Myocardial Ischaemia National Audit Project - University College ...

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