithout the influence of comparative clinicaldata? Would there be confidence in the evidenceto support the decisions made over primary PCIwithout MINAP?”MINAPAlan KeysPatient representative for MINAP43

44 MINAPTable 4: Reperfusion treatment in EnglandThis table shows the proportion of all patients with discharge diagnosis of STEMI that received either in-hospital thrombolytic treatment or primary PCI. ‘n’ represents number of patients thatreceived either thrombolytic treatment or primary PCI. 30% of patients received no reperfusion compared to 31% in 2010/2011.Patients that receivedthrombolytic treatmentPatients that received primaryPCIPatients that receivedthrombolytic treatmentPatients that received primaryPCIYear 2010/11 2011/12n % n % n % n %England: Overall 3461 17.8% 15942 82.2% 1074 5.3% 19139 94.7%Addenbrooke's Hospital, Cambridge 1 0 1 0Airedale General Hospital, Steeton 8 0 2 0Alexandra Hospital, Redditch 61 100% 0 9 0Arrowe Park Hospital, Wirral 30 100% 0 8 0Barnsley Hospital, Barnsley 3 0 2 0Barts and the London, London 1 557 99.8% 11 639 98.3%Basildon Hospital, Basildon 43 6.8% 587 93.2% 4 615 99.4%Basingstoke and North Hampshire Hospital,Basingstoke0 119 100% 0 105 100%Bassetlaw Hospital, Nottingham 5 0 4 0Bedford Hospital, Bedford 3 0 1 0Birmingham City Hospital, Birmingham 0 82 100% 2 120 98.4%Birmingham Heartlands Hospital, Birmingham 2 332 99.4% 0 304 100%Blackpool Victoria Hospital, Blackpool 7 171 96.1% 10 554 98.2%Bradford Royal Infirmary, Bradford 6 2 7 2Bristol Royal Infirmary, Bristol 1 554 99.8% 2 599 99.7%Broomfield Hospital, Chelmsford 2 1 3 0Calderdale Royal Hospital, Halifax 3 0 6 0Castle Hill Hospital, Hull 36 8.9% 370 91.1% 8 520 98.5%

Cheltenham General Hospital, Cheltenham 8 77 90.6% 0 68 100%Chesterfield Royal Hospital, Chesterfield 13 0 1 0Chorley and South Ribble Hospital, Chorley 29 100% 0 4 0Colchester General Hospital, Colchester 3 0 0 0Conquest Hospital, St Leonards on Sea 16 70 81.4% 10 100 90.9%Countess of Chester Hospital, Chester 35 100% 0 15 0County Hospital Hereford, Hereford 105 100% 0 62 100% 0Croydon University Hospital, Croydon 1 4 0 1Cumberland Infirmary, Carlisle 94 100% 0 86 100% 0Darent Valley Hospital, Dartford 8 6 2 12Derriford Hospital, Plymouth 0 162 100% 0 184 100%Dewsbury District Hospital, Dewsbury 6 0 5 0Diana, Princess of Wales Hospital, Grimsby 59 100% 0 4 0Doncaster Royal Infirmary, Doncaster 8 0 3 0Dorset County Hospital, Dorchester 34 55.7% 27 44.3% 28 47.5% 31 52.5%East Surrey Hospital, Redhill 65 51.6% 61 48.4% 2 17Eastbourne DGH, Eastbourne 28 41.2% 40 58.8% 10 72 87.8%Epsom Hospital, Epsom 28 100% 0 0 0Fairfield General Hospital, Bury 22 100% 0 0 0Freeman Hospital, Newcastle 1 768 99.9% 2 837 99.8%Frenchay Hospital, Bristol 5 3 3 1Frimley Park Hospital, Frimley 2 163 98.8% 0 283 100%Furness General Hospital, Barrow-in-Furness 29 100% 0 8 0George Elliot Hospital, Nuneaton 3 0 1 0Glenfield Hospital, Leicester 54 16.2% 279 83.8% 6 357 98.3%Gloucestershire Royal Hospital, Gloucester 2 0 0 0MINAPGood Hope Hospital, Sutton Coldfield 2 0 0 0Grantham and District Hospital, Grantham 48 100% 0 29 100% 045

46 MINAPPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIYear 2010/11 2011/12n % n % n % n %Hammersmith Hospital, London 1 338 99.7% 0 355 100%Harefield Hospital 3 623 99.5% 0 796 100%Harrogate District Hospital, Harrogate 5 0 5 0Hexham General Hospital, Hexham 1 0 0 0Hillingdon Hospital, Uxbridge 5 0 2 0Hinchingbrooke Hospital, Huntingdon 2 0 0 0Horton General Hospital, Banbury 1 0 0 0Huddersfield Royal Infirmary, Huddersfield 5 0 4 0James Cook University Hospital, Middlesborough 1 571 99.8% 0 639 100%John Radcliffe Hospital, Oxford 13 368 96.6% 8 346 97.7%Kent and Canterbury Hospital, Canterbury 8 0 0 0Kettering General Hospital, Kettering 34 21.8% 122 78.2% 3 269 98.9%King's College Hospital, London 3 373 99.2% 1 318 99.7%King's Mill Hospital, Nottingham 119 100% 0 4 0Leeds General Infirmary, Leeds 18 1075 98.4% 7 1032 99.3%Leicester Royal Infirmary, Leicester 5 0 0 0Leighton Hospital, Crewe 82 100% 0 3 0Lincoln County Hospital, Lincoln 84 83.2% 17 16.8% 67 46.5% 77 53.5%Lister Hospital, Stevenage 0 81 100% 4 100 96.2%Liverpool Heart and Chest Hospital, Liverpool 0 720 100% 0 803 100%Luton & Dunstable Hospital, Luton 0 0 2 0Macclesfield District General Hospital, Macclesfield 29 100% 0 3 0Maidstone Hospital, Maidstone 2 0 0 0

Manchester Royal Infirmary, Manchester 2 358 99.4% 7 533 98.7%Medway Maritime Hospital, Gillingham 22 61.1% 14 8 15Milton Keynes General Hospital, Milton Keynes 1 0 0 0Musgrove Park Hospital, Taunton 3 185 98.4% 2 190 99%New Cross Hospital, Wolverhampton 10 536 98.2% 2 561 99.6%Newark Hospital, Newark 12 0 0 0Norfolk and Norwich University Hospital, Norwich 7 438 98.4% 2 454 99.6%North Devon District Hospital, Barnstable 19 0 7 0North Manchester General Hospital, Manchester 4 0 1 0North Middlesex Hospital, London 1 0 1 0North Tyneside General Hospital, North Shields 0 0 1 0Northampton General Hospital, Northampton 41 51.9% 38 48.1% 1 22 95.7%Northern General Hospital, Sheffield 3 572 99.5% 6 1% 621 99%Northwick Park Hospital, Harrow 0 5 0 3Nottingham City Hospital, Nottingham 24 10.6% 203 89.4% 3 384 99.2%Papworth Hospital, Cambridge 34 6.9% 461 93.1% 2 512 99.6%Peterborough City Hospital, Peterborough 7 0 6 0Pilgrim Hospital, Boston 103 100% 0 104 100% 0Pinderfields General Hospital, Wakefield 8 0 9 1Poole Hospital, Poole 34 100% 0 45 100% 0Princess Royal Hospital, Haywards Heath 9 0 1 0Princess Royal Hospital, Telford 9 0 3 0Queen Alexandra Hospital, Portsmouth 51 20.2% 202 79.8% 2 380 99.5%Queen Elizabeth Hospital, Birmingham 3 156 98.1% 6 248 97.6%Queen Elizabeth Hospital, King's Lynn 3 0 4 0Queen Elizabeth Hospital, Woolwich 3 0 1 0MINAPQueen Elizabeth the Queen Mother Hospital, Margate 5 0 1 0Queen's Hospital, Burton-upon-Trent 5 0 0 047

48 MINAPPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIYear 2010/11 2011/12n % n % n % n %Queens Hospital, Romford 1 0 0 0Rotherham Hospital, Rotherham 3 0 2 0Royal Albert Edward Infirmary, Wigan 125 99.2% 1 2 0Royal Berkshire Hospital, Reading 1 165 99.4% 0 175 100%Royal Blackburn Hospital, Blackburn 159 98.8% 2 32 80% 8Royal Bolton Hospital, Bolton 98 100% 0 4 0Royal Bournemouth General Hospital, Bournemouth 77 49.4% 79 50.6% 91 52.6% 82 47.4%Royal Brompton Hospital, London 0 2 0 21 100%Royal Cornwall Hospital, Truro 125 77.6% 36 22.4% 0 210 100%Royal Derby Hospital, Derby 128 64% 72 36% 0 187 100%Royal Devon & Exeter Hospital, Exeter 8 214 96.4% 5 295 98.3%Royal Free Hospital, London 0 196 100% 5 190 97.4%Royal Hampshire County Hospital, Winchester 1 0 2 0Royal Lancaster Infirmary, Lancaster 33 100% 0 7 0Royal Liverpool University Hospital, Liverpool 7 0 4 0Royal Oldham Hospital, Oldham 26 100% 0 4 0Royal Preston Hospital, Preston 81 100% 0 6 0Royal Shrewsbury Hospital, Shrewsbury 20 100% 0 3 0Royal Surrey County Hospital, Guildford 8 0 0 0Royal Sussex County Hospital, Brighton 2 209 99.1% 3 260 98.9%Royal United Hospital Bath, Bath 6 61 91% 4 66 94.3%Royal Victoria Infirmary, Newcastle 3 0 2 0Russells Hall Hospital, Dudley 0 1 5 0

Salford Royal Hospital, Manchester 3 0 5 0Salisbury District Hospital, Salisbury 38 97.4% 1 0 4Sandwell General Hospital, West Bromwich 1 109 99.1% 1 112 99.1%Scarborough General Hospital, Scarborough 42 100% 0 0 0Scunthorpe General Hospital, Scunthorpe 54 100% 0 2 0Skegness District Hospital, Skegness 7 0 3 0Solihull Hospital, Birmingham 0 1 0 0Southampton General Hospital, Southampton 1 255 99.6% 1 297 99.7%Southend University Hospital, Westcliffe on Sea 2 0 0 0Southport and Formby District General, Southport 17 0 1 0St George's Hospital, London 1 342 99.7% 1 476 99.8%St Mary's Hospital, Newport 48 100% 0 19 0St Peter's Hospital, Chertsey 41 56.9% 31 43.1% 1 10St Richards Hospital, Chichester 57 100% 0 2 0St Thomas' Hospital, London 4 154 97.5% 0 122 100%Stepping Hill Hospital, Stockport 9 0 5 0Stoke Mandeville Hospital, Aylesbury 11 0 1 0Sunderland Royal Hospital, Sunderland 0 12 0 7Tameside General Hospital, Ashton Under Lyme 4 0 4 0The Great Western Hospital, Swindon 14 37 72.5% 4 69 94.5%The Ipswich Hospital, Ipswich 7 0 2 0Torbay Hospital, Torquay 43 33.1% 87 66.9% 30 21.3% 111 78.7%Tunbridge Wells Hospital, Tunbridge Wells 3 4 1 8University College Hospital, London 3 166 98.2% 0 137 100%University Hospital Aintree, Liverpool 6 0 1 0University Hospital Coventry, Coventry 4 370 98.9% 2 416 99.5%MINAPUniversity Hospital Of North Durham, Durham 0 0 2 0University Hospital of North Staffordshire,Stoke-on-Trent23 5.3% 410 94.7% 6 515 98.8%49

50 MINAPPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIYear 2010/11 2011/12University Hospital Queen's Medical Centre,Nottinghamn % n % n % n %54 100% 0 2 0Wansbeck General Hospital, Ashington 0 0 1 0Warrington Hospital, Warrington 9 0 1 0Warwick Hospital, Warwick 0 0 1 0Watford General Hospital, Watford 1 54 98.2% 0 53 100%West Cornwall Hospital, Penzance 9 0 0 0West Cumberland Hospital, Whitehaven 76 100% 0 48 100% 0West Suffolk Hospital, Bury St Edmunds 1 0 0 0Weston General Hospital, Weston-Supermare 1 0 0 0Wexham Park Hospital, Slough 3 46 93.9% 0 44 100%Whipps Cross Hospital, London 3 0 1 0Whiston Hospital, Prescott 10 0 4 0Whittington Hospital, London 1 0 0 0William Harvey Hospital, Ashford 10 531 98.2% 3 527 99.4%Worcestershire Royal Hospital, Worcester 83 85.6% 14 36 28.1% 92 71.9%Worthing Hospital, Worthing 22 43.1% 29 56.9% 1 26 96.3%Wycombe Hospital, High Wycombe 14 35 71.4% 0 63 100%Wythenshawe Hospital, Manchester 5 324 98.5% 0 476 100%Yeovil District Hospital, Yeovil 3 0 0 0York District Hospital, York 11 0 1 0

“MINAP, and its long history, is a testament tothe huge efforts of all those responsible: staffand hospitals collecting the data, data managersand analysts, researchers and publishers.”MINAPProfessor Huon GrayInterim National Clinical Director forCardiovascular Disease (England)51

52 MINAPTable 5: Reperfusion treatment in Wales and BelfastThis table shows the proportion of all patients with discharge diagnosis of STEMI that received either in-hospital thrombolytic treatment or primary PCI. ‘n’ represents number of patients thatreceived either thrombolytic treatment or primary PCI. In Wales 27 % of patients received no reperfusion in 2011/12 compared to 31% in 2010/11. In Belfast 29% of patients received no reperfusioncompared to 30% in 2010/11.Patients that receivedthrombolytic treatmentPatients that receivedprimary PCIPatients that receivedthrombolytic treatmentPatients that receivedprimary PCIYear 2010/11 2011/12n % n % n % n %Wales: Overall 699 69.8% 302 30.2% 525 49.9% 528 50.1%Bronglais General Hospital, Aberystwyth 14 0 11 0Glan Clwyd Hospital, Rhyl 87 93.5% 6 75 82.4% 16Llandough Hospital, Llandough 2 0 1 0Morriston Hospital, Swansea 1 200 99.5% 6 305 98.1%Neath Port Talbot Hospital, Neath 13 0 1 0Nevill Hall Hospital, Abergavenny 59 100% 0 54 100% 0Prince Charles Hospital, Merthyr Tydfil 62 100% 0 37 100% 0Prince Philip Hospital, Llanelli 16 0 8 0Princess Of Wales Hospital, Bridgend 40 100% 0 15 0Royal Glamorgan, Llantrisant 16 0 13 0Royal Gwent Hospital, Newport 102 100% 0 76 97.4% 2Singleton Hospital, Swansea 1 0 0 0University Hospital of Wales, Cardiff 37 27.8% 96 72.2% 6 205 97.2%West Wales General Hospital, Camarthen 52 100% 0 27 100% 0Withybush General Hospital, Haverfordwest 37 100% 0 35 100% 0Wrexham Maelor Hospital, Wrexham 79 100% 0 93 100% 0Ysbyty Gwynedd, Bangor 74 100% 0 67 100% 0Belfast: Overall 4 2.3% 173 97.7% 3 1.9% 153 98.1%Belfast City Hospital, Belfast 0 3 0 5Mater Infirmorum Hospital, Belfast 3 0 1 0Royal Victoria Hospital, Belfast 1 170 99.4% 2 148 98.7%

Table 6: Ambulance Services in England, Wales and BelfastThis table presents results of 12 Ambulance NHS Trusts in England. Wales is served by Welsh Ambulance Services NHS Trust that covers the entire region. ‘n’ represents all patients that meetinclusion criteria for each analysis.Patients having thrombolytictreatment within 60 mins of callingfor helpPatients havingpre-hospitalthrombolysisPrimary PCI within 150 minutes ofcalling for help for patients with directadmission to Heart Attack CentrePrimary PCI within 120 minutes ofcalling for help for patients with directadmission to Heart Attack CentrePrimary PCI within 150 minutesof calling for help for patientstransferred to Heart Attack CentrePrimary PCI within 120 minutesof calling for help for patientstransferred to Heart Attack CentreYear 2010/11 2011/12 2011 2012 2010/11 2011/12 2010/11 2011/12 2010/11 2011/12 2010/11 2011/12n % n % n n n % n % n % n % n % n % n % n %England: Overall 1731 69% 480 52% 765 210 10008 89% 12860 89% 10008 67% 12860 67% 1561 49% 2044 50% 1548 28% 2016 29%East Midlands 512 72% 133 52% 298 66 673 89% 1112 88% 673 69% 1112 71% 25 12% 26 31% 25 0% 26 12%East of England 47 72% 7 44 1 1320 90% 1461 89% 1320 64% 1461 64% 278 53% 268 60% 277 29% 267 34%Great Western 29 52% 7 14 0 546 84% 602 87% 546 56% 602 64% 75 57% 146 35% 75 36% 146 21%Isle of Wight 26 85% 7 17 5 2 2 2 2 0 0 0 0London 7 9 3 1 1411 88% 1528 90% 1411 65% 1528 68% 268 50% 316 56% 266 33% 313 39%North East 6 1 1 0 888 97% 989 97% 888 88% 989 90% 165 58% 141 66% 165 43% 139 51%North West 580 73% 133 62% 142 51 848 94% 1492 87% 848 78% 1492 67% 329 45% 457 38% 322 15% 445 12%South Central 52 38% 5 4 1 876 93% 987 91% 876 75% 987 75% 64 31% 60 55% 64 9% 59 22%South East Coast 103 72% 12 45 9 808 80% 1042 89% 808 50% 1042 59% 91 69% 193 75% 91 48% 192 58%South Western 204 68% 105 55% 130 55 464 90% 849 87% 464 71% 849 63% 29 90% 23 74% 29 86% 23 65%West Midlands 124 67% 41 63% 58 21 1141 88% 1422 88% 1141 63% 1422 66% 125 48% 112 46% 125 22% 106 33%Yorkshire 41 34% 20 5% 9 0 1031 84% 1374 85% 1031 56% 1374 59% 112 16% 302 28% 109 8% 300 16%MINAP53Wales 401 53% 320 49% 213 154 221 75% 381 80% 221 46% 381 60% 6 38 47% 6 37 41%Belfast 1 1 0 1 89 89% 96 89% 89 70% 96 83% 36 92% 10 36 78% 10

