Myocardial Ischaemia National Audit Project - University College ...

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