54 MINAPTable 7: Secondary prevention medicationThese analyses are based on all patients discharged from hospital with a diagnosis of myocardial infarction. Patients are excluded if they are transferred from the admitting hospital to anotherhospital for further treatment. Patients are also excluded from analyses if there is a contraindication to a drug, if they refuse treatment, or have severe non cardiac co-morbidity tht limitsprognosis. ‘n’ represents number of patients that received relevant secondary prevention medication.Aspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %England: Overall 54770 99% 50137 96% 51320 95% 55058 97% 53436 96%Addenbrooke's Hospital, Cambridge 142 100% 114 100% 110 100% 135 100% 105 100%Airedale General Hospital, Steeton 156 99% 148 99% 146 99% 159 99% 171 95%Alexandra Hospital, Redditch 138 92% 135 83% 138 88% 138 93% 137 85%Arrowe Park Hospital, Wirral 217 99% 191 96% 210 83% 253 92% 212 89%Barnet General Hospital, Barnet 84 99% 79 97% 77 100% 87 97% 83 99%Barnsley Hospital, Barnsley 109 97% 97 96% 99 93% 109 98% 108 88%Barts and the London, London 1014 98% 1008 94% 1012 93% 1017 99% 1016 94%Basildon Hospital, Basildon 786 99% 756 97% 761 98% 790 99% 774 99%Basingstoke and North Hampshire Hospital,Basingstoke212 99% 192 99% 210 100% 216 99% 211 100%Bassetlaw Hospital, Nottingham 182 100% 170 100% 181 100% 190 100% 177 99%Bedford Hospital, Bedford 88 100% 79 97% 87 95% 89 98% 89 96%Birmingham City Hospital, Birmingham 249 100% 182 100% 204 100% 247 100% 249 100%Birmingham Heartlands Hospital, Birmingham 607 100% 545 94% 580 92% 606 98% 610 99%Blackpool Victoria Hospital, Blackpool 1158 100% 1131 99% 1091 99% 1180 98% 1096 98%

Bradford Royal Infirmary, Bradford 536 99% 501 98% 519 97% 536 99% 529 97%Bristol Royal Infirmary, Bristol 831 99% 829 92% 833 92% 832 98% 829 96%Broomfield Hospital, Chelmsford 362 99% 276 100% 285 100% 357 99% 306 99%Calderdale Royal Hospital, Halifax 395 100% 360 99% 349 99% 402 99% 374 99%Castle Hill Hospital, Hull 1170 97% 1196 90% 1193 89% 1196 93% 1195 91%Central Middlesex Hospital, London 114 100% 100 92% 114 81% 120 97% 118 92%Charing Cross Hospital, London 26 96% 24 88% 26 81% 26 96% 24 92%Chase Farm Hospital, Enfield 48 100% 46 100% 41 100% 50 100% 39 0%Chelsea & Westminster Hospital, London 21 100% 18 16 20 95% 19Cheltenham General Hospital, Cheltenham 116 99% 105 100% 114 100% 111 100% 117 100%Chesterfield Royal Hospital, Chesterfield 333 100% 299 99% 319 98% 332 99% 313 99%Chorley and South Ribble Hospital, Chorley 63 100% 62 90% 64 89% 66 98% 60 93%Colchester General Hospital, Colchester 356 99% 325 99% 342 99% 362 98% 349 98%Conquest Hospital, St Leonards on Sea 258 100% 225 100% 231 99% 246 100% 246 99%Countess of Chester Hospital, Chester 172 100% 174 99% 161 99% 203 100% 153 98%County Hospital Hereford, Hereford 48 100% 48 100% 48 100% 48 100% 48 100%Croydon University Hospital, Croydon 97 99% 80 91% 95 75% 100 99% 96 98%Cumberland Infirmary, Carlisle 296 99% 236 97% 293 76% 305 85% 302 82%Darent Valley Hospital, Dartford 265 99% 241 98% 233 95% 270 99% 262 100%Darlington Memorial Hospital, Darlington 60 98% 57 98% 60 95% 63 98% 59 93%Derriford Hospital, Plymouth 208 98% 208 89% 208 89% 208 98% 208 98%Dewsbury District Hospital, Dewsbury 376 99% 336 99% 364 97% 382 99% 370 98%MINAPDiana, Princess of Wales Hospital, Grimsby 110 98% 105 98% 111 93% 120 97% 116 88%55

56 MINAPAspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %Doncaster Royal Infirmary, Doncaster 310 100% 298 100% 302 99% 324 99% 326 90%Dorset County Hospital, Dorchester 236 100% 205 95% 226 94% 229 96% 236 97%Ealing Hospital, Southall 127 94% 127 86% 127 86% 128 97% 128 81%East Surrey Hospital, Redhill 250 99% 218 96% 218 93% 258 93% 235 97%Eastbourne DGH, Eastbourne 298 100% 267 100% 256 100% 292 100% 287 97%Epsom Hospital, Epsom 27 96% 26 88% 25 96% 27 89% 27 96%Fairfield General Hospital, Bury 311 99% 271 99% 296 97% 315 98% 297 98%Freeman Hospital, Newcastle 1643 100% 1514 100% 1570 100% 1623 100% 1636 100%Frenchay Hospital, Bristol 284 100% 280 99% 266 94% 302 91% 259 99%Friarage Hospital, Northallerton 18 17 18 16 11Frimley Park Hospital, Frimley 517 100% 411 100% 456 98% 508 99% 514 99%Furness General Hospital, Barrow-in-Furness 18 18 20 100% 18 19George Elliot Hospital, Nuneaton 118 99% 114 99% 104 95% 118 94% 116 99%Glenfield Hospital, Leicester 694 100% 665 98% 655 100% 695 99% 681 98%Gloucestershire Royal Hospital, Gloucester 70 100% 60 100% 65 100% 70 100% 69 100%Good Hope Hospital, Sutton Coldfield 149 100% 112 100% 132 100% 149 100% 145 100%Grantham and District Hospital, Grantham 78 100% 81 99% 69 100% 90 98% 65 98%Hammersmith Hospital, London 529 92% 529 79% 528 71% 528 90% 529 90%Harefield Hospital 1130 94% 1119 92% 1121 92% 1124 94% 1128 78%Harrogate District Hospital, Harrogate 261 100% 255 98% 257 98% 269 100% 261 100%

Hexham General Hospital, Hexham 17 13 18 17 17Hillingdon Hospital, Uxbridge 189 99% 135 100% 148 100% 157 99% 155 100%Hinchingbrooke Hospital, Huntingdon 21 95% 16 17 19 18Homerton University Hospital, London 33 97% 32 94% 31 90% 32 88% 32 97%Horton General Hospital, Banbury 61 100% 51 100% 48 100% 58 100% 52 100%Huddersfield Royal Infirmary, Huddersfield 326 100% 275 100% 288 100% 317 98% 293 100%Hull Royal Infirmary, Hull 83 82% 87 76% 87 59% 86 70% 87 84%James Cook University Hospital, Middlesborough 802 100% 736 99% 770 100% 802 100% 768 100%James Paget Hospital, Great Yarmouth 62 90% 63 70% 66 76% 66 89% 66 79%John Radcliffe Hospital, Oxford 659 100% 568 99% 610 99% 638 100% 621 99%Kent and Canterbury Hospital, Canterbury 165 96% 133 88% 141 92% 172 90% 156 92%Kettering General Hospital, Kettering 495 100% 456 100% 452 99% 492 100% 483 100%King George Hospital, Goodmayes 124 100% 115 100% 121 96% 126 99% 119 100%King's College Hospital, London 509 99% 468 96% 548 94% 478 99% 544 94%King's Mill Hospital, Nottingham 276 99% 255 96% 258 90% 271 97% 280 100%Kingston Hospital, Kingston-upon-Thames 13 14 12 14 13Leeds General Infirmary, Leeds 1023 100% 948 100% 934 100% 1000 100% 924 99%Leicester Royal Infirmary, Leicester 2 1 2 2 2Leighton Hospital, Crewe 261 99% 232 99% 258 99% 273 98% 249 98%Lincoln County Hospital, Lincoln 432 99% 400 98% 384 95% 427 98% 412 96%Lister Hospital, Stevenage 346 100% 342 98% 341 98% 347 100% 342 98%Liverpool Heart and Chest Hospital, Liverpool 843 100% 819 100% 815 100% 846 100% 842 99%MINAP57Luton & Dunstable Hospital, Luton 219 100% 182 98% 205 100% 260 97% 232 100%Macclesfield District General, Macclesfield 185 98% 163 90% 172 92% 188 96% 184 91%

58 MINAPAspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %Maidstone Hospital, Maidstone 130 93% 122 81% 124 83% 126 92% 126 89%Manchester Royal Infirmary, Manchester 339 99% 337 92% 341 92% 343 97% 330 95%Manor Hospital, Walsall 60 97% 55 84% 60 83% 60 90% 54 87%Medway Maritime Hospital, Gillingham 324 100% 321 99% 314 99% 338 100% 331 98%Milton Keynes General Hospital, Milton Keynes 38 95% 38 84% 39 85% 39 97% 39 79%Montagu Hospital, Mexborough 4 1 2 4 3Musgrove Park Hospital, Taunton 416 98% 412 90% 405 90% 418 94% 399 96%New Cross Hospital, Wolverhampton 885 100% 716 99% 748 99% 873 100% 833 97%Newark Hospital, Newark 1 1 1 1 1Newham General Hospital, London 86 100% 72 63 100% 86 100% 75 100%Norfolk and Norwich University Hospital, Norwich 1156 99% 1024 100% 1085 100% 1123 100% 1161 96%North Devon District Hospital, Barnstable 143 100% 104 100% 124 98% 143 100% 124 100%North Manchester General Hospital, Manchester 211 100% 192 99% 192 97% 217 99% 204 100%North Middlesex Hospital, London 56 91% 57 81% 57 82% 57 96% 56 82%North Tyneside General Hospital, North Shields 100 99% 87 95% 77 97% 94 98% 81 100%Northampton General Hospital, Northampton 355 100% 296 100% 280 100% 338 100% 339 99%Northern General Hospital, Sheffield 803 99% 688 99% 683 99% 801 99% 773 99%Northwick Park Hospital, Harrow 357 99% 298 84% 338 83% 355 96% 343 94%Nottingham City Hospital, Nottingham 452 100% 428 100% 425 99% 447 99% 452 97%

Papworth Hospital, Cambridge 560 99% 528 97% 547 97% 555 99% 545 99%Peterborough City Hospital, Peterborough 270 100% 219 100% 228 100% 275 100% 261 100%Pilgrim Hospital, Boston 125 91% 120 89% 127 83% 130 93% 127 90%Pinderfields General Hospital, Wakefield 398 99% 371 99% 375 96% 406 99% 387 98%Poole Hospital, Poole 4 5 5 5 4Princess Alexandra Hospital, Harlow 138 96% 139 97% 132 93% 141 96% 138 97%Princess Royal Hospital, Haywards Heath 111 100% 95 97% 95 97% 112 96% 102 94%Princess Royal Hospital, Telford 180 100% 158 98% 152 96% 187 97% 157 100%Princess Royal University Hospital, Orpington 23 100% 20 75% 23 87% 23 96% 21 95%Queen Alexandra Hospital, Portsmouth 670 99% 667 96% 657 90% 668 97% 668 94%Queen Elizabeth Hospital, Birmingham 548 100% 456 98% 506 97% 540 98% 526 100%Queen Elizabeth Hospital, Gateshead 172 94% 161 92% 150 85% 184 94% 178 88%Queen Elizabeth Hospital, King's Lynn 308 99% 265 97% 275 95% 328 92% 286 96%Queen Elizabeth Hospital, Woolwich 91 99% 77 99% 90 97% 91 100% 87 98%Queen Elizabeth II Hospital, Welwyn Garden City 16 16 13 17 13Queen Elizabeth the Queen Mother Hospital,Margate121 95% 108 86% 110 78% 131 86% 111 84%Queen's Hospital, Burton-upon-Trent 81 100% 62 100% 59 98% 76 100% 79 97%Queens Hospital, Romford 162 100% 152 99% 162 100% 166 100% 145 100%Rotherham Hospital, Rotherham 280 100% 242 100% 249 100% 275 100% 277 100%Royal Albert Edward Infirmary, Wigan 338 100% 318 100% 319 100% 343 100% 333 100%Royal Berkshire Hospital, Reading 409 100% 397 100% 366 100% 408 100% 402 100%MINAPRoyal Blackburn Hospital, Blackburn 669 99% 633 95% 660 89% 700 95% 668 95%Royal Bolton Hospital, Bolton 397 100% 345 100% 362 100% 401 100% 375 100%59

60 MINAPAspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %Royal Bournemouth General Hospital,Bournemouth305 100% 289 95% 306 96% 299 98% 322 98%Royal Brompton Hospital, London 149 96% 150 92% 150 90% 149 96% 150 92%Royal Cornwall Hospital, Truro 694 100% 563 100% 533 99% 647 100% 709 94%Royal Derby Hospital, Derby 248 100% 229 96% 229 96% 242 99% 239 99%Royal Devon & Exeter Hospital, Exeter 450 100% 413 99% 431 97% 456 97% 449 100%Royal Free Hospital, London 336 97% 337 90% 337 87% 338 95% 337 91%Royal Hampshire County Hospital, Winchester 79 100% 68 100% 59 100% 74 99% 69 100%Royal Lancaster Infirmary, Lancaster 66 98% 64 97% 67 97% 67 100% 62 98%Royal Liverpool University Hospital, Liverpool 144 98% 150 99% 146 95% 165 100% 149 97%Royal London Hospital, London 20 100% 20 65% 20 75% 20 100% 20 80%Royal Oldham Hospital, Oldham 389 100% 343 100% 352 100% 400 100% 388 99%Royal Preston Hospital, Preston 104 96% 107 94% 102 80% 108 99% 104 92%Royal Shrewsbury Hospital, Shrewsbury 240 100% 190 99% 166 97% 234 99% 223 100%Royal Surrey County Hospital, Guildford 29 90% 29 86% 28 93% 29 97% 29 83%Royal Sussex County Hospital, Brighton 416 100% 365 98% 392 97% 417 97% 404 97%Royal United Hospital Bath, Bath 249 99% 223 99% 217 99% 236 99% 218 99%Royal Victoria Infirmary, Newcastle 86 100% 68 100% 77 100% 81 100% 82 98%Russells Hall Hospital, Dudley 161 98% 169 97% 159 91% 181 97% 171 91%Salford Royal Hospital, Manchester 300 100% 259 99% 252 96% 299 98% 271 98%

Salisbury District Hospital, Salisbury 376 100% 315 100% 325 100% 368 100% 354 100%Sandwell District Hospital, West Bromwich 264 100% 227 100% 247 100% 263 100% 260 100%Scarborough General Hospital, Scarborough 20 100% 17 16 22 100% 22 86%Scunthorpe General Hospital, Scunthorpe 210 91% 203 82% 197 81% 210 91% 210 95%Solihull Hospital, Birmingham 42 98% 42 93% 46 91% 47 96% 46 98%South Tyneside District Hospital, South Shields 229 99% 181 99% 197 97% 242 100% 209 99%Southampton General Hospital, Southampton 764 100% 725 96% 730 96% 761 99% 707 97%Southend University Hospital, Westcliffe on Sea 345 100% 325 100% 311 100% 371 100% 341 100%Southmead Hospital, Bristol 234 97% 216 92% 176 82% 247 87% 204 98%Southport and Formby District General, Southport 65 100% 51 98% 64 98% 67 100% 64 100%St George's Hospital, London 571 99% 570 86% 571 96% 571 98% 571 97%St Helier Hospital, Carshalton 62 98% 60 98% 60 98% 61 97% 62 100%St Mary's Hospital, London 21 100% 21 67% 21 48% 21 76% 21 71%St Mary's Hospital, Newport 41 100% 32 100% 27 100% 27 100% 28 100%St Peter's Hospital, Chertsey 194 100% 185 100% 193 100% 194 99% 190 99%St Richard’s Hospital, Chichester 81 95% 74 91% 74 84% 83 80% 79 78%St Thomas' Hospital, London 273 100% 242 99% 244 100% 271 100% 254 100%Stafford Hospital, Stafford 121 98% 114 96% 124 93% 131 96% 111 92%Stepping Hill Hospital, Stockport 587 96% 573 96% 581 93% 626 93% 617 70%Stoke Mandeville Hospital, Aylesbury 25 96% 24 83% 25 64% 26 88% 24 92%Sunderland Royal Hospital, Sunderland 133 98% 124 96% 113 90% 134 96% 132 98%Tameside General Hospital, Ashton Under Lyme 281 99% 253 96% 277 90% 304 92% 287 86%MINAPThe Great Western Hospital, Swindon 357 100% 301 92% 330 89% 350 97% 327 98%61

62 MINAPAspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %The Ipswich Hospital, Ipswich 302 92% 288 78% 310 66% 329 81% 285 85%Torbay Hospital, Torquay 344 100% 288 94% 315 94% 339 98% 341 95%Trafford General Hospital, Manchester 46 96% 43 88% 44 91% 44 98% 44 86%Tunbridge Wells Hospital, Tunbridge Wells 146 99% 131 86% 132 93% 143 96% 144 92%University College Hospital Gower Street, London 68 99% 62 97% 62 97% 67 99% 67 91%University College Hospital, London 203 100% 191 99% 197 98% 201 99% 201 95%University Hospital Aintree, Liverpool 223 100% 201 100% 180 96% 255 99% 205 100%University Hospital Coventry, Coventry 477 99% 454 96% 472 95% 479 99% 475 98%University Hospital Lewisham, London 51 100% 52 94% 51 94% 54 94% 53 96%University Hospital of Hartlepool, Hartlepool 53 100% 38 100% 46 100% 50 98% 51 100%University Hospital of North Durham, Durham 157 96% 155 88% 148 80% 166 87% 156 74%University Hospital of North Staffordshire,Stoke-on-Trent1140 97% 992 89% 1150 86% 1150 95% 1151 91%University Hospital of North Tees, Stockton on Tees 76 100% 67 97% 66 100% 77 92% 72 97%University Hospital Queen's Medical Centre,Nottingham54 100% 41 98% 37 97% 47 96% 47 89%Wansbeck General Hospital, Ashington 112 100% 104 100% 104 100% 108 99% 112 99%Warrington Hospital, Warrington 215 100% 191 100% 188 98% 217 100% 205 99%Warwick Hospital, Warwick 44 100% 44 86% 46 89% 46 89% 45 98%Watford General Hospital, Watford 323 96% 319 88% 318 85% 325 94% 320 91%West Cumberland Hospital, Whitehaven 85 91% 72 88% 79 71% 86 85% 84 74%

West Middlesex University Hospital, Isleworth 50 100% 51 96% 51 96% 51 100% 49 10%West Suffolk Hospital, Bury St Edmunds 97 98% 86 90% 86 87% 102 87% 90 97%Weston General Hospital, Weston-Supermare 130 100% 105 100% 115 99% 131 98% 135 99%Wexham Park Hospital, Slough 222 99% 209 86% 214 90% 222 99% 223 99%Whipps Cross Hospital, London 124 99% 99 96% 104 98% 120 96% 105 99%Whiston Hospital, Prescott 246 100% 219 100% 237 98% 253 100% 245 100%Whittington Hospital, London 88 99% 87 99% 89 100% 89 100% 89 100%William Harvey Hospital, Ashford 634 100% 565 97% 572 96% 640 99% 626 100%Worcestershire Royal Hospital, Worcester 247 99% 218 99% 240 99% 247 99% 244 99%Worthing Hospital, Worthing 172 100% 155 99% 149 99% 160 98% 157 99%Wycombe Hospital, High Wycombe 214 100% 211 100% 209 100% 211 99% 213 97%Wythenshawe Hospital, Manchester 428 100% 423 99% 426 100% 429 100% 425 99%Yeovil District Hospital, Yeovil 189 98% 150 96% 134 91% 175 93% 190 99%York District Hospital, York 440 100% 338 100% 390 98% 435 99% 422 99%Wales: Overall 1653 99% 1504 96% 1547 90% 1693 96% 1555 95%Bronglais General Hospital, Aberystwyth 33 88% 29 86% 32 81% 35 94% 28 71%Glan Clwyd Hospital, Rhyl 278 99% 278 95% 262 85% 289 94% 281 92%Llandough Hospital, Llandough 58 98% 49 96% 49 82% 64 83% 51 100%Wrexham Maelor Hospital, Wrexham 138 100% 131 98% 116 96% 148 94% 96 96%Morriston Hospital, Swansea 253 100% 242 99% 250 99% 252 99% 238 98%Neath Port Talbot Hospital, Neath 10 9 10 11 10MINAPNevill Hall Hospital, Abergavenny 51 98% 47 100% 45 93% 54 98% 52 98%63

64 MINAPAspirin Beta blocker ACE inhibitor Statins Clopidogrel/Thienopyridine inhibitorYear 2011/12n % n % n % n % n %Prince Charles Hospital, Merthyr Tydfil 70 96% 62 85% 73 84% 80 91% 71 90%Prince Philip Hospital, Llanelli 18 17 18 19 17Princess Of Wales Hospital, Bridgend 26 100% 22 100% 24 100% 28 100% 26 100%Royal Glamorgan, Llantrisant 6 4 6 6 6Royal Gwent Hospital, Newport 254 100% 211 99% 232 96% 247 98% 244 98%Singleton Hospital, Swansea 13 11 12 13 11University Hospital of Wales, Cardiff 381 100% 334 95% 362 83% 383 97% 369 93%West Wales General Hospital, Camarthen 13 12 12 12 12Withybush General Hospital, Haverfordwest 42 100% 38 97% 35 94% 43 93% 34 100%Ysbyty Gwynedd, Bangor 9 8 9 9 9Belfast: Overall 462 100% 442 100% 392 98% 469 99% 442 99%Belfast City Hospital, Belfast 144 100% 132 100% 109 96% 150 98% 139 99%Mater Infirmorum Hospital, Belfast 96 100% 95 98% 94 98% 98 100% 96 100%Royal Victoria Hospital, Belfast 222 100% 215 100% 189 100% 221 100% 207 100%

“We have participated in MINAP from its inception.By so doing we believe that we have been forcedto look critically at our practice to ensure wemeet nationally agreed targets and optimise theoutcomes for our patients.”Amelia Hilton - Clinical Audit Co-ordinator(Pathology, Imaging and Medicine)Sandwell West Birmingham Hospitals NHS TrustMINAP65

66 MINAPTable 8: Cardiac networks in England, Wales and BelfastThis table presents results for Cardiac Networks in England, Wales as well as results for Belfast hospitals. Results for call-to-balloon within 120 and 150 minutes include all patients irrespectiveof their method of admission (direct admissions and transferred to a Heart Attack Centre). The thrombolytic treatment within 60 minutes analyses include all patients that receivedeither pre-hospital or in-hospital thrombolysis.Patients havingthrombolytictreatment within60 mins ofcalling for helpPatients havingpre-hospitalthrombolytictreatmentPatients havingin-hospitalthrombolytictreatmentPrimary PCIwithin 150 minsof calling forhelpPrimary PCIwithin 120 minsof calling forhelpPatients havingprimary PCIPatients havingthrombolytictreatment within60 mins ofcalling for helpPatients havingpre-hospitalthrombolytictreatmentPatients havingin-hospitalthrombolytictreatmentPrimary PCIwithin 150 minsof calling forhelpPrimary PCIwithin 120 minsof calling forhelpPatients havingprimary PCIYear 2010/11 2011/12n % n % n % n % n % n % n % n % n % n % n % n %England: Overall 1757 69% 887 5% 2512 13% 12955 81% 12955 59% 15942 82% 495 54% 248 1% 803 4% 15922 83% 15922 62% 19139 95%Anglia Stroke & Heart Network 21 76% 46 5% 16 799 81% 799 52% 899 94% 8 6 10 825 80% 825 53% 966 98%Avon, Gloucestershire, Wiltshireand Somerset Cardiac and StrokeNetworkBedfordshire & Hertfordshire Heartand Stroke NetworkBirmingham Sandwell & SolihullCardiac and Stroke NetworkBlack Country CardiovascularNetworkCardiac and Stroke Networks inLancashire & CumbriaCardiovascular and Stroke NetworkNorth East LondonCheshire and Merseyside Cardiacand Stroke NetworkCoventry & WarwickshireCardiovascular Network37 54% 18 56 6% 825 81% 825 58% 915 93% 7 0 12 906 80% 906 61% 996 99%1 0 4 111 91% 111 86% 135 97% 0 0 6 134 98% 134 87% 153 96%3 1 6 487 84% 487 53% 680 99% 2 2 6 578 88% 578 63% 784 99%2 7 3 384 81% 384 62% 537 98% 0 2 5 376 81% 376 58% 561 99%204 73% 55 11% 275 55% 140 95% 140 73% 173 34% 42 67% 12 52 8% 439 80% 439 54% 562 90%2 0 5 418 80% 418 57% 557 99% 6 1 10 491 84% 491 65% 639 98%55 82% 19 89 11% 605 82% 605 65% 720 87% 11 8 25 3% 641 82% 641 66% 803 96%4 0 7 303 84% 303 67% 370 98% 2 0 4 354 86% 354 70% 416 99%

Dorset Cardiac and Stroke Network 78 69% 43 17% 102 41% 93 91% 93 72% 106 42% 85 59% 39 14% 124 45% 92 85% 92 67% 113 41%East Midlands Cardiac and StrokeNetwork427 70% 243 17% 464 32% 596 87% 596 67% 731 51% 123 53% 63 4% 155 10% 1092 86% 1092 68% 1296 86%Essex Cardiac and Stroke Network 28 75% 43 7% 7 587 84% 587 58% 588 92% 3 2 5 623 85% 623 57% 615 99%Greater Manchester & CheshireCardiac and Stroke NetworkHereford & Worcestershire Cardiac& Stroke Network246 75% 27 2% 396 36% 499 74% 499 50% 684 62% 13 1 35 3% 818 67% 818 44% 1009 97%114 73% 64 25% 182 70% 11 11 14 34 76% 20 10% 86 43% 67 78% 67 55% 92 46%Kent Cardiovascular Network 13 2 53 9% 443 74% 443 40% 555 91% 7 1 14 511 84% 511 45% 562 97%North and East Yorkshire andNorthern Lincolnshire Cardiac &Stroke NetworkNorth Central LondonCardioVascular & Stroke NetworkNorth of England CardiovascularNetworkNorth Trent Network of CardiacCareNorth West London CardioVascular& Stroke NetworkPeninsula Cardiac ManagedClinical NetworkShropshire and Staffordshire Heartand Stroke Network86 77% 85 15% 115 20% 300 89% 300 78% 370 65% 4 2 17 390 91% 390 75% 520 96%2 1 4 310 81% 310 55% 362 99% 2 0 5 273 86% 273 65% 327 98%94 73% 40 3% 136 9% 1129 89% 1129 78% 1351 88% 77 70% 44 3% 97 6% 1235 92% 1235 83% 1483 91%14 10 25 4% 573 75% 573 48% 572 94% 8 1 16 546 74% 546 48% 621 97%2 0 8 718 81% 718 65% 968 99% 0 0 2 1092 87% 1092 65% 1175 100%121 66% 79 11% 124 18% 380 82% 380 61% 499 71% 21 43% 14 28 3% 609 84% 609 56% 800 95%8 12 39 8% 282 73% 282 48% 410 89% 5 4 7 356 77% 356 55% 515 98%South Central Vascular Network 76 55% 34 3 108 8% 970 86% 970 68% 1190 89% 11 14 18 1168 85% 1168 68% 1410 98%South East London Cardiac andStroke Network3 2 5 379 71% 379 46% 527 99% 0 0 2 361 75% 361 45% 440 100%MINAPSouth West London Cardiac andStroke Network0 1 1 306 90% 306 70% 346 99% 1 0 1 451 92% 451 71% 477 100%67

68 MINAPPatients havingthrombolytictreatment within60 mins ofcalling for helpPatients havingpre-hospitalthrombolytictreatmentPatients havingin-hospitalthrombolytictreatmentPrimary PCIwithin 150 minsof calling forhelpPrimary PCIwithin 120 minsof calling forhelpPatients havingprimary PCIPatients havingthrombolytictreatment within60 mins ofcalling for helpPatients havingpre-hospitalthrombolytictreatmentPatients havingin-hospitalthrombolytictreatmentPrimary PCIwithin 150 minsof calling forhelpPrimary PCIwithin 120 minsof calling forhelpPatients havingprimary PCIYear 2010/11 2011/12n % n % n % n % n % n % n % n % n % n % n % n %Surrey Heart and Stroke Network 43 81% 19 129 32% 201 85% 201 61% 258 64% 1 0 6 213 92% 213 77% 311 98%Sussex Heart and Stroke Network 49 69% 26 5% 108 22% 283 83% 283 59% 348 72% 6 11 16 397 87% 397 67% 458 94%West Yorkshire CardiovascularNetwork24 12% 10 45 4% 823 64% 823 35% 1077 95% 16 1 39 4% 884 66% 884 43% 1035 96%Wales: Overall 398 53% 212 21% 478 48% 224 75% 224 46% 302 30% 313 48% 146 14% 371 36% 448 78% 448 59% 528 51%North Wales Cardiac Network 146 52% 72 29% 170 69% 3 3 6 145 53% 69 28% 161 65% 11 11 16South Wales Cardiac Network 252 54% 140 19% 308 41% 221 76% 221 47% 296 40% 168 43% 77 10% 210 26% 437 78% 437 60% 512 64%Belfast: Overall 1 0 0% 3 2% 127 91% 127 72% 173 98% 1 1 1% 2 1% 104 88% 104 84% 153 98%

“Participation in MINAP has helped to strengthenthe partnerships East Midlands AmbulanceService has with local hospital trusts. This hasbenefited our cardiac patients as working togetherwith the hospitals has helped us to identify areasof care which could be improved.”MINAPDeborah Shaw – Clinical Audit and ResearchManagerEast Midlands Ambulance Service69

70 MINAPTable 9: Care of patients with non-ST-elevation infartion (nSTEMI) in EnglandIt is recognised that not all nSTEMI are entered into MINAP. A number of hospitals report lack of resources to collect data on nSTEMI, and more generally those patients not admitted to cardiac unitare less likely to be entered. Thus the percentages reported below do not take into account every patient admitted to hospital with nSTEMI but only reflect those entered in the MINAP database. ‘n’represents number of patients that were seen by cardiologist, were admitted to a cardiac ward or were referred for or had angiography.nSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %England: Overall 43124 91% 23744 50% 27078 63% 43996 93% 24134 51% 28974 69%Addenbrooke's Hospital, Cambridge 318 98% 217 67% 144 45% 174 75% 167 72% 95 58%Airedale General Hospital, Steeton 157 98% 85 53% 62 39% 164 99% 74 45% 97 60%Alexandra Hospital, Redditch 165 96% 33 19% 105 66% 161 98% 39 24% 101 64%Arrowe Park Hospital, Wirral 344 83% 273 66% 247 60% 366 89% 299 73% 240 60%Barnet General Hospital, Barnet 51 100% 23 45% 31 62% 107 98% 86 79% 75 70%Barnsley Hospital, Barnsley 165 89% 137 74% 98 53% 134 96% 119 86% 90 65%Barts and the London, London 440 100% 433 98% 369 86% 376 100% 376 100% 318 85%Basildon Hospital, Basildon 366 99% 357 96% 185 52% 397 100% 363 91% 211 57%Basingstoke and North Hampshire Hospital, Basingstoke 113 99% 49 43% 92 81% 124 95% 96 73% 95 73%Bassetlaw Hospital, Nottingham 212 84% 181 72% 22 9% 155 90% 119 69% 65 38%Bedford Hospital, Bedford 95 99% 53 55% 63 78% 84 99% 59 69% 75 96%Birmingham City Hospital, Birmingham 163 100% 39 24% 139 87% 153 100% 63 41% 140 95%Birmingham Heartlands Hospital, Birmingham 312 99% 229 73% 308 98% 403 98% 340 83% 401 98%

Blackpool Victoria Hospital, Blackpool 376 81% 126 27% 232 51% 546 85% 178 28% 384 61%Bradford Royal Infirmary, Bradford 384 99% 179 46% 258 66% 390 99% 231 59% 252 69%Bristol Royal Infirmary, Bristol 193 97% 101 51% 170 86% 208 98% 112 53% 195 92%Broomfield Hospital, Chelmsford 338 88% 73 19% 176 60% 415 94% 42 10% 206 57%Calderdale Royal Hospital, Halifax 291 85% 134 39% 159 94% 363 95% 129 34% 232 95%Castle Hill Hospital, Hull 458 98% 415 89% 317 91% 603 99% 539 89% 421 98%Central Middlesex Hospital, London 116 98% 5 84 74% 135 99% 1 89 67%Charing Cross Hospital, London 42 100% 5 38 90% 33 100% 1 20 65%Chase Farm Hospital, Enfield 155 100% 155 100% 126 82% 59 98% 60 100% 50 85%Chelsea & Westminster Hospital, London 82 100% 9 62 86% 70 100% 0 50 83%Cheltenham General Hospital, Cheltenham 114 88% 40 31% 64 98% 65 86% 36 47% 51 100%Chesterfield Royal Hospital, Chesterfield 219 94% 112 48% 21 9% 303 96% 84 27% 33 11%Chorley and South Ribble Hospital, Chorley 67 81% 21 25% 23 37% 62 84% 26 35% 27 55%Colchester General Hospital, Colchester 342 87% 220 56% 247 82% 388 92% 203 48% 270 95%Conquest Hospital, St Leonards on Sea 201 89% 163 72% 123 56% 188 94% 130 65% 103 53%Countess of Chester Hospital, Chester 386 89% 126 29% 191 87% 370 92% 137 34% 205 94%County Hospital Hereford, Hereford 103 74% 40 29% 95 70% 100 78% 43 34% 106 85%Croydon University Hospital, Croydon 75 89% 74 88% 46 57% 95 98% 32 33% 74 78%Cumberland Infirmary, Carlisle 225 89% 76 30% 72 31% 322 85% 110 29% 144 44%Darent Valley Hospital, Dartford 313 98% 253 79% 239 76% 317 98% 209 65% 233 73%Darlington Memorial Hospital, Darlington 196 91% 53 25% 118 76% 123 99% 44 35% 85 97%Derriford Hospital, Plymouth 33 59% 11 54 96% 35 97% 2 36 100%MINAPDewsbury District Hospital, Dewsbury 219 81% 102 38% 125 46% 225 82% 106 39% 141 52%71

72 MINAPnSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %Diana, Princess of Wales Hospital, Grimsby 229 93% 161 65% 135 56% 179 98% 97 53% 112 62%Doncaster Royal Infirmary, Doncaster 270 92% 90 31% 179 88% 217 87% 69 28% 135 94%Dorset County Hospital, Dorchester 177 94% 97 51% 156 87% 180 99% 81 45% 155 88%Ealing Hospital, Southall 81 99% 75 91% 60 78% 152 100% 91 60% 120 94%East Surrey Hospital, Redhill 315 82% 177 46% 201 91% 270 87% 150 48% 178 96%Eastbourne DGH, Eastbourne 198 92% 173 80% 108 57% 270 95% 234 82% 109 42%Epsom Hospital, Epsom 143 100% 121 85% 87 61% 86 99% 79 91% 59 68%Fairfield General Hospital, Bury 152 97% 36 23% 101 68% 229 96% 52 22% 139 68%Freeman Hospital, Newcastle 788 100% 778 99% 788 100% 906 100% 881 97% 906 100%Frenchay Hospital, Bristol 271 79% 140 41% 122 43% 311 81% 122 32% 138 61%Friarage Hospital, Northallerton 102 100% 66 65% 70 69% 91 100% 81 89% 69 82%Frimley Park Hospital, Frimley 291 95% 122 40% 211 87% 310 99% 115 37% 218 84%Furness General Hospital, Barrow-in-Furness 21 37% 29 51% 8 23 42% 22 40% 13George Elliot Hospital, Nuneaton 164 96% 77 45% 89 90% 128 96% 58 43% 69 96%Glenfield Hospital, Leicester 201 98% 158 77% 172 84% 324 100% 218 67% 270 84%Gloucestershire Royal Hospital, Gloucester 115 94% 88 72% 61 100% 83 88% 64 68% 49 100%Good Hope Hospital, Sutton Coldfield 229 100% 54 24% 172 83% 216 99% 39 18% 176 95%Grantham and District Hospital, Grantham 193 100% 82 42% 114 59% 217 98% 117 53% 122 62%Hammersmith Hospital, London 149 90% 102 62% 154 96% 243 98% 200 81% 228 94%

Harefield Hospital 139 84% 156 94% 145 90% 145 80% 174 96% 157 90%Harrogate District Hospital, Harrogate 277 87% 287 91% 75 24% 239 94% 235 93% 60 24%Hexham General Hospital, Hexham 12 27 24% 49 46% 21 29% 7 46 82%Hillingdon Hospital, Uxbridge 368 86% 359 84% 115 27% 323 88% 290 79% 130 36%Hinchingbrooke Hospital, Huntingdon 40 100% 24 60% 26 79% 49 98% 36 72% 24 55%Homerton Hospital, London 25 100% 20 80% 18 82% 39 98% 27 68% 27 73%Horton General Hospital, Banbury 58 48% 9 8% 69 57% 40 43% 12 58 62%Huddersfield Royal Infirmary, Huddersfield 237 91% 102 39% 149 94% 291 89% 72 22% 175 96%Hull Royal Infirmary, Hull 45 60% 2 2 78 90% 2 0James Cook University Hospital, Middlesborough 185 100% 165 89% 148 80% 157 100% 138 88% 134 86%James Paget Hospital, Great Yarmouth 172 100% 153 89% 129 82% 244 100% 210 86% 182 83%John Radcliffe Hospital, Oxford 422 89% 172 36% 322 68% 325 92% 146 41% 248 70%Kent and Canterbury Hospital, Canterbury 162 69% 129 55% 30 13% 148 69% 125 58% 33 15%Kettering General Hospital, Kettering 226 95% 149 63% 160 90% 211 98% 145 67% 162 96%King George Hospital, Goodmayes 157 88% 126 71% 133 75% 171 96% 157 88% 139 79%King's College Hospital, London 184 55% 145 44% 281 86% 242 91% 146 55% 247 95%King's Mill Hospital, Nottingham 335 100% 62 18% 174 53% 315 100% 57 18% 268 87%Kingston Hospital, Kingston-upon-Thames 29 52% 2 4% 26 93% 18 0 7Leeds General Infirmary, Leeds 626 99% 534 84% 441 72% 727 99% 720 98% 462 65%Leicester Royal Infirmary, Leicester 75 88% 35 41% 23 27% 2 1 1Leighton Hospital, Crewe 383 94% 133 33% 240 60% 369 89% 99 24% 237 60%Lincoln County Hospital, Lincoln 243 93% 74 28% 174 69% 318 95% 100 30% 241 77%MINAPLister Hospital, Stevenage 224 91% 143 58% 153 62% 310 98% 215 68% 215 70%73

74 MINAPnSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %Liverpool Heart and Chest Hospital, Liverpool 5 5 5 6 6 6Luton & Dunstable Hospital, Luton 446 98% 73 16% 256 60% 495 95% 58 11% 285 56%Macclesfield District General, Macclesfield 247 92% 71 26% 119 45% 213 89% 84 35% 94 51%Maidstone Hospital, Maidstone 157 99% 90 57% 102 64% 148 97% 50 33% 105 69%Manchester Royal Infirmary, Manchester 142 99% 19 89 73% 141 99% 9 93 76%Manor Hospital, Walsall 176 81% 128 59% 118 66% 115 63% 94 52% 107 79%Medway Maritime Hospital, Gillingham 292 90% 161 49% 165 60% 334 92% 106 29% 180 83%Milton Keynes General Hospital, Milton Keynes 48 96% 39 78% 38 79% 34 85% 27 68% 30 77%Montagu Hospital, Mexborough 12 0 0% 8 7 0 4Musgrove Park Hospital, Taunton 229 96% 55 23% 137 60% 244 96% 193 76% 144 63%New Cross Hospital, Wolverhampton 273 100% 51 19% 229 85% 266 100% 63 24% 225 86%Newark Hospital, Newark 29 63% 0 0% 7 0 0 0Newham General Hospital, London 188 99% 187 99% 119 98% 109 100% 109 100% 68 97%Norfolk and Norwich University Hospital, Norwich 706 100% 388 55% 578 82% 765 100% 462 60% 629 82%North Devon District Hospital, Barnstable 283 87% 55 17% 145 46% 329 87% 125 33% 191 62%North Manchester General Hospital, Manchester 184 99% 38 20% 124 79% 242 97% 56 22% 162 93%North Middlesex Hospital, London 159 98% 101 62% 101 67% 65 90% 7 49 88%North Tyneside General Hospital, North Shields 276 85% 110 34% 117 40% 258 89% 109 38% 158 62%Northampton General Hospital, Northampton 434 97% 336 75% 240 54% 404 96% 295 70% 208 50%

Northern General Hospital, Sheffield 732 95% 483 63% 355 49% 626 97% 553 86% 391 61%Northwick Park Hospital, Harrow 370 99% 3 277 76% 387 98% 12 294 76%Nottingham City Hospital, Nottingham 85 98% 43 49% 57 69% 34 100% 32 94% 21 66%Papworth Hospital, Cambridge 15 16 2 14 15 2Peterborough City Hospital, Peterborough 316 89% 175 49% 73 22% 335 92% 256 70% 78 22%Pilgrim Hospital, Boston 352 85% 130 31% 170 47% 342 90% 136 36% 214 67%Pinderfields General Hospital, Wakefield 270 84% 64 20% 199 62% 330 88% 68 18% 218 58%Poole Hospital, Poole 14 10 3 15 14 12Princess Alexandra Hospital, Harlow 230 93% 144 59% 163 73% 169 95% 28 16% 135 78%Princess Royal Hospital, Haywards Heath 99 81% 101 83% 67 57% 88 88% 86 86% 50 51%Princess Royal Hospital, Telford 116 92% 17 87 70% 268 92% 16 185 65%Princess Royal University Hospital, Orpington 263 94% 97 35% 122 44% 34 89% 18 47% 29 78%Queen Alexandra Hospital, Portsmouth 310 100% 50 16% 241 78% 299 100% 55 18% 252 84%Queen Elizabeth Hospital, Birmingham 231 100% 229 99% 211 92% 232 100% 167 72% 218 94%Queen Elizabeth Hospital, Gateshead 338 89% 252 66% 151 40% 309 90% 256 74% 190 55%Queen Elizabeth Hospital, King's Lynn 307 73% 24 6% 78 39% 493 71% 39 6% 213 62%Queen Elizabeth Hospital, Woolwich 129 97% 29 22% 101 91% 99 98% 12 88 92%Queen Elizabeth II Hospital, Welwyn Garden City 171 88% 110 56% 115 61% 52 90% 39 67% 34 64%Queen Elizabeth the Queen Mother Hospital, Margate 135 63% 80 37% 73 34% 87 55% 56 35% 43 27%Queen's Hospital, Burton-upon-Trent 216 89% 190 79% 108 70% 167 92% 162 89% 76 72%Queens Hospital, Romford 282 75% 212 57% 256 69% 231 96% 193 80% 181 77%Rotherham Hospital, Rotherham 254 81% 105 34% 75 53% 234 93% 169 67% 81 69%MINAPRoyal Albert Edward Infirmary, Wigan 309 99% 203 65% 155 53% 344 99% 279 80% 205 64%75

76 MINAPnSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %Royal Berkshire Hospital, Reading 262 95% 211 77% 208 78% 247 97% 199 78% 199 83%Royal Blackburn Hospital, Blackburn 497 91% 246 45% 308 57% 652 84% 317 41% 416 54%Royal Bolton Hospital, Bolton 320 98% 135 41% 200 71% 342 99% 120 35% 228 83%Royal Bournemouth General Hospital, Bournemouth 60 97% 55 89% 55 90% 148 97% 144 95% 133 90%Royal Brompton Hospital, London 13 13 15 117 98% 85 71% 119 100%Royal Cornwall Hospital, Truro 421 68% 254 41% 373 62% 508 87% 240 41% 358 77%Royal Derby Hospital, Derby 316 100% 237 75% 177 56% 117 98% 95 80% 87 73%Royal Devon & Exeter Hospital, Exeter 240 94% 115 45% 177 94% 195 95% 78 38% 161 96%Royal Free Hospital, London 90 100% 88 98% 85 96% 227 97% 144 62% 230 99%Royal Hampshire County Hospital, Winchester 249 94% 43 16% 117 45% 202 96% 25 12% 112 56%Royal Lancaster Infirmary, Lancaster 83 99% 65 77% 51 61% 76 99% 36 47% 49 66%Royal Liverpool University Hospital, Liverpool 233 95% 155 63% 134 62% 265 94% 174 62% 149 57%Royal London Hospital, London 0 12 14 23 100% 7 16Royal Oldham Hospital, Oldham 234 94% 28 11% 130 53% 353 96% 50 14% 171 47%Royal Preston Hospital, Preston 52 84% 6 9 107 83% 26 20% 48 56%Royal Shrewsbury Hospital, Shrewsbury 107 92% 34 29% 83 74% 324 79% 67 16% 176 44%Royal Surrey County Hospital, Guildford 32 97% 11 11 37 97% 9 20 54%Royal Sussex County Hospital, Brighton 102 100% 84 82% 77 79% 156 99% 73 46% 117 75%Royal United Hospital Bath, Bath 184 83% 110 49% 115 56% 225 91% 198 80% 138 60%

Royal Victoria Infirmary, Newcastle 276 99% 8 176 64% 262 99% 7 187 72%Russells Hall Hospital, Dudley 315 100% 314 100% 141 46% 274 100% 273 100% 140 51%Salford Royal Hospital, Manchester 280 92% 78 26% 94 37% 288 92% 200 64% 148 94%Salisbury District Hospital, Salisbury 268 100% 91 34% 154 58% 389 99% 306 78% 228 59%Sandwell General Hospital, West Bromwich 155 99% 45 29% 140 90% 186 100% 50 27% 173 94%Scarborough General Hospital, Scarborough 191 98% 159 82% 55 30% 42 98% 38 88% 20 49%Scunthorpe General Hospital, Scunthorpe 252 82% 41 13% 155 51% 199 99% 20 10% 148 83%Solihull Hospital, Birmingham 96 99% 74 76% 88 91% 118 100% 87 74% 103 88%South Tyneside District Hospital, South Shields 205 93% 58 26% 70 53% 333 96% 67 19% 116 59%Southampton General Hospital, Southampton 430 98% 344 79% 349 80% 475 99% 391 82% 362 76%Southend University Hospital, Westcliffe on Sea 363 96% 301 79% 189 50% 327 96% 285 83% 204 60%Southmead Hospital, Bristol 282 85% 137 41% 118 41% 261 84% 105 34% 115 53%Southport and Formby District General, Southport 207 100% 61 29% 101 49% 204 99% 57 28% 135 67%St George's Hospital, London 120 99% 91 75% 92 82% 90 95% 65 68% 71 76%St Helier Hospital, Carshalton 127 100% 94 74% 56 44% 91 100% 77 85% 29 32%St Mary's Hospital, London 134 100% 114 85% 62 50% 26 100% 23 88% 14St Mary's Hospital, Newport 153 99% 123 79% 91 60% 140 100% 130 93% 101 73%St Peter's Hospital, Chertsey 161 99% 156 96% 126 78% 199 94% 195 92% 175 86%St Richard’s Hospital, Chichester 191 97% 39 20% 114 62% 124 93% 49 37% 77 79%St Thomas' Hospital, London 111 100% 75 68% 101 97% 165 99% 108 65% 137 84%Stafford Hospital, Stafford 190 96% 74 37% 116 60% 159 99% 69 43% 105 77%Stepping Hill Hospital, Stockport 457 80% 223 39% 172 31% 652 82% 202 25% 284 37%MINAPStoke Mandeville Hospital, Aylesbury 64 56% 23 20% 29 33% 42 40% 25 24% 1077

78 MINAPnSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %Sunderland Royal Hospital, Sunderland 173 99% 152 87% 145 84% 136 100% 129 95% 117 87%Tameside General Hospital, Ashton Under Lyme 379 97% 21 5% 125 33% 389 96% 40 10% 145 37%The Great Western Hospital, Swindon 403 86% 83 18% 281 75% 345 84% 134 32% 243 93%The Ipswich Hospital, Ipswich 482 67% 369 52% 250 42% 503 81% 354 57% 205 40%Torbay Hospital, Torquay 252 94% 189 71% 186 71% 213 95% 141 63% 167 88%Trafford General Hospital, Manchester 18 6 14 48 94% 7 26 81%Tunbridge Wells Hospital, Tunbridge Wells 85 99% 31 36% 80 95% 145 99% 76 52% 121 86%University College Hospital Gower Street, London 57 93% 8 46 77% 67 87% 6 37 49%University College Hospital, London 26 96% 22 81% 14 70 99% 65 92% 52 73%University Hospital Aintree, Liverpool 521 89% 260 44% 291 95% 414 96% 157 36% 244 95%University Hospital Coventry, Coventry 94 100% 82 87% 80 89% 90 97% 88 95% 81 91%University Hospital Lewisham, London 63 94% 34 51% 50 91% 44 86% 6 30 83%University Hospital of Hartlepool, Hartlepool 208 75% 166 59% 157 65% 167 80% 82 39% 145 99%University Hospital Of North Durham, Durham 250 99% 160 63% 135 56% 365 89% 221 54% 225 55%University Hospital of North Staffordshire, Stoke-on-Trent 466 88% 498 94% 416 82% 523 96% 498 91% 426 79%University Hospital of North Tees, Stockton on Tees 236 90% 104 40% 134 93% 222 88% 165 66% 153 96%University Hospital Queen's Medical Centre, Nottingham 103 77% 80 60% 93 70% 188 82% 164 72% 177 79%Wansbeck General Hospital, Ashington 331 91% 191 52% 184 87% 277 95% 125 43% 158 81%

Warrington Hospital, Warrington 435 98% 136 31% 202 55% 380 98% 178 46% 198 67%Warwick Hospital, Warwick 37 100% 12 34 92% 43 96% 17 30 70%Watford General Hospital, Watford 295 99% 25 8% 244 83% 289 96% 67 22% 213 89%West Cumberland Hospital, Whitehaven 181 87% 125 60% 107 55% 234 86% 188 69% 163 64%West Middlesex University Hospital, Isleworth 38 88% 21 49% 35 85% 33 92% 33 92% 25 69%West Suffolk Hospital, Bury St Edmunds 256 93% 61 22% 109 63% 240 90% 62 23% 165 78%Weston General Hospital, Weston-Supermare 143 83% 104 60% 95 57% 159 92% 7 117 70%Wexham Park Hospital, Slough 107 96% 111 100% 88 95% 175 99% 175 99% 152 90%Whipps Cross Hospital, London 263 90% 37 13% 141 54% 145 90% 20 12% 87 62%Whiston Hospital, Prescott 552 92% 240 40% 250 42% 471 96% 224 46% 236 50%Whittington Hospital, London 75 99% 68 89% 44 59% 96 99% 92 95% 59 64%William Harvey Hospital, Ashford 195 86% 154 68% 101 46% 195 91% 129 60% 114 54%Worcestershire Royal Hospital, Worcester 128 99% 29 22% 113 90% 138 99% 19 101 77%Worthing Hospital, Worthing 195 98% 141 71% 134 96% 142 100% 115 81% 102 96%Wycombe Hospital, High Wycombe 154 87% 162 92% 123 72% 178 95% 178 95% 124 66%Wythenshawe Hospital, Manchester 155 98% 45 28% 112 90% 55 100% 13 38 88%Yeovil District Hospital, Yeovil 126 98% 44 34% 60 47% 275 96% 87 30% 118 41%York District Hospital, York 391 87% 103 23% 271 98% 378 97% 101 26% 293 100%MINAP79

80 MINAPTable 10: Care of patients with non-ST-elevation infartion (nSTEMI) in Wales and BelfastIt is recognised that not all nSTEMI are entered into MINAP. A number of hospitals report a lack of resources to collect data on nSTEMI, and more generally those patients not admitted to acardiac unit are less likely to be entered. Thus the percentages reported below do not take into account every patient admitted to hospital with nSTEMI but only reflect those entered in theMINAP database.’n’ represents number of patients that were seen by cardiologist, were admitted to a cardiac ward or were referred for or had angiography.nSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographynSTEMI patients seen by acardiologist or a memberof teamnSTEMI patients admitted tocardiac unit or wardnSTEMI patients thatwere referred for or hadangiographyYear 2010/11 2011/12n % n % n % n % n % n %Wales : Overall 1367 84% 959 59% 925 71% 1653 81% 1322 64% 1262 74%Bronglais General Hospital, Aberystwyth 71 89% 68 85% 25 38% 124 95% 123 95% 94 88%Glan Clwyd Hospital, Rhyl 202 89% 57 25% 116 61% 186 94% 73 37% 117 73%Llandough Hospital, Llandough 0 0 0 55 30% 67 37% 91 53%Morriston Hospital, Swansea 4 4 1 0 0 0Neath Port Talbot Hospital, Neath 47 65% 46 67% 28 85% 1 24 77%Nevill Hall Hospital, Abergavenny 190 98% 147 76% 122 82% 163 98% 154 93% 115 89%Prince Charles Hospital, Merthyr Tydfil 59 100% 46 78% 36 63% 154 94% 127 77% 71 48%Prince Philip Hospital, Llanelli 50 86% 25 50% 37 97% 17 23 70%Princess Of Wales Hospital, Bridgend 72 100% 62 86% 52 78% 56 100% 41 73% 42 82%Royal Glamorgan, Llantrisant 0 0 0 20 100% 20 100% 17Royal Gwent Hospital, Newport 285 99% 109 38% 181 82% 299 100% 147 49% 225 88%Singleton Hospital, Swansea 50 94% 42 79% 37 70% 19 4 17University Hospital of Wales, Cardiff 0 0 0 158 87% 130 71% 101 58%West Wales General Hospital, Camarthen 40 98% 33 80% 32 86% 73 99% 53 72% 54 79%

Withybush General Hospital, Haverfordwest 64 32% 133 68% 140 76% 66 31% 136 64% 149 79%Wrexham Maelor Hospital, Wrexham 228 82% 221 79% 109 69% 215 78% 229 83% 122 81%Ysbyty Gwynedd, Bangor 0 0 0 0 0 0Belfast: Overall 375 99% 307 81% 268 82% 430 100% 377 87% 325 91%Belfast City Hospital, Belfast 129 98% 82 63% 92 82% 151 99% 117 77% 116 86%Royal Victoria Hospital, Belfast 123 99% 109 88% 103 97% 116 100% 106 91% 91 94%Mater Infirmorum Hospital, Belfast 123 100% 116 94% 73 66% 163 99% 154 94% 118 95%MINAP81

11. Difference in performance between Englandand WalesIn previous annual reports we have commented on differencesin performance between Wales and England. Thesedifferences, which are becoming less obvious, have been felt toreflect the largely rural nature of Wales, and the effect this hashad on the configuration of cardiac services. The shift fromthrombolytic therapy to primary PCI has occurred more slowlyin Wales than in most (but not all) of the English regions, andwhile a patient with STEMI is more likely to receive eitherform of reperfusion therapy (primary PCI or thrombolysis)in Wales than in England they are far less likely to undergoprimary PCI (50% vs. 95% of all reperfusion), particularly inNorth Wales. However the two Welsh Cardiac Networks areworking closely with the Welsh Ambulance Service and localhospitals to develop management strategies that promote theuse of primary PCI, and pre-hospital thrombolysis in moregeographically remote areas. This is the first year in which themajority of patients receiving reperfusion therapy underwentprimary PCI. Two Heart Attack Centres in the South of Wales(in Swansea and Cardiff) are now able to offer continuousavailability of primary PCI to their local populations, and havebeen increasing access for more distant populations. Also, afew patients have received primary PCI opportunistically atYsbyty Glan Clwyd in the North of Wales.The number of patients receiving primary PCI has thereforeincreased from 301 in 2010/11 to 528 this year – an increaseof 75% in the number of patients so treated. Gratifyingly theproportion of these patients admitted directly to the heart attackcentres is similar to the pattern seen in England as a whole, andthe proportion of patients treated within 150 minutes and 120minutes of calling for help is also similar (call-to-balloon within150 minutes: 78% vs. 83%; call-to-balloon within 120 minutes:59% vs. 62% in Wales and England respectively).The use of secondary preventive medication remains good andequivalent to English hospitals.Reassuringly, in 2011/12 the 30-day mortality rates forboth STEMI and nSTEMI are similar for patients in Walesand England.Figure 21. 30 day mortality (with 95% confidence limitsaround the point estimate within each year) for STEMI inEngland and Wales%1510502003-4England2004-5Wales2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12YearFigure 22. 30 day mortality (with 95% confidence limitsaround the point estimate within each year) for nSTEMI inEngland and Wales1412In keeping with best practice, most (74 %) of those who receivethrombolytic treatment for STEMI, or have no reperfusiontreatment at all, subsequently undergo coronary angiography.We remain concerned that some of the Welsh hospitals are notsubmitting data on the management they provide to patientswith nSTEMI (the commonest type of acute coronary syndrome).This weakens the capacity of the National Audit to assure goodquality care is being delivered. It may also explain the variationin outcome with respect to annual 30-day mortality for Welshpatients with nSTEMI (Figure 20). Participation is likely toimprove as Health Boards respond to recent Welsh Governmentdocuments that re-emphasise the imperative to participate innational audits (including MINAP) as part of Quality Assuranceand Quality Improvement initiatives 21 .%10864202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12EnglandWalesYear21. NHS Wales National Clinical Audit and Outcomes Review Plan Annual RollingProgramme from 2012–2013.82 MINAP How the NHS cares for patients with heart attack

Part Three: Case Studies1. Call activation system for primary PCIsMichelle Holt - Senior Sister, CCU SandwellSandwell West Birmingham Hospitals NHS TrustWhen primary PCI first became continuously available – a 24hour service, 7 days a week (24/7) – once an ‘alert call’ wasreceived from A&E, staff on the Cardiac Care Unit (CCU) hadto contact each member of the on-call PCI team individuallyto call them to the cardiac catheter (angiography) laboratory.This was often time-consuming and sometimes frustrating,particularly when occasionally the call was not answeredimmediately and voicemail-messaging services needed tobe activated. This would cause small but significant delaysto a service that was intended to provide rapid intervention.Consequently we developed our current PCI activation system.This simply requires the CCU staff to click on the appropriatecomputer icon, which is available on all CCU computers. Onentering a code and activating the call all on-call staff receivea simultaneous mobile telephone alert, informing them allthat there is a patient requiring primary PCI. Each member ofthe on-call team then enter a response code. This confirms toCCU that they have received and accepted the call, are on theirway, and records an estimated time of arrival. This system hasproved to be easy to use and much more convenient for allconcerned. Delays to catheter lab access have reduced.Staff at CCU2. Streamlining MINAP data collectionAmelia Hilton - Clinical Audit Co-ordinator (Pathology,Imaging and Medicine)Sandwell West Birmingham Hospitals NHS TrustWe have participated in MINAP from its inception. By so doingwe believe that we have been forced to look critically at ourpractice to ensure we meet nationally agreed targets andoptimise the outcomes for our patients.Over the years, we have changed not only the way we manageheart attack but also our approach to collecting data. Wewould like to share our ‘best practice’, with the MINAPcommunity, of a data collection process that takes minimaltime, while remaining highly accurate; inaccurate data isn’tworth collecting.Our A&E, CCU, Catheter laboratory and Clinical Effectiveness(audit) department, work together to get the best out ofMINAP. Cases are identified mainly via CCU, as the majorityof patients with chest pain are admitted to this ward (unlessthey require ITU admission, e.g. out of hospital cardiacarrest). Because the CCU staff start a MINAP form duringthe admission process, all the information available whilstthe patient is on the ward. They also photocopy relevantparts from case notes (i.e. ambulance sheet, ‘Casualtycard’, ECGs, patient ward admission form, Catheter labprocedure report) and attach these to the MINAP form.Dedicated “MINAP champions”, on each hospital site (mainlysenior staff nurses, ward managers and selected cardiologyconsultants) help check forms. We ensure all cases werecorrectly identified for the month and a form for each eligiblepatient is completed. We examine the BCIS database (i.e.a list of all non-elective PCI cases). The forms then cometo the Clinical Effectiveness department where the ClinicalAudit Co-ordinator for Medicine assesses each for accuracy,using the copied information from notes, CDA (clinical dataarchive) electronic patient records (i.e. GP details, patientdemographics, test results, ward activity, discharge summaryand any referrals for surgery), Ambulance data downloadsand BCIS database. It may sound extensive, but, having allthree databases open simultaneously allows a quick scanthrough the form and electronic data to ensure all fields werecompleted correctly. It only takes me about 5mins. Our trusthas around 60-70 MINAP eligible cases per month. With thisprocess I’m able to verify data quality and input data ontoNICOR via Lotus notes within one week. We hold a MINAPmeeting each month to discuss any queries and to learn fromany cases with a delay in reperfusion time. Minutes of thismeeting are circulated to all cardiology staff.MINAP Eleventh Public Report 201283

Once entered centrally, the full monthly dataset is exportedand saved in an Excel spreadsheet for each hospital site.These MINAP dataset exports have proved useful to auditspecific parts of the chest pain pathway and to demonstratesecondary prevention drug use in line with NICE guidance. It’struly useful to download your dataset every month. With theMINAP data we are also able to report to the trust Planning& Performance Management department as well as theInformation department with regards to PCI trends.MINAP can be daunting, but once you’ve streamlined asystem that works, it holds great benefit for the Trust and forclinicians and can be useful in many ways. Our Trust is proudto be part of the MINAP community.Example of MINAP dataset export84 MINAP How the NHS cares for patients with heart attack

3. Implementing a high-risk nSTEACSpathway across London as part of the LondonCardiovascular ProjectSotiris Antoniou - Consultant Pharmacist, Barts & theLondon NHS Trust, North-East London Cardiovascular andStroke NetworkSue Sawyer - Assistant Director of North-East LondonCardiovascular and Stroke NetworkJanet Lailey - Director of North-East London Cardiovascularand Stroke NetworkOn behalf of the London NSTEACS working group (Cardiacand Stroke network).Whilst primary PCI is recommended as the treatment ofchoice for patients with ST-elevation myocardial infarction(STEMI), evidence suggests that patients with acute coronarysyndromes presenting without ST elevation (nSTEACS)also benefit from early angiography and intervention. Thismanagement strategy reduces the likelihood of re-infarction,recurrent angina, hospital readmission, and long-term deathrates compared with medical therapy alone in this group ofpatients. This has led international professional bodies, suchas European Society of Cardiology to recommend that PCIshould be performed within 48 hours of hospital admission forpatients with high-risk nSTEACS.The London Cardiovascular Project was developed as a casefor change to improve cardiovascular services in London. Theavailable evidence suggested that clinical outcomes for thehigh-risk nSTEACS could be improved and the service for thesepatients further developed. The London Cardiac Networks weredirected by NHS London to support local implementation acrossthe capital with North East London Cardiac and Stroke Networkleading on the nSTEACS workstream.The nSTEACS model describes a pathway across a clinicalnetwork that sees the direct transfer of ‘high risk’ nSTEACSpatients from A&E to a specialist interventional centre forassessment and, if indicated, coronary intervention. In thismodel, patients are offered angiography within 24 hours ofinitial assessment. If a patient is triaged in a hospital thatcannot provide angiography within 24 hours, the patient isto be transferred to a unit that can provide this service. Thispathway improves access to the interventional centre, avoidsan admission at the district general hospital and long waits forinter-hospital transfer.The initiative involved close collaboration across organisations,including the London Ambulance Service, the local primarycare trusts (PCTs) and emergency physicians. The workincluded defining the patient group and clinical assessmentcriteria, education and training to DGH accident andemergency departments and modelling capacity implicationsat the interventional centre. Quality standards have alsobeen developed and agreed with the involvement of Londonclinicians and patient representatives to ensure the highestpossible quality of care is available at each stage of thepatients’ journey.With the avoidance of an inpatient admission, PCTs will nolonger be charged for the “actual or suspected myocardialinfarction”, and thus save the tariff of £3,662.Early implementers of the pathway started in September2011 and since March 2012, all London hospitals “fast-track”high-risk nSTEACS patients. The network has commissioned ajoint evaluation of this service with results expected in the nextfinancial year.4. Using the Myocardial Ischaemia National AuditProject (MINAP) to improve patient care in EastMidlands Ambulance Service (EMAS)Deborah Shaw – Clinical Audit and Research ManagerEast Midlands Ambulance ServiceMINAP was established to examine the quality of managementof heart attacks (myocardial infarctions (MI)) in hospitals inEngland and Wales. Participation in MINAP has helped tostrengthen the partnerships EMAS has with local hospitaltrusts. This has benefited our cardiac patients as workingtogether with the hospitals has helped us to identify areas ofcare which could be improvedThere is strong evidence to show that mortality rates in MIimprove the faster thrombolytic treatment or angioplastyare delivered. 22 23 24 EMAS therefore take seriously breachesin the time to treatment targets set in MINAP. To this end,representatives from EMAS attend regular meetings with thelocal hospital trusts where individual cases identified as beingpossible breaches in the MI care pathway are discussed. Oncediscrepancies between ambulance records and the entereddata have been identified the remaining cases are examined.Breaches identified as having occurred whilst the patient wasin the care of EMAS are taken back and discussed with theclinicians who attended the patient. Valid reasons for delaysare fed back to the group and, where appropriate, amended inthe MINAP data. This process also allows us to identify training22. De Luca G, van’t Hof AWJ, de Boer M et al; Time-to-treatment significantlyaffects the extent of ST - segment resolution and myocardial blush in patientswith acute myocardial infarction treated by primary angioplasty. Eur Heart J2004:25: 1009-101323. Brodie BR, Stuckey TD, Wall TC, et al. Importance of time to reperfusion for30-day and late survival and recovery of left ventricular function after primaryangioplasty for acute myocardial infarction. J Am Coll Cardiol 1998 32(5): 1312-924. Gibert AB. Importance of time delay in selecting reperfusion therapy. Rev EspCardiol 2007:60(8):791-3MINAP Eleventh Public Report 201285

issues or problems within the EMAS care processes enabling usto put in place steps to improve our service to patients.This practice has led to several joint educational initiativesbeing developed. It was noted that MIs weren’t always beingidentified from ECGs and therefore a series of ECG recognitionworkshops for ambulance clinicians were developed by aparamedic who is also one of the Trust’s quality improvementleads. These are co-delivered by a consultant cardiacnurse from one of the local hospital trusts. The workshopsemphasise MI recognition, identification of reciprocal changesand the need to keep on-scene times to a minimum to ensurethe patient has quick access to appropriate interventions.Information leaflets were also produced which can be given topatients’ relatives. One primary PCI centre contacted the Trustto commend paramedic Claire Hill on her quick thinking andskilled treatment which had certainly saved the patient’s lifeand led to an extremely good prognosis; Claire commented,”Clinical decision making is a vital element of the paramedicrole, I feel that the excellent foundations laid down by AlunRoebuck and Mark Hall during the ECG cardiac workshops,provided me the confidence and knowledge to ‘think out of thebox’ whilst making a clinical decision that was ‘the correctone’ and, more importantly, right for the patient. Additionally,being able to provide a primary PCI information leaflet tothe patient’s anxious daughter enabled me to leave scenepromptly, knowing that the daughter had a point of contact.”A project aimed at reducing on-scene times for chestpain patients is also in progress in one division of EMAS.Ambulance clinicians attend quality improvement workshopsand use process mapping and cause and effect diagrams toidentify causes of on-scene delays and solutions for reducingor eliminating those delays. Interventions will be developed,trialled and measured to see whether they do reduce timeon scene. A spread process will be used to trial the mosteffective interventions in other areas of the Trust to seewhether the improvements are reproduced. The intention willbe to establish the most effective interventions into the careprocesses across the whole trust.These are just some of the positive effects on patient carewhich involvement in MINAP is having in EMAS.5. Reducing the delay to reperfusion by calling999 - Primary Care Acute Chest Pain AwarenessProject in South West WalesAlison Turner - MINAP/Call to Reperfusion ImprovementFacilitator, South Wales Cardiac NetworkMarc Thomas - Information, Communications & ProjectManager,South Wales Cardiac NetworkThe Primary Care Acute Chest Pain Awareness Projectaddressed the evidence demonstrated by analysis of theMINAP database that people in Wales are more likely thantheir English counterparts to call their GP than dial 999directly. In conjunction with the British Heart Foundation,resources were developed to support a systematic approachto raising awareness, in both primary care and the public, ofthe need to respond to chest pain by dialling 999 rather thancalling surgeries by telephone or attending in person.Questionnaires performed before and after educationalsessions in primary care and the provision of printedinformation, demonstrated that there was an increase inthose STEMI patients contacting 999 directly (8.7%) with acorresponding reduction in those being admitted after seeingtheir GP.Data for a similar region in England and a neighbouringregion in Wales were compared. The greatest improvementwas demonstrated where both resources and primary careeducation had been provided.Alun Roebuck and Paramedic Hannah Coppack studying anECG during one of the workshops.Concerns that the project would create a significantly higherworkload for the Welsh Ambulance Service were allayedby the analysis of all chest pain calls pre and post projectimplementation. There was no increase in these calls, leadingto the conclusion that the calls would have been made to the999 system eventually; but were now being made in a moretimely way.86 MINAP How the NHS cares for patients with heart attack

The British Heart Foundation is a registered charity in England and Wales (225971) and in Scotland (SC039426)The project started when thrombolysis was the first linetreatment for STEMI patients in South West Wales. However,this approach to accessing reperfusion is just as applicable toprimary PCI where patients are conveyed straight to the tertiarycentre. Both treatment options have better outcomes the earlierthe intervention; reducing access delays are important.The resources developed include (Figure 23):Posters for public places, depicting signs and symptoms ofacute chest pain and what to doConcertina leaflets with a similar message, for use inrehabilitation / chronic disease management clinics, or anypublic eventA flow chart providing a systematic approach for nonclinicalstaff to signpost those complaining of acute chestpain to the 999 system (both presenting over the telephonerequesting a GP appointment or in person presenting to theGP surgery)A flow chart providing a systematic approach for clinicalstaff, who may not regularly deal with acute chest painpresentations, to enable a systematic approach.These resources can be downloaded from the South WalesCardiac Network website along with a generic PowerPointpresentation that can be adapted to suit local use.For further information please contact either Alison Turneralison.turner@wales.nhs.uk or Marc Thomas marc.thomas@wales.nhs.ukThe South Wales Cardiac Network project team would like tothank the following for their support:British Heart FoundationWelsh Ambulance Service TrustNorth East England Cardiovascular NetworkFigure 23. Posters, leaflets and flowcharts to raise awarenessof the need to respond to chest pain by dialling 999heart attack?know these symptomsless common symptomsIt is important to know that women are morelikely to have these less common symptoms.However, they may also experience the moretypical symptomsheart attacks...the facts– every year approximately 90,000 people diefrom heart attacks - that’s around 245 per day– around a third of heart attack patients diebefore reaching hospital– you are three times more likely to survive aheart attack if you call the emergency servicesimmediately and receive medical help in thefirst hour than if you waitheart attack?know these symptomsturn doubt into actionand call 999– a dull pain, ache or heavy feeling in the chest– a mild discomfort in the chest that makesAlthough the most common symptoms of a heart attackyou feel generally unwellare widely known, they vary from person to person.– a pain like indigestion which may spread However, not everyone having a heart attack has theseto the lower back and stomachtypical symptoms. Some people may only get one of thesesymptoms; some people may even get no symptoms at all.– feeling light-headed and dizzy, as well ashaving chest pain– jaw and neck ache, as well as having chest pain– aching in your jaw, neck or shoulders, usuallyas well as having chest pain.think quick... act fastturn doubt into actionand call 999.When someone has a heart attack it is vitalthat they act really quickly.Calling 999 immediately for an ambulance means you canget emergency treatment as soon as possible. This couldinclude clotbusting drugs – to restore the blood supplyto the heart – which should be given within minutesafter symptoms start.– central chest pain or tightness, which doesn’tMany people delay calling for an ambulance becausego away. This is often described as crushing orthey don’t recognise the symptoms... or because theyconstricting or like a tight band. The pain maydon’t believe that a heart attack may be happening.spread to the left arm, right arm, shoulders or jawIt is vital that people recognise the symptoms of a heart – feeling sick or being sickattack and take the right action quickly. If you suspect– shortness of breaththat you or someone else is having a heart attack youmust call 999 immediately.– sweating, although the skin may feel coldto the touch– reduced level of consciousness; or unconsciousness.don’t forget, doubt kills.so turn doubt into action –it could save your heartand your life.common symptomspain or discomfort in thechest that doesn’t go awayor may spread to neckand jawthink quick… act fastcall 999 immediatelythe pain may spread to theleft or right armyou may feel sick orshort of breathBHF_Symptoms Posters WALES_AW.indd 1 26/1/09 11:54:05The British Heart Foundation is a registered charity in England and Wales (225971) and in Scotland (SC039426)HistoryPatient complainsof acute chest painFurther HistoryCall emergencyservices andupgrade call to 999ExaminationDiagnosisof acutecoronary eventAcute Chest PainPatient ManagementAcute Chest Pain Management(Clinical) Patient complains of chest pain ordiscomfort and/or has collapsedPatient maycomplain of associatedsymptoms** AssociatedSymptoms• Shortness of breath• Nausea/vomiting• Sweating• Feeling light-headed• PallorTelephoneAsk Patient:Somebody is withIf patient is alone* Risk Factors the patient• Character/severity/location/radiation of pain• Smoking• Time of onset• Hyperlipidaemia• Is pain continuous?• Hypertension• Factors relieving pain• Diabetes• Past history of similar pain• Existing CHD• Risk Factors* • Ask for brief details • Family history of CHD• Related to activity (name, or exercise DOB, address) • Recent • cocaine Ask use for brief details• Is pain related to • trauma/injury? Note date/timeof patient (name, DOB,• Transfer the call toaddress)a doctor or nurse• Ask caller to redial 999Examination immediately• General appearance - pallor/clammy/cyanosedExamination• Vital signs – Pulse/BP/should not delayResp. rate/O2 Saturation/JVPtransport of patient• Auscultate chest•Dial 999 and ask to secondary careAbdominal examination – forsuspected aneurysm for ambulance forInform doctor• ECGchest pain to attendof the callat patient’s addressIn practiceCall 999 then alertdoctor or nurseImmediately• Sit patient down• Reassure help ison the way• Stay with patientuntil help arrivesEmergencyTreatmentSupport Equipment(where available):• Aspirin 300mgRemember:• Oxygen• Defibrillator• GTN sprayFor every minute • delay Oxygen in thrombolytic treatment 11 days survival is lost• Opiate analgesia/antiemetic• Suction• If not already called, call ambulance.• Airway• Bag Valve MaskThe British Heart Foundation’s Chest Pain Programmeaims to raise awareness of the symptoms Concertina_leaflet_WALES_AW.indd of a heart1 26/1/09 11:52:44attack and what action to take when someone thinksthey are having one. For information on the ChestPain Programme, email chestpain@bhf.org.ukRemember:For every minute delay in thrombolytic treatment 11 days survival is lostRegistered Charity Number 225971Registered Charity Number 225971Concertina_leaflet_WALES_AW.indd 2 26/1/09 11:52:47MINAP Eleventh Public Report 201287

6. Using MINAP data to reduce Call to Needletime in North WalesLucy Trent – Independent Nurse Practitioner, CardiologyWrexham Maelor HospitalWrexham Maelor Hospital is one of three general hospitalsthat form part of Betsi Cadwaladr University Health Board- the largest health trust in Wales. Our area is one of thefew places in the UK where medication (thrombolysis) is thecommonest treatment for acute heart attack (rather thanimmediate coronary stenting) and we continue to strive toincrease the delivery of thrombolysis in the community, beforearrival at hospital - pre-hospital thrombolysis (PHT) - whichis around 19% of the total. Because of the rural geography ofNorth Wales, there are significant challenges in meeting theCall-to-Needle (CTN) time standard of 60 minutes, unlessthe patient receives PHT. Monitoring the level of PHT throughMINAP and close working with the Welsh Ambulance Serviceis crucial for us to provide a high quality service for patients.Other issues influencing achievement of the CTN timeare the level of Paramedic confidence in interpretationof the ECG and the fairly restrictive Joint Royal CollegesAmbulance Liaison Committee protocol for pre-hospitalthrombolysis administration.Various methods have been adopted in an attempt to increasethe confidence of Paramedics in North Wales to give PHT. Forexample, a rolling programme of ECG teaching incorporatingBasic, Advanced and Arrhythmia days have been provided on amonthly basis for the past 4 years. These days are delivered byCardiology Nurse Practitioners at all three sites across NorthWales and are aimed at Primary and Secondary care staff andat Ambulance Service personnel. Additionally, ThrombolysisUpdate days, targeted at Paramedics, incorporate discussionabout real cases, advanced ECG recognition and how to accesssupport, advice and feedback about cases they have dealt with.Monthly Thrombolysis Review meetings take place and involvea Consultant Cardiologist, and staff from the cardiologyward, the emergency department (ED) and the WelshAmbulance Service, the ED/Cardiology Ward Matron and aCardiology Nurse Practitioner. MINAP data and particularcases are reviewed and critiqued in order to identify areas forimprovement. Examples of good practice are also highlightedand fed back to the relevant staff.Later this year an exciting development will be thetransmission of ECGs via email as pdf files from theambulance directly to the ED or Coronary Care Unit atthe receiving hospital. This has been a difficult project todevelop in no small part due to transmission problemswithin the beautiful but mountainous landscape of NorthWales. Following technological advances the quality of thetransmitted ECG is now good enough for clinicians in theED to give advice to the Paramedic on scene. This shouldenhance the decision making skills of the Paramedic whileensuring that the clinical decision of whether or not to deliverthrombolysis rests firmly with the Ambulance staff on theground. A telemetered ECG will also enhance the ‘pre-alert’sent to the receiving unit, even on those occasions when theParamedic cannot deliver PHT. This can save valuable minutesin providing definitive treatment.We hope that these initiatives will continue to improve the carefor heart attack patients in North Wales.7. Using MINAP to reduce Call to Needle times inNorth WalesPhilip M. Jones - Clinical Support Officer,North Region, Welsh Ambulance Service TrustTime is critical in the management of people with myocardialinfarction. Minutes lost at any stage may adversely affectoutcomes. Early diagnosis is pivotal and early treatment maybe life-saving. If, as in North Wales, primary PCI is not readilyavailable, thrombolysis should be given to patients with STEMIas soon as possible and within 60 minutes of their call forhelp, by the first appropriately trained person available. In ourlargely rural community, for many patients this can only beachieved by the delivery of pre-hospital thrombolysis (PHT)– intravenous thrombolytic treatment given before or duringtransport to hospital by paramedic ambulance personnel.During the past year 86 patients have received PHT.One of my responsibilities within the Welsh Ambulance ServiceTrust is to review all cases of PHT. This requires close liaisonwith colleagues in our receiving hospitals, with our team ofparamedics and our audit department.88 MINAP How the NHS cares for patients with heart attack

of six individual criteria - all interventions that should, whenadded to PHT, optimize the chances of restoring coronaryblood flow in someone with STEMI. Together they constitute acare bundle, namely:Aspirin administrationGlyceryl Trinitrate (GTN) administrationPain assessmentMorphine administrationAnalgesia (Morphine and/or Entonox) administrationOxygen saturation measurementExisting national guidelines for ambulance personnelmanagement of heart attack exclude some patients fromconsideration for PHT, e.g. age limit. Such clinical practiceguidelines are being reviewed and we will continue to referto them in our efforts to provide the best of care for thepopulation we serve.8. Our serviceLuke Coleman - Service Improvement Analyst, GreaterManchester and Cheshire Cardiac and Stroke NetworkNorth Regional Thrombolysis NewsletterA “call to needle” time is calculated for every patient whohas received PHT. Acquired 12 lead ECG rhythm stripsare reviewed and collated on to a database prior to beingforwarded to the audit department. Acute Coronary Syndromeforms and Patient Clinical Records relating to these patientsare scrutinised for exceptions to the 60-minute target. Whenthe target is not met, a review takes place in an attempt toimprove the service.Meetings are held each month at each of the hospitals,allowing detailed discussions of all relevant cases, focussingon areas for improvement – lessons to learn. Individualparamedics are offered feedback and any necessary support.I work closely with each of the hospital leads to ensure accurateMINAP data entry, particularly insofar as it reflects the earlieststage of heart attack care. We also support each other throughtraining. It is important that all paramedics are confident in 12lead ECG interpretations. Paramedics attend a programme ofECG refresher training, organised and delivered by CardiologyNurse Practitioners from Betsi Cadwalader University HealthBoard. Each month a North Regional Pre-Hospital ThrombolysisNewsletter is circulated to operational staff.Within the Ambulance Trust the pre hospital management ofSTEMI, including PHT, are included as a part of overall clinicalperformance indicators (CPI). This is a useful tool in theclinical effectiveness toolbox that can be used in the drive toimprove the quality of patient care. The STEMI CPI is made upSamantha Chapman - Primary PCI Coordinator, CentralManchester University Hospitals NHS Foundation TrustAdelaide Berrie - Primary PCI Coordinator, UniversityHospital of South Manchester NHS Foundation TrustRoger Gamon - Programme Manager, Greater Manchesterand Cheshire Cardiac and Stroke NetworkDr Farzin Fath-Ordoubadi - Consultant InterventionalCardiologist, Central Manchester University Hospitals NHSFoundation TrustIn Greater Manchester and Cheshire, we have two Heart AttackCentres (HACs) that perform primary PCI – Manchester RoyalInfirmary and Wythenshawe Hospital. They treat about 1200heart attacks a year, accepting patients directly from NorthWest Ambulance Service (NWAS) and from twelve Accidentand Emergency (A&E) departments across the local DistrictGeneral Hospitals. We serve a population of nearly 3 millionpeople (equivalent to the population of Wales!)We have the benefit of two primary PCI co-ordinators, onebased at each HAC. Although busy members of the cardiologyteam, they also act as a point of contact for any problemsthat may occur. They collect data for MINAP and the CardiacNetwork; monitor performance; as well as run educationalroad-shows with local A&E staff.All primary PCI services are keenly watching their call-toballoontimes and monitoring for bottlenecks in their servicewhich may lead to delays in patients receiving the best care.MINAP Eleventh Public Report 201289

MINAP data is essential to inform service improvement work.Broadly speaking we have three potential sources of delay:Ambulance availability (with a paramedic crew)Assessment and referral at A&E departmentsAccess to catheter labs at the HACWe strive to maintain data that are as current as possible. Wecollaborated with NWAS to ensure our IT systems integrate.As well as call-to-balloon times we monitor every step ofthe patient’s journey. In addition, the co-ordinators act onindividual cases when necessary. The Network also producesaggregated and individual hospital reports on different aspectsof the pathway.Direct referral by the ambulance service will always prove tobe the better option to ensure patients are treated in a timelymanner. Whenever a patient is picked up by NWAS but takento a local A&E rather than the nearest HAC, the primary PCIco-ordinators and NWAS clinical governance team investigatethe reasons why. There are many valid reasons for this, butif it was a missed opportunity for immediate transfer to theHAC then the details are fed back to the crew involved and theAdvanced Paramedic team to assist with training.DIDO?A&E departments have played an invaluable role in heartattack management, especially over the last 25 years, andin our view A&E departments will continue to be a crucialelement of our heart attack service. However, as the servicehas matured, more and more patients are being directlyreferred by the ambulance service to the HACs. As a result,District General Hospital A&E departments are seeing lessand less heart attack patients. Many of them no longerhave the chest pain specialist nurses available from thethrombolysis era. MINAP data shows that only about half ofthe patients that are admitted to a local A&E en route to theHAC achieve the call-to-balloon target of 150 minutes. Closerscrutiny of the data at the A&E shows that many patientshave long Door-In-Door-Out (DIDO) times, averaging about 60minutes for straightforward cases.To help improve this, the primary PCI co-ordinators arerunning educational road shows – highlighting the details ofthe pathway and presenting each A&E’s clinical audit resultsfor their DIDO times.Looking to 2012-13, the Network is also looking at introducinga local quality indicator to measure: the DIDO times forstraight forward cases. Harking back to the days whenpatients were treated with thrombolysis within 30 minutes, wehope patients will be in and out of the A&E within 30 minutes(Figure 24). Another goal is to invite A&E staff to visit catheterlabs as part of their training to see the end results of theirgood work in keeping DIDO times as low as possible.Figure 24. Call to balloon times and breakdown ofjourney stepsAverage time1801501209060300DirectCall to 1st doorTransferCall to balloonDoor-in-door-outHAC Door to balloonNational limitIndirect90 MINAP How the NHS cares for patients with heart attack

9. Use of MINAP data to develop and evaluate a24/7 primary PCI service.Lynne Charlton - Clinical Co-ordinator, CardiologyThe Belfast Trust pPCI GroupBelfast Health & Social Care TrustThe Cardiology Team in the Belfast Health & Social Care Trust(BHSCT) delivers care on three acute hospital sites withinthe City of Belfast, and in addition provides a regional cardiaccatherisation service for the Northern Ireland population.In 2008, following a review of trial evidence and clinicalguidelines, the BHSCT Cardiology team decided to developa primary PCI pilot service delivered on the Royal VictoriaHospital site on a ‘24/7’ basis and accessible to all patientswith STEMI within the Belfast Trust City catchment area.The Belfast Trust has submitted data to MINAP for severalyears. MINAP data from all three acute sites was instrumentalfrom the outset of the primary PCI pilot implementation planto estimate the number of potential patients who would accessthe service, and to determine trends in method, time and siteof presentation. Analysis of the data was key to informingdiscussions and in engagement with our colleagues fromthe Emergency Departments (ED) and the Northern IrelandAmbulance Service (NIAS), in order that they could assess thepotential impact on their services.In 2008/9 47% of patients in England and Wales receivedprimary PCI as their treatment for STEMI. Our Primary PCIpilot, which commenced in December 2009, was the first inIreland to offer a primary PCI service on a 24/7 basis and todate there have been 603 activations of this service.Evaluating the safety and quality of the pilot service is ofparamount importance. Robust audit is carried out by collatingindividual patient level data. The data extracted from MINAP,alongside other data sources, is used to construct timelinesrelating to each patient’s pathway of care which are crucial inassessing how well the pilot service is performing in relationto national and international standards.Data is reviewed at the primary PCI steering group wherethe primary PCI Co-ordinator, nurses, clinicians andmanagers meet regularly to review performance and qualitymatters, identify potential ways of improving the patientpathway and highlight excellent practices and outcomes tostaff within the Belfast Cardiology team, and also to our EDand NIAS colleagues.As part of the Programme for Government, the Departmentof Health, Social Services & Public Safety Northern Irelandplan to further develop a new primary PCI service model inNorthern Ireland.MINAP Eleventh Public Report 201291

10. Effective data collection for nSTEMIFiona Robinson – Cardiac Nurse PractitionerMid Essex Hospital Services NHS TrustWhen we started collecting data for MINAP we needed afool-proof method of identifying patients. It quickly becameapparent that if we were to rely on colleagues informingus of patients admitted with acute coronary syndrome, wewere unlikely to capture all the patients requiring entry intoMINAP. Therefore patients admitted to hospital with obviousor dynamic changes on their ECGs would have been identified,but those with more subtle changes may have been missed.We approached our colleagues in our Biochemistry laboratoryand, by liaising directly with them, we arranged that we wouldget a daily print out of all the patients who had had a Troponinblood analysis performed.We have adapted the MINAP data collection form, dividing itinto two parts. The data for Part 1 (Figure 25) is collected bythe Acute Cardiology Nurses who see the patients shortly afteradmission to the hospital. The patients’ demographic datais obtained from the Patient Administration System, alongwith dates of admission, names of admitting consultants,and General Practice details. Patients are then located withinthe hospital and visited on an individual basis and reviewed.Audit data is collected from the patient’s notes. It also givesus an opportunity to review the patient’s history, symptoms,risk factors and ECG and ensure an appropriate managementplan is in place for the patient. This therefore combines theprocess of data collection with enhanced clinical care. Themajority of the patients we follow up are situated on our AcuteAdmission Wards and therefore have been reviewed by theCardiology team who perform a daily ward round. Howeverthere are a few who have been admitted to outlying wardsand are picked up as a result of the elevated blood Troponinlevel. A typical example of such a case would be an elderlypatient, possibly admitted with a fracture to an Orthopaedicward, who may have had a Troponin estimation on admissionblood testing to investigate the cause of his/her fall. We wouldthen ask the Orthopaedic team to consider getting a formalCardiology review and to consider transfer of the patient to amore appropriate area. By identifying these patients they canFigure 25. Part 1 collected by Acute Cardiology NursesPart 1Part 1 BFH BFH PreviousmedicalhistoryPrevious medical history ng/ml ng/ml Data set V9.1 Data set V9.1 ECTC ECTC *Cath lab access delayed14. Delay in activating cath lab teamPre-PCI complication16. Equipment failure *Complete section below if 3.10 =5.Cardiac Arrest NB: All fields marked with # should be completed to achieve 100% on Data Completeness.92 MINAP How the NHS cares for patients with heart attack

Figure 26. Part 2 collected by Cardiac Rehabilitation TeamData set V9Part 2 – REHAB Data set V9Part 2 – REHAB NB: All fields marked with # should be completed to achieve 100% on Data Completeness.NB: All fields marked with # should be completed to achieve 100% on Data Completeness. NB: All fields marked with # should be completed to achieve 100% on Data Completeness.NB: All fields marked with # should be completed to achieve 100% on Data Completeness.be offered further investigations and also have the opportunityto be seen by the Cardiac Rehab team prior to discharge.When Part 1 is complete the data is passed over to the CardiacRehabilitation team who will collect the remaining information(Figure 26) with regards to discharge medication, rehab advice,any referrals for investigation/interventions etc. Once completethis form is passed to our Information Services departmentwho enter the data for us.11. St George’s Hospital’s pPCI ServiceDr Maciej Marciniak – Specialist RegistrarDr Pitt O Lim - Consultant CardiologistDepartment of Cardiology, St George’s Hospital, LondonThe major determinant of good outcome in MI is early coronaryrevascularisation. Hence the challenge is increasing publicawareness for symptoms and signs of MI so that those whoare having an MI will “call for help” as soon as possible. Theambulance service then takes the patients to designated HeartAttack Centres (HAC) for emergency primary percutaneouscoronary intervention (pPCI). The occluded coronary arteryis unblocked with a balloon and the culprit segment ofthe coronary artery is stented. This “call to balloon” timetherefore describes the patient journey from home to thecardiac catheter laboratory. It is a marker of the robustness ofambulance service and hospital set up, this duration closelyand inversely correlates with survival and outcome of MI. TheDanish researchers demonstrated that each hour delay isassociated with a 10% reduction in survival (Terkelsen andcolleagues JAMA 2010; 304: 763).The pPCI service at St George’s Hospital (SGH) has been inplace since October 2005 covering the population in the southwest of London with the help of the London Ambulance Service(LAS), and the service was extended to Surrey from May 2006with the help of the South East Coast Ambulance Service(SECAMB). As it takes longer for patients to journey fromSurrey to St George’s Hospital, we have installed the LIFENETsystem whereby an ECG can be wirelessly transmitted to ourCoronary Care Unit (CCU) for confirmation of MI prior to thejourney which can take up to 45 minutes.MINAP Eleventh Public Report 201293

Our pPCI service can be illustrated by the case, a 68 yearold man who experienced pain across his chest at 11:45. Hefortunately called for help early at 12:13, and was attended toby the SECAMB within five minutes, see the ECG transmittedto the CCU (Figure 27).He was taken to St George’s Hospital, bypassing his localhospital (8 miles), arriving at the door of the HAC at 13:15 (15miles), and was taken to the CCU first as the pPCI team wasnot on site over the weekend, and then to the cardiac catheterlaboratory when the pPCI team was fully assembled. The callfor help to door time was therefore 62 minutes.He underwent right radial approach emergency coronaryangiography and was found to have occluded his right coronaryartery. The artery re-opened with wiring, without the need forthrombectomy, and it was directly stented at 13:52 (Figure 28,upper panel). Hence the door to balloon time was 35 minutes(well below the golden hour) and the call to balloon time was97 minutes (< 150 minutes).He was also found to have a sub-totally occluded left anteriordescending artery, the distal vessel was collateralised bycollaterals from the re-opened right coronary artery. As therewas high likelihood that he would be symptomatic from thislesion, the artery was wired and directly stented (Figure 28,lower panel). Subsequent echocardiogram revealed preservedcardiac function with mild hypokinesia in the right coronaryartery territory and apical akinesia suggestive of previousdistal left anterior descending artery MI. His recovery wasuneventful. He was discharged 3 days later and was followedup at his local hospital.It has now been one year since the patient’s MI, he hascompleted his cardiac rehabilitation program locally and heis completely asymptomatic. This case illustrates that it ispossible to deliver a world class primary PCI service whendifferent service components work in concert to achieve acommon goal.Figure 27. ECG transferredvia LIFENET system to StGeorge’s Hospital by theambulance crew showingacute ST segment elevationMI in inferoposterior leads.Figure 28. Stages of pPCI toright coronary artery (top),and left anterior descendingartery (bottom). Arrowindicates occluded vessel – leftpanel; star shows inflatedstent balloon – middle panel;and final result of followingstenting – right panel.94 MINAP How the NHS cares for patients with heart attack

12. Shifting the FocusNicola Manning – Cardiology Audit NurseEmma Gendall - Cardiology Audit NurseNorth Bristol NHS Trust (NBT)During the past 10 years we have been committed to MINAPdata collection at North Bristol NHS Trust (NBT), working hardto ensure our data is accurate and robust. We regularly reviewour data locally and discuss it with our clinicians.In 2009, NBT ceased to operate a primary PCI (pPCI) servicefollowing a strategic decision to transfer STEMI patients tothe nearby Heart Institute. This provided us with a uniqueopportunity to shift our focus toward nSTEMI patient care.We seized this opportunity and after securing additionalstaff, commenced data collection on all nSTEMI patients.This additional data enabled us to perform in-depth analysisof our nSTEMI pathway in order to identify potential areasfor improvement.The Avon, Gloucester, Wiltshire and Somerset (AGWS) Cardiac& Stroke Network and local clinicians were also keen to lookat nSTEMI care on a regional level. As a result, five standards,directly relating to NICE guidance (CG94) for Acute CoronarySyndrome (ACS), were devised. In formulating these standardsit was important to ensure they correlated with the MINAPdataset enabling easy data extraction and analysis. The 5standards are as follows:All hospitals within the AGWS Network agreed to provide thisdata from MINAP and this is currently reviewed at quarterlymeetings. This is an example of national audit being usedto improve regional services. At NBT this enables us todirectly compare ourselves in specific areas of nSTEMI careagainst other local hospitals. Where we identify variationin performance this is discussed with other hospital teamsto determine how performance can be improved. Thiscollaborative working has enabled us to progress nSTEMIpatient care and service provision network-wide.An example of this is the role of outreach ACS nurse specialists,which appeared to be a key element of those hospitalsperforming well. At NBT we were able to take this evidence,derived from MINAP, to aid development of a cardiologyoutreach nurse position. We have now appointed and a 6 monthtrial is due to commence shortly. With this nurse in post we areconfident that an improvement in our admission to angiographytimings and length of stay will be evident. The MINAP databasewill be instrumental in continually tracking this progress,enabling our service to evolve.Percentage of patients cared for in CCUPercentage of patients reviewed by a cardiologistwithin 24 hoursPercentage of patients reviewed by a cardiologistduring admissionPercentage of patients receiving Glycoprotein IIb/IIIainhibitorsPercentage of patients receiving angiography within72 & 96 hours of admissionMINAP Eleventh Public Report 201295

Part 4: Research use of MINAP data1. OverviewProf Adam Timmis – Chairman of MINAP AcademicGroup & Professor of Clinical Cardiology, Barts and theLondon School of Medicine and DentistryLucia Gavalova – MINAP Project ManagerMINAP now has over 1 million records with almost 100%hospital participation since 2003, making it the largestcollection of ACS data in the world covering most of thepatient population in England and Wales. As such it is aninvaluable research resource for observational studies.The MINAP Academic Group was delegated responsibility bythe Health Quality Improvement Partnership (HQIP) to releaseits audit data to external researchers. Research applicationsare considered by the MINAP Academic Group, and if approvalis given the data fields required for the research are madeavailable. Some preference is given to those researcherswith a track record and experience in working with large andcomplex datasets. More recently, the NICOR Research Grouphas been set up to oversee research strategy across all thedatasets under its custodianship.When NICOR was established in 2011, it facilitated the linkageof the national cardiovascular audits providing researcherswith a unique resource for tracking patients through theircardiovascular journey. MINAP has also been linked withCPRD (Clinical Practice Research Database) to explore patientcare before and after a heart attack..Vital status is updated annually by the Office of NationalStatistics. Researchers only have access to anonymised data.This is in compliance with the strict governance rules thatensure patient confidentiality.The MINAP Academic Group welcomes applications fromMINAP hospitals that are interested in regional or nationalanalyses that seek answers to valid research questions,and are able to facilitate collaborations with experiencedacademics and statisticians.To date, over 35 publications have resulted from the useof MINAP data and more projects are currently on-goingfollowing an approval by the MINAP Academic Group. Thefollowing sections highlight just a few that were published inthe last year or so.2. Evaluation of a composite performanceindicator in the assessment of hospitals care forpatients after a heart attack, MINAP 2008 to 2009.Dr Alex Simms - Cardiology Specialist RegistrarDr Chris Gale - Consultant CardiologistCentre for Epidemiology and Biostatistics, University of LeedsMINAP reports hospital performance – the care providedat each hospital to patients admitted there – in terms of anumber of different indicators of good quality care. Each ofthese indicators identifies one intervention, among many,that has been shown to improve the outcome for patientsexperiencing heart attack. We used data from MINAP to designand study a summary or composite score of how hospitalsprovided a number of these previously described singlemeasures. We advocate summary scores rather than singleindicators of care (such as “did all patients receive aspirin ondischarge”) because they measure achievements across awider range of care. Our indicator was an opportunity-basedcomposite score (OBCS) designed to be incorporate data frompatients discharged from hospital following a heart attack.The score measured all the fulfilled opportunities a hospitalhad to provide a care process, expressed as a percent. Thecare processes we used were the prescription of aspirin,thienopyridine inhibitors, β-blocker, ACE inhibitor and statin,as well as referral for cardiac rehabilitation.We found that, overall, 95% of opportunities to provide carewere achieved. This varied between hospitals in Englandand Wales – ranging from 76% to 100% across 199 acutehospitals. A funnel plot of hospital OBCS allowed visualisationof this variation between hospital (Figure 29). We also foundthat the OBCS more readily highlighted hospitals (24%)that needed to improve their performance, than using theindividual components of the OBCS, and that it showed greaterconsistency in identifying lower performing hospitals.Importantly, our study demonstrated that the OBCS had asignificant inverse relationship with death at 30-days and at6-months. It showed that better performing hospitals hadlower mortality rates. This effect persisted despite adjustmentfor differences in patient characteristics and the performanceof coronary artery catheterisation. Each percentage increasein hospital OBCS was associated with, on average, a 3% and2% decline in 30-day and 6-month death rate, respectively.In conclusion, our study found that the OBCS offered a summaryof hospital care for patients with heart attack, discriminatedhospital performance and was linked with longer-termoutcomes. The OBCS may therefore be suitable for inclusion inhospital quality-improvement strategies and for the comparisonof hospital performance in England and Wales.96 MINAP How the NHS cares for patients with heart attack

Figure 29. Funnel plot of hospital OBCS. Red line showsoverall hospital median performance with dashed lines representing99.8% confidence intervals.1004. Prognosis following cardiac arrestcomplicating ST-elevation myocardial infarctionIain Squire – University of Leicester, Department ofCardiovascular Sciences and NIHR Biomedical Research Unitin Cardiovascular DiseaseHospital OBCS performance (%)9080700 3000 6000 9000 12000Number of hospital opportunities to provide careUCL 99.8% LCL 99.8%Albert E Alahmar - University Hospitals of Leicester,Department of CardiologyKym Snell – University of Leicester, Department ofCardiovascular Sciences and NIHR Biomedical Research Unitin Cardiovascular DiseaseMatthew F Yuyun - University Hospitals of Leicester,Department of CardiologyMuntaser D. Musameh - University of Leicester, Departmentof Cardiovascular Sciences and NIHR Biomedical ResearchUnit in Cardiovascular DiseaseNational AverageHospital OBCSAdam Timmis - Barts and the London School of Medicine andDentistry3. International comparisonsProf Adam Timmis – Chairman of MINAP Academic Group &Professor of Clinical Cardiology, Barts and the London Schoolof Medicine and DentistryAn exciting development in MINAP based research has been aninternational collaboration with Swedish Investigators. Swedenis the only other country in the world which, like England andWales, has a national registry (SWEDEHEART) recording alladmissions of patients with acute coronary syndromes. Thisprovides a unique opportunity to compare patient outcomesand develop insights into differences that might exist betweenthe process and quality of care in the two countries. The UKteam is headed by Harry Hemingway with Sheng-Chia Chungat UCL - plus representatives from NICOR - while the Swedishteam comprises a renowned group that includes Stefan James,Anders Jeppsson, and Tomas Jernberg. The project requiredcareful alignment of the MINAP and SWEDEHEART registriesin order that the respective data-fields were comparablebefore proceeding to a 30-day survival analysis. The data willbe presented later this year at the American Heart Associationmeeting and already a draft paper has been prepared forpublication in late 2012 or early 2013. Special attention will begiven to comparing emergency management and how it affectssurvival. So successful has been the MINAP-SWEDEHEARTcollaboration that plans are now being made for furthercomparative studies to learn more about differences in themanagement and prognosis of patients with myocardialinfarction in England and Wales and Sweden. The expectation isthat in future years collaborative research of this sort will extendto other countries in order to maximise MINAP’s researchpotential and learn more about effective ways to further reducecoronary mortality in England and Wales.John Birkhead – Former MINAP Clinical Director, NationalInstitute for Cardiovascular Outcomes and ResearchNilesh J Samani - University of Leicester, Department ofCardiovascular Sciences and NIHR Biomedical Research Unitin Cardiovascular DiseaseCardiac arrest is a dramatic complication of acute myocardialinfarction (AMI), one which often has important psychologicalconsequences for the patients, their family, and healthcareprofessionals. Instinctively one might think that cardiac arrestwould be associated with poor outcome after AMI. Howeverthe relevance of cardiac arrest complicating AMI to futureMINAP Eleventh Public Report 201297

prognosis is, surprisingly, unclear. The MINAP database allowsconsideration of this issue. We assessed the relevance tosurvival of cardiac arrest. We were particularly interested inthe impact of cardiac arrest on survival in patients who werelater discharged alive from hospital. Similarly, we consideredwhether cardiac arrest influenced outcome after 30 days if thepatient lived to that point, and whether it influenced outcomeafter 1 year if the patient was alive at that time.We analysed data from 41,467 patients admitted with STsegmentelevation AMI between 2008 and 2010. Cardiac arrestwas surprisingly common, recorded for 4,240 individuals,10.2% of the population. Approximately 30% of patientsexperiencing cardiac arrest died before discharge.Without adjustment for other clinical factors, cardiac arrestwas associated with increased risk of 30-day mortality, aswere greater age, higher heart rate and lower blood pressureon admission to hospital. However, after adjustment forcovariates, cardiac arrest had association with mortality upto, but not after, 30-days. In other words, the occurrence ofcardiac arrest during the early stages of AMI is associatedwith increased risk of death only up to 30 days after the event.Our results suggest that, for patients surviving to dischargefrom hospital after AMI, cardiac arrest is associated withincreased risk of death by 30-days, but not thereafter. Patientsexperiencing cardiac arrest after AMI may merit intensivemonitoring for one month, but can be reassured that thisdramatic event has no apparent association with mortality riskafter that point.5. The effects of hourly differences in airpollution on the risk of myocardial infarction:case crossover analysis of the MINAP 25Dr Krishnan Bhaskaran – Lecturer in Statistical Epidemiology,London School of Hygiene and Tropical MedicineProf Paul Wilkinson – Professor in EnvironmentalEpidemiology, London School of Hygiene and Tropical MedicineA unique strength of MINAP for research is the availability oftiming data on acute coronary syndromes. As part of a studyinvestigating the associations between environmental exposuresand myocardial infarction (MI) risk, we linked 79288 MI eventsin MINAP by time and location to data on ambient pollutionlevels obtained from pollution monitoring stations in 15 largeconurbations in England and Wales during the period 2003-2006. We assigned times to individual MIs using the recordedtime of symptom onset, where it was available (74% of cases);for the remainder we used time of call for help, or time ofarrival at hospital. For each individual experiencing an MI, wecompared their exposure to five key pollutants at the time oftheir MI, with their exposure at the same time of day on otherdays in the same calendar month (when they did not have anMI). We also looked for associations between pollution levelsand MI risk that might be delayed (lagged) by up to 72 hours,since exposure to pollution at a particular time might affect MIrisk some time later.Higher ambient levels of small particles (known as PM10),and nitrogen dioxide (NO 2 ), which are typically traffic-related,appeared to be associated with transiently increased risk ofmyocardial infarction 1-6 hours after exposure (Figure 30.For every 10µg/m 3 increase in PM10 and NO 2 levels, MI riskwas estimated to increase by 1.2% and 1.1% respectively.Interestingly, we observed that later reductions in risk appearedto offset the initial risk increase; over a 3-day period, higherpollution levels were not associated with a net increase in MIrisk. This suggests that exposure to traffic-related air pollutionmay be associated with triggering MIs early in highly vulnerablepatients who would in any case have experienced an MI a littlelater. For ozone, carbon monoxide (CO) and sulphur dioxide (SO 2 )there was no evidence of any detrimental effect.Our study was the largest to date to investigate associationsbetween the commonly measured pollutants and myocardialinfarction risk at an hourly temporal resolution. MINAP’scoverage means that hospital admissions recorded shouldhave been representative of those occurring within theconurbations under study, though one must be mindful of thefact that MIs leading to death before hospital admission wouldhave been excluded from our analysis. A further strengthwas that we were able to use information within MINAP tovalidate MI diagnoses: 89% of diagnoses were backed up byelectrocardiogram (ECG) or blood marker data (troponin/creatine kinase) consistent with MI.Our results suggest that there may be limited potential forreducing the net burden of MI through reductions in pollutionalone, but that should not undermine calls for action onair pollution, which has well established associations withbroader health outcomes including overall, respiratory, andcardiovascular mortality. One implication of our findings isthat other, perhaps non-thrombotic, mechanisms are moreimportant drivers of this net mortality increases associatedwith higher pollution levels.25. Bhaskaran K, Hajat S, Armstrong B, Haines A, Herrett E, Wilkinson P,Smeeth L. The effects of hourly differences in air pollution on the risk of myocardialinfarction: case crossover analysis of the MINAP database. BMJ 2011;343:d5531doi98 MINAP How the NHS cares for patients with heart attack

Figure 30. Estimated excess risk of myocardial infarction over time associated with exposure to different pollutantsMINAP Eleventh Public Report 201299

Part 5: Conclusions/Recommendations1. Importance of nSTEMI data collectionSome years ago the Myocardial Infarction National AuditProject became the Myocardial Ischaemia NationalAudit Project. This subtle change of title was intendedto emphasise that participation in MINAP provided anopportunity to analyse the care of all patients admitted tohospital with ACS, and not just those with ST-elevation.Patients presenting with, rather than without, STelevationare more easy to identify and their immediatemanagement lends itself to audit – through reportingreperfusion rates and delays to reperfusion (e.g. Door-toballoon).However most patients with ACS have nSTEMI.Compared with STEMI, patients with nSTEMI tend to be olderand have more associated medical (and presumably social)problems. While most patients with STEMI are taken directlyto Heart Attack Centres for primary PCI, those with nSTEMI –who do not require immediate PCI – tend to be taken directlyto the nearest non-interventional hospital, and in some caseslater transferred to Heart Attack Centres. Their length of stayin hospital is longer and their risk of dying is greater – albeitthose at greatest risk can be identified using validated riskscoring systems.The identification of nSTEMI (and therefore the collectionof data about these patients) is not always easy – see thecase study by Fiona Robinson to understand the amount ofeffort and time that may need to be invested. Nevertheless,as that case study shows, it is not an impossible task, andshould, we believe, be the aspiration of all admitting hospitalsthat are interested in assuring and improving the quality ofcare provided to this group. Although there has been animprovement in nSTEMI data collection, there are still anumber of hospitals that are submitting limited, and in somecases no, data.MINAP is committed to provide its participating hospitals allpossible support, in term of understanding the database, thedataset and its definitions and the available analyses that willinform the hospital about their performance. We will facilitatepeer support, where possible, and networking to foster thesharing of good practice for hospitals to learn from eachother’s successes.2. Rapidity of transfer for angiography followingnSTEMIThe need for comparative audit is particularly pressing forpatients with nSTEMI given the significant variation in theinterval from admission to performance of coronary angiographypresented in this report. The optimum timing of angiography(and subsequent revascualrisation) remains unclear. Groupsdeveloping guidelines have interpreted differently the resultsof trials comparing medical treatment (drugs) and PCI withmedical treatment alone, suggesting maximum acceptabledelays of anything from 24 to 96 hours. Large numbers ofpatients are not yet receiving this standard of care. Even ifthere is no direct relationship between earlier angiographyand outcome (judged by mortality and further heart attack),those who do receive earlier angiography are more likely to bedischarged home and avoid prolonged hospitalisation.3. Continued investment in time, personnel andmoney in participation in national clinical auditSome perceive national clinical audit as a burden upon alreadybusy NHS staff, the collection and submission of data beingdivorced from caring for patients. During times of financialconstraint there is a temptation to reduce investment insuch exercises, even though participation in clinical auditis mandated by the Department of Health. Conversely, wewould argue that such conditions – a working environmentcharacterised by cost containment and efficiency – increase,rather than decrease the need for reliable contemporaryknowledge of hospital performance. As demonstrated in thecase studies, such information, when used wisely, can beused to inform local improvements. Further, it can be used toreassure users, providers and commissioners that the qualityof care provided to individual patients is not being sacrificed asservices are reconfigured.The quality of contemporary data is extremely important ifa true picture is to emerge. MINAP data are quite complexand its collection, often needing extraction from medicalnotes, requires experience – it becomes more manageableover time. We strongly recommend that each hospital/Trusthas a designated individual responsible for clinical auditdata and that they are supported by a local cardiologist asclinical input has shown to result in higher quality data. Highturnover and reduction in the number of staff in clinical auditdepartments is in no one’s interest.100 MINAP How the NHS cares for patients with heart attack

Part 6: AppendicesAppendix 1: MINAP Steering GroupAppendix 2: MAG membershipDr Clive WestonDr Mark de BelderProf Sir Roger Boyle CBEChairmanClinical Director MINAPInterventional Cardiologist,James Cook University HospitalCo-director of NICORProf Adam TimmisDr Mark de BelderChair, Professor of ClinicalCardiology, Barts and theLondon School of Medicine andDentistryInterventional Cardiologist,James Cook University HospitalDr David CunninghamDr Kevin StewartSenior Strategist for NationalCardiac Audits, NICORClinical Director, ClinicalEffectiveness & Evaluation Unit,Royal College of PhysiciansDr Clive WestonProf Sir Roger Boyle CBEDr David CunninghamClinical Director, MINAPCo-director of NICORSenior Strategist for NationalCardiac Audits, NICORProf Peter WeissbergMedical Director, British HeartFoundationProf Keith FoxProfessor of Cardiology,University of EdinburghProf Tom QuinnMs Fiona DudleyProf Adam TimmisDr Mark DancySue ManuelAssociate Dean for Health &Medical Strategy, University ofSurreyLead Nurse for Cardiology:Mid Yorkshire HospitalsNHS TrustChairman of MINAP AcademicGroupNational Clinical Chair forNHS ImprovementMINAP Senior Developer, NICORDr Chris GaleProf Harry HemingwayDr Owen NicholasNIHR Clinician Scientist AwardSenior Lecturer in CardiovascularHealth Research and HonoraryConsultant CardiologistProfessor of ClinicalEpidemiology, Department ofEpidemiology and Public Health,University College of LondonSenior Research Associate,Department of Epidemiology andPublic Health, University CollegeLondonMrs Lynne WalkerMr Alan KeysNICOR Programme ManagerMINAP Patient/Carer GroupRepresentativeProf Iain SquireProfessor of CardiovascularMedicine, Department ofCardiovascular Science,University of LeicesterMr Iain ThomasMINAP Patient/Carer GroupRepresentativeProf Paul WilkinsonProfessor of EnvironmentalEpidemiology, London School ofHygiene & Tropical MedicineDr Iain SimpsonMs Lucia GavalovaPresident, BritishCardiovascular SocietyMINAP Project ManagerDr Spiros DenaxasCALIBER Data Manager,Department of Epidemiology andPublic Health, University CollegeLondonMr Ronald van LeevenMINAP Project Co-ordinatorLynne WalkerNICOR Programme ManagerMs Lucia GavalovaMINAP Project ManagerDr Emmanuel LazaridisSenior Information Analyst,NICORMINAP Eleventh Public Report 2012 101

Appendix 3: GlossaryACE inhibitorsA class of drug with powerful vasodilating effects on arteries.Used – in the context of heart attack - for the treatment andprevention of heart failure. Also used widely for treatment ofhigh blood pressure. Angiotensin receptor blockers (ARBs)have broadly similar effects.Acute coronary syndrome (ACS)This term covers all cardiac episodes that result from suddenand spontaneous blockage or near blockage of a coronaryartery, often resulting in some degree of cardiac damage. Theunderlying cause of the clot is rupture of the fine lining of aheart artery (plaque rupture), which allows blood to come incontact with the tissues of the wall of the artery, promotingthe development of clot. The degree of damage and the typeof syndrome (heart attack) that results from the blockagedepends on the size and position of the artery and the amountof clot that develops within the artery. Not all acute coronarysyndromes are suitable for treatment with primary angioplastyor thrombolytic drugs, and the decision is mainly guided by theappearances of the ECG.AnginaSymptoms of chest pain that occur when narrowing of thecoronary arteries prevent enough oxygen containing bloodreaching the heart muscle when its demands are high, such asduring exercise.AngiogramAn X-ray investigation performed under a local anaestheticthat produces images of the flow of blood within an artery(in this case the coronary artery). Narrowings and completeblockages within the arteries can be identified during theangiogram and this allows decisions to be made regardingtreatment. Often an angiogram is an immediate precursor toan angioplasty and stent implantation or to coronary arterybypass grafting.Anti-platelet drugsDrugs including aspirin, clopidogrel, prasugrel and ticagrelorthat prevent blood clotting. Anti-platelet drugs act by reducingthe ‘stickiness’ of the small blood cells that can clumptogether to form a clot.ApicalAt the apex or tip of the heart.ArrhythmiaA group of conditions in which there is abnormal electricalactivity in the heart. The heartbeat may be too fast or too slow,and may be regular or irregular.AspirinAn anti-platelet drug used to help prevent bloodclots forming.Beta blockersBeta blockers are drugs that block the actions of the hormoneadrenaline that makes the heart beat faster and morevigorously. They are used to help prevent attacks of angina, tolower blood pressure, to help control abnormal heart rhythmsand to reduce the risk of further heart attack in people whohave already had one. They may also be used in the treatmentof heart failure.Call-to-balloon (CTB) timeThe interval between the patient alerting the healthservices that they have symptoms of a heart attack and theperformance of primary angioplasty.Call-to-needle (CTN) timeThe interval between the patient alerting the healthservices that they have symptoms of a heart attack and theadministration of thrombolytic therapy.Cardiac arrestWhen the heart stops pumping blood around the body.The most common cause of a cardiac arrest is a lifethreatening abnormal heart rhythm.Cardiac enzymesCardiac enzyme tests (including troponin tests) help to show ifheart muscle has been damaged.Cardiac ruptureA laceration or tearing of the walls of the heart mostcommonly seen as a serious complication of a heart attack.Cardiogenic shockAn inadequate circulation of blood caused by the failure of theheart to pump effectively. It can be due to damage to the heartmuscle, most often from a large myocardial infarction.CardiomyopathyA disease of the heart muscle that leads to generaliseddeterioration of the muscle and its pumping ability.CholesterolA fatty substance mainly made by the liver. It plays a vital rolein the functioning of every cell wall throughout the body. Thebody also uses cholesterol to make other vital chemicals.However, too much cholesterol in the blood increases the riskof coronary heart disease and heart attacks.ClopidogrelAn anti-platelet drug that has been shown to have added benefitwhen given with aspirin during an acute coronary syndrome.Clot dissolving drugsDrugs used to dissolve the thrombus within a heartartery which is the underlying cause of heart attack, see‘thrombolytic treatment’.102 MINAP How the NHS cares for patients with heart attack

Coronary thrombosisThe formation of a blood clot one of the arteries carrying bloodto the heart muscle.Contractile functionThe ability of the heart to pump blood.Contractile dysfunction/HypocontractilityA decline in pumping action of the heart where contractionis inefficient and unable to adequately supply oxygen andnutrients to body organs.Door-to-balloon (DTB) timeThe interval between the ambulance arriving at a hospital andthe performance of primary angioplasty.Door-to-needle (DTN) timeThe interval between the ambulance arriving at a hospital andthe administration of thrombolytic therapy.ElectrocardiogramAlso known as ‘ECG’. A test to record the rhythm and electricalactivity of the heart. The ECG can often show if a person has hada heart attack, either recently or some time ago. It can also tellif reperfusion therapy is appropriate and if it has been effective.EchocardiographyA test that uses sound waves to create moving pictures ofthe heart. The pictures show the size and shape of theheart, pumping capacity and the location and extent of anytissue damage.Heart attackThe term applied to the symptoms, usually but not alwaysinvolving chest pain, which develop when a clot (thrombus)develops within a heart artery as a result of spontaneousdamage to the inner lining of the artery (plaque rupture).The heart muscle supplied by the blocked artery sufferspermanent damage if the blood supply is not restored quickly.The damage to heart muscle carries a risk of sudden death,and heart failure in people who survive.Heart Attack CentreA hospital that provides coronary interventions for patientswith acute coronary syndromes.Heart failureHeart failure occurs when a damaged heart becomes lessefficient at pumping blood round the body. This may resultfrom damage to the heart muscle caused by a heart attack.There are typically symptoms of breathlessness with exertionand, later, swelling (oedema) of lower limbs.IQRInterquartile range; the value at 25% and 75% of an orderedset of values.Left ventricleThe left lower chamber of the heart that receives oxygenatedblood from the left atrium and pumps it out under highpressure through the aorta to the body.MedianThe number falling in the middle of a ranked series ofnumbers.Myocardial infarctionA heart attack in which heart muscle damage is confirmed byblood testing.NecrosisA form of cell injury that results in the death of cells inliving tissue.Non-ST elevation myocardial infarction (nSTEMI)A heart attack that occurs in the absence of ST segmentelevation on the ECG. In these patients urgent admission tohospital is mandated but immediate reperfusion therapy isnot required.PericarditisInflammation of the outer sac that surrounds the heart. Whenpericarditis occurs, the amount of fluid between the two layersof the pericardium increases. This increased fluid presses onthe heart and restricts its pumping action.Pre-hospital thrombolysisThrombolytic treatment given before arrival in hospital, usuallyin the ambulance by paramedics. This saves time in providingtreatment and is used with longer journey times.Primary percutaneous coronary intervention (PCI)A technique to re-open the blocked coronary arteryresponsible for the heart attack. A fine catheter (tube) ispassed, under local anaesthetic, from an artery in the leg orarm into the blocked heart artery. A small inflatable balloonis then passed through the catheter and across the blockage,allowing the artery to be re-opened by temporary inflation ofthe balloon. This part of the technique is called angioplastyand when used as the initial treatment for heart attack canbe referred to as ‘primary angioplasty’. Following opening ofthe artery, this is normally kept open by a small expandablemetal tube (stent) whichis passed into the arterywith the angioplastyballoon. The umbrellaterm that encompassesboth balloon dilatation(angioplasty) and stentinsertion (stenting) is‘percutaneous coronaryintervention’ (PCI).MINAP Eleventh Public Report 2012 103

Pulmonary oedemaAn abnormal buildup of fluid in the air sacs of the lungs, whichleads to shortness of breath.QT intervalA measure of the time between the start of the Q wave and theend of the T wave in the heart’s electrical cycle.Re-infarctionThe development of evidence of re-occlusion (furtherblockage) of, or development of blood clot within, the coronaryartery that was responsible for the original heart attack. Thiswould normally occur after the original blockage had beensuccessfully treated.Reperfusion treatmentThe term used to cover both techniques, thrombolytic treatmentand primary PCI, for reopening a coronary artery as anemergency. These treatments are suitable only for certain typesof heart attack characterised by typical electrocardiographicappearances described as ST segment elevation.RevascularisationInterventions that improve the blood supply to the heart,including PCI or coronary artery bypass graftingSecondary prevention treatmentMedication that reduces the risk of further heart attack, or therisk of complications such as heart failure. See aspirin, betablockers, ACE inhibitors and ARBs, clopidogrel and statins.These medications are usually initially prescribed to allpatients who can tolerate them.StatinsDrugs used to reduce cholesterol levels in the blood.ST elevation myocardial infarctionA heart attack characterized by a specific abnormalappearance on the ECG (ST segment elevation) thought to beindicative of complete occlusion of a coronary artery.Thienopyridine inhibitorsAntiplatelet agents, of which clopidogrel and prasugrel arepresently licensed for use. A similar drug, ticagrelor, is alsonow being used in some patients.Thromboembolic complicationsFormation of a clot (thrombus) in a blood vessel that breaksloose and is carried by the blood stream to plug anothervessel. The clot may plug a vessel in the lungs, brain,gastrointestinal tract, kidneys, or leg.Thrombolytic treatmentThe outcome for certain types of heart attack can be improvedby using clot-dissolving (thrombolytic) drugs. Thrombolytictreatment is effective up to about 12 hours after the onset ofsymptoms but is most effective when given very early afterthe symptoms started. Thrombolytic drugs are not givenunless there are typical changes on the electrocardiogram(ECG). As these drugs are designed to dissolve clots, they maybe unsuitable for some patients who are at risk of internalbleeding. Patients at significant risk of bleeding may not begiven this treatment where the risk of bleeding is greater thanany potential benefit. Where this risk exists primary PCI maybe an effective alternative.ThrombusA blood clot, the development of which is known a thrombosis.VentriculographyA medical imaging test used to determine a patient’s cardiacfunction which involves an injection of a dye that shows up onX-rays, into the heart’s ventricles to measure the volume ofblood pumped.Appendix 4: MINAP Publications1999Rickards A, Cunningham D. From quantity to quality: the centralcardiac audit database project. Heart 1999;82: 1118-1122Birkhead JS, Norris RM, Quinn T et al. Acute myocardialinfarction: a core dataset. Royal College of Physicians 1999.2000Birkhead JS. Responding to the requirements of the NationalService Framework for coronary heart disease: a core dataset formyocardial infarction. Heart 2000; 84: 116-72001Birkhead JS, Pearson M, Norris RM et al. Measurement ofClinical Performance: Practical approaches in acute myocardialinfarction. Eds Robert West and Robin Norris. Royal College ofPhysicians 2001.Birkhead JS, Georgiou A, Knight L et al. (eds) A baselinesurvey of facilities for the management of acute myocardialinfarction in England 2000. London: Royal College ofPhysicians 20012002Birkhead JS. The National Audit of Myocardial Infarction: A newdevelopment in the audit process. Journal of Clinical Excellence2002; 4: 379-85.2004Norris RM, Lowe D, Birkhead JS. Can successful treatmentof cardiac arrest be a performance indicator for hospitals?Resuscitation. 2004; 60: 263-269.104 MINAP How the NHS cares for patients with heart attack

Birkhead J, Walker L. MINAP, a project in evolution. Hospitalmedicine 2004; 452-53.Birkhead J, Walker L, Pearson M, at al. Improving care forpatients with acute coronary syndromes; initial results fromthe National Audit of Myocardial Infarction (MINAP). Heart2004; 90: 1004-9.2005Quinn T, Weston C, Birkhead J, et al on behalf of SteeringGroup. Redefining the coronary care unit: an observational studyof patients admitted to hospital in England and Wales in 2003-2005. Quarterly Journal of Medicine 2005; 98 (11): 797-802.2006Birkhead, J, Weston, C, Lowe, D on behalf of the NationalAudit of Myocardial Infarction project (MINAP) SteeringGroup. Impact of specialty of admitting physician and type ofhospital on care and outcome for myocardial infarction in Englandand Wales during 2004-5: observational study. BMJ 2006;332:1306-1311.Gale CP, Roberts AP, Batin PD, Hall AS. Funnel plots,performance variation and the Myocardial Infarction NationalAudit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug2;6:34.2007Weston C, Walker L, and Birkhead J. Early impact of insulintreatment on mortality for hyperglycaemic patients withoutknown diabetes who present with an acute coronary syndrome.Heart 2007; 93: 542-1546.Birkhead J, Pearson J, Walker L on behalf of the MINAPSteering Group. Management of acute coronary syndromes inEngland and Wales: a survey of facilities in 2006. Royal College ofPhysicians, London 2007. ISBN 978-1-86016-314-2.2008Weston C. Performance indicators in acute myocardial infarction:a proposal for future assessment of good quality care. Heart2008; 94:139-1401.Gale CP, Manda SO, Batin PD, et al. Predictors of inhospitalmortality for patients admitted with ST-elevationmyocardial infarction: a real-world study using the MyocardialInfarction National Audit Project (MINAP) database. 2008Nov;94(11):1407-12.Ben-Shlomo Y, Naqvi H, Baker I. Ethnic differences inhealthcare-seeking behaviour and management for acutechest pain: secondary analysis of the MINAP dataset 2002–2003. Heart 2008; 94: 354 - 3592009Gale CP, Manda SO, Weston CF, et al. Evaluation of riskscores for risk stratification of acute coronary syndromes in theMyocardial Infarction National Audit Project (MINAP) database.2009 Mar;95(3):221-7.Bhaskaran K, Hajat S, Haines A, et al. Effects of air pollution onthe incidence of myocardial infarction. Heart,2009; 95, 1746-59.Horne S, Weston C, Quinn T, et al. The impact of pre-hospitalthrombolytic treatment on re-infarction rates: analysis of theMyocardial Infarction National Audit Project (MINAP). Heart 2009;95: 559-563.Birkhead J, Weston C, Chen R. Determinants and outcomes ofcoronary angiography after non-ST-segment elevation myocardialinfarction. A cohort study of the Myocardial Ischaemia NationalAudit Project (MINAP). Heart 2009; 95:1593-9.Bhaskaran K, Hajat S, Haines AP, et al. Effects of ambienttemperature on the incidence of myocardial infarction. Heart2009, 95, 1760-9.2010Herrett E, Smeeth L, Walker L, Weston C; on behalf of theMINAP Academic Group. The Myocardial Ischaemia NationalAudit Project (MINAP). Heart 2010;96:1264-1267.Bhaskaran K, Hajat S, Haines AP, et al. The short termeffects of temperature on the risk of myocardial infarction inEngland and Wales – a multicity daily time series study using theMyocardial Ischaemia National Audit Project (MINAP) database.BMJ 2010;341: c3823.West RM, Cattle BA, Bouyssie M et al. Impact of hospitalproportion and volume on primary PCI performance in Englandand Wales. European Heart Journal 2010.; 32(6):706-11McNamara RL. Cardiovascular registry research comes of age.Heart 2010; 96:908-10.Brophy S, Cooksey R, Gravenor MB, et al. Population basedabsolute and relative survival to 1 year of people with diabetesfollowing a myocardial infarction: a cohort study using hospitaladmissions data. BMC Public Health 2010;10:338.Widimsky P, Wijns W, Fajadet J, et al. European Associationfor Percutaneous Cardiovascular Interventions. Reperfusiontherapy for ST elevation acute myocardial infarction in Europe:description of the current situation in 30 countries. Eur Heart J2010; 31:943-572011Gale CP, Cattle BA, Woolsten A, et al. Resolving inequalitiesin care? Reduced mortality in the elderly after acute coronarysyndromes: Myocardial Ischaemia National Audit Project 2004-2010. Eur Heart J. 2012 Mar;33(5):630-9. Epub 2011 Oct 18.MINAP Eleventh Public Report 2012 105

Cattle BA, Baxter PD, Greenwood DC, Gale CP, West RM.Multiple imputation for completion of a national clinical auditdataset. Statistics in Medicine 2011; 30(22):2736-53Gale CP, Cattle BA, Moore J, et al. Impact of missing data onstandardised mortality ratios for acute myocardial infarction:Evidence from the Myocardial Ischaemia National Audit Project(MINAP) 2004-2007. Heart 2011 Dec; 97(23):1926-31Bhaskaran K, Hajat S, Armstrong B, et al. The effects of hourlydifferences in air pollution on the risk of myocardial infarction:case crossover analysis of the MINAP database. BMJ 2011;343:d5531doiHuynh T, Birkhead J, Huber K, et al. The pre-hospitalfibrinolysis experience in Europe and North America andimplications for wider dissemination. JACC Cardiovasc Interv.2011 Aug;4(8):877-83.White, C. UK access to primary angioplasty services is still highlyvariable. BMJ 2011; 343 doi: 10.1136/bmj.d5508 (Published 2September 2011)Boggon R, van Staa TP, Timmis A, et al. Clopidogreldiscontinuation after acute coronary syndromes: frequency,predictors and associations with death and myocardial infarction--a hospital registry-primary care linked cohort (MINAP-GPRD).Eur Heart J. 2011 Oct;32(19):2376-86. Epub 2011 Aug 29.2012Douglas IJ, Evans SJ, Hingorani AD, et al. Clopidogrel andinteraction with proton pump inhibitors: comparison betweencohort and within person study designs. BMJ. 2012 Jul10;345:e4388. doi: 10.1136/bmj.e4388.Gale CP, Weston C, Denaxas S, et al. Engaging with the clinicaldata transparency initiative: a view from the National Institutefor Cardiovascular Outcomes Research (NICOR). Heart. 2012Jul;98(14):1040-1043.Birkhead J, Weston C, Hammersley M. Failure of NICE toresolve the question about the management of hyperglycaemia inacute coronary syndrome. Heart. 2012 Aug;98(16):1192-3. Epub2012 May 9.Simms A, Reynolds S, Pieper K, et al. Evaluation of the NICEmini-GRACE risk scores for acute myocardial infarction using theMyocardial Ischaemia National Audit Project (MINAP) 2003-2009:National Institute for Cardiovascular Outcomes Research (NICOR).Heart. 2012 Sep 22. [Epub ahead of print]Simms AD, Baxter PD, Cattle BA, et al.Do composite measures of hospital performance predict mortalityin survivors of acute myocardial infarction? Analysis of individualhospital performance and outcome for the National Institute forCardiovascular Outcomes Research (NICOR). European HeartJournal Acute Cardiovascular Care (in press)Gale CP, Cattle BA, Baxter PD, et al. Improving quality of carein the elderly after acute myocardial infarction? Age and sexdependentimprovements in care and early mortality of 478,242patients with acute myocardial infarction in the MyocardialIschaemia National Audit Project (MINAP) 2004–2009: NationalInstitute for Cardiovascular Outcomes Research (NICOR).International Journal of Cardiology (in press)Appendix 5: Contacts for information on heartand heart related conditionsAmerican Heart Associationhttp://www.heart.org/HEARTORG/Conditions/Conditions_UCM_001087_SubHomePage.jspPatient.co.ukhttp://www.patient.co.uk/doctor/epidemiology-of-coronaryheart-diseaseBlood Pressure Associationhttp://www.bloodpressureuk.org/HomeBritish Cardiac Patients Associationhttp://www.bcpa.co.uk/British Cardiovascular Societyhttp://www.bcs.com/pages/default.aspBritish Heart Foundationhttp://www.bhf.org.uk/NB: The British Heart Foundation runs a heart informationline that provides information about heart conditions and theirmanagement. It cannot respond to questions about services inindividual hospitals. Tel: 0300 330 3311 (similar cost to 01 or 02numbers). Lines are usually open 9am-5pm Monday to Friday.Diabetes UKhttp://www.diabetes.org.uk/National Obesity Forumhttp://www.nationalobesityforum.org.uk/Department of Health websitehttp://www.dh.gov.uk/en/index.htmHEART UKhttp://www.heartuk.org.uk/Heart UK advice helpline 08454 505988NHS Evidence – cardiovascularhttp://www.evidence.nhs.uk/search?q=Cardiovascular+DiseasesNHS Choiceshttp://www.nhs.uk/Pages/HomePage.aspxNHS DirectTel: 0845 46 47Healthwatchhttp://www.healthwatch.co.uk/106 MINAP How the NHS cares for patients with heart attack

Heart attacks recorded in MINAP in 2011/12