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Heart Attack

Our vision

We said we would improve access to specialist care for people who have heart attacks.

We want people in the East Midlands who have a heart attack to get the best possible treatment. We plan to widen access to specialist care, and to make sure as many people as possible benefit from the newest clinical procedures which get better results for some kinds of heart attack.

A heart attack happens when there's a blockage in the arteries that supply the heart muscle with blood. The usual cause is a blood clot. The blockage stops your heart getting a proper supply of blood, and the heart muscle starts to die.

Less serious than a heart attack, but still needing urgent care, is unstable angina (chest pain). It happens when a blood vessel gets clogged, but not completely blocked. Unstable angina causes chest pain but doesn’t damage the heart muscle. However, without treatment, it can get worse and turn into a heart attack.

 

Why we're changing heart attack services

There are two main options when treating certain heart attacks. One is to use drugs that help clear the blocked artery. Thrombolytic drugs work by dissolving blood clots and getting blood flowing to the heart again. You have this treatment as an injection.

The other option is a procedure called primary percutaneous coronary intervention, or PPCI for short. A thin tube is fed into the blood vessels, usually through a small cut in your groin or arm. The tube is fed through until it reaches your heart. A wire and a tiny balloon are put through the tube. The balloon is blown up, widening the artery and clearing the blockage. A metal ‘stent’ is left in place to hold open the artery. PPCI is sometimes called primary angioplasty.

At the moment in the East Midlands, few people are treated with PPCI. Last year only 133 people had the procedure, out of around 2,000 who might have benefited from it. In future, we want to make sure this life-saving treatment is available to as many people as possible.

PPCI is the best treatment for people having some types of heart attack, but it needs to be available quickly. Compared with clot-busting drugs, it can save more lives, reduce the risk of a further heart attack and help people go home from hospital sooner. However, PPCI must be given by highly trained staff using specialist equipment.

A procedure called PPCI is the best option for some types of heart attack. However, making sure people get this treatment can be challenging. It needs to be given quickly, and patients must first reach a hospital with the equipment and specialist staff needed to perform the procedure.

Despite the challenges, we think it's important to make sure as many people as possible have access to PPCI. In the East Midlands alone, it could save dozens of lives a year. Medical trials have consistently shown the advantages of PPCI.

If it can be given quickly, PPCI saves lives and cuts the risk of a further heart attack in the future. There is growing evidence to show that it is better than clot-busting drugs (thrombolysis), providing it can be carried out within a similar time frame (and no more than 90 minutes later than the time at which thrombolysis could have been given).

What the research says

We looked at the latest and best research on treating heart attacks. Here are some of the details.

  • A review several studies, published in the Heart journal in 2007, looked at how patients were doing six months after treatment. About 7.7 percent of thrombolysis patients had died during this time. PPCI patients fared better, with a death rate of only 5.5 percent.

  • A more recent study, from the European Heart Journal and published last year, randomly split 1,572 people between PPCI and thrombolysis. After three years, 25.2 percent of people treated with thrombolysis had died, suffered a further heart attack or became disabled because of a stroke. The figure was only 19.6 percent for people treated with PPCI. 

 

How we are changing heart attack services

We are changing the way certain types of heart attacks are treated by making a new procedure, called PPCI, more widely available to people in the East Midlands.

We are accrediting some hospitals to specialise in performing PPCI. These hospitals will have the skills, experience and equipment to offer PPCI as an emergency, 24 hours a day. Ambulance crews will be trained to recognise appropriate patients and take them straight to a specialist centre.

In Leicestershire a full service is already operational. All our other counties are currently offering a restricted hours service and are progressing plans for 24-hour provision. Nottinghamshire and Northamptonshire will have realised their plans by this autumn, Derbyshire will have progressed to full service provision by the beginning of 2011, and Lincolnshire in the late summer/early autumn of 2011.

The changes are part of a wider plan for all hospitals. New guidance will make sure everyone with chest pain or a suspected heart attack also gets urgent and high-quality treatment to reduce the amount of damage to their heart.

Under the new system, anyone who has a PPCI should get treatment in a specialist hospital within two hours. People will be taken by ambulance directly to the nearest hospital with a specialist centre that can offer PPCI, rather than the closest hospital. For most people, these will be located no more than 60 minutes away by ambulance.

On arrival, patients will be admitted directly to the catheter laboratory (where PPCI is performed), be assessed by a specialist, have access to tests, and receive PPCI (if appropriate).

The patient will stay in the specialist hospital until they are well enough to be discharged or transferred to a hospital closer to their home where they will continue to receive specialist heart care. Patients will also be referred to a cardiac rehabilitation programme offering support, information and exercise plans. This can improve a person’s chances of recovering from their heart attack and prevent further attacks.

When it is not possible to get to a specialist hospital in time for PPCI, clot-busting drugs can be given by paramedics on the spot, or by staff in the nearest hospital. 

Other types of heart attack can be treated safely at local hospitals, as can unstable angina (chest pain). All hospitals will be expected to follow new guidance on how to manage people with urgent heart problems.

Specialist care will mean better emergency treatment and improved rehabilitation. These plans will save lives.

Journey times

If someone is having a heart attack that can be treated with PPCI, the first two hours are the most important. PPCI saves more lives than the best alternative treatment, as long as it's done within this time. We need to make sure patients reach a specialist hospital and get treated within this time limit.

It takes time to realise someone has had a heart attack and call for help. Once in hospital, doctors need time to do tests and start treatment. We’ve allowed for a 60-minute journey time, and for 30 minutes spent in hospital being examined and having tests. So, our plans should allow us to reach the two-hour goal.

How did we work out journey times?

To calculate journey times, we've taken into account the real experiences of ambulance drivers who make these journeys every day. We’ve looked at records of journeys in rural and urban areas, which give details of how quickly an ambulance can travel down particular roads with its siren on and lights flashing.

The East Midlands Public Health Observatory then took these average speeds and used sophisticated software – as recommended by the Department of Health – to predict how long journeys to individual hospitals would take.

We've used this information to help us plan where specialist hospitals should go, giving everyone the best chance of reaching a specialist heart attack centre within 60 minutes. We've also taken into account different levels of traffic at different times. People should still have a good chance of reaching hospital within 60 minutes even when the roads are busy.

Wouldn't it be quicker to go to A&E?

For some people, it might be quicker to go to their nearest A&E. However, this might not mean the best care. Treating a heart attack with PPCI needs a team of skilled and experienced staff, with access to sophisticated equipment. Specialist teams also need to treat several hundred patients each year to hone their skills and get the best results. Not all hospitals are able to provide this level of care or see enough patients, so it's worth travelling further to a hospital that can.

What if someone just can't get treatment within two hours?

When it's not possible to get to a specialist hospital in time for PPCI, clot-dissolving drugs can be given by paramedics on the spot, or by staff in the nearest hospital. Clot-dissolving drugs (called thrombolytics) are the best alternative treatment if PPCI isn't available.

 

Benefits for patients

Better access to specialist care will reduce the devastation caused by heart attacks in the East Midlands.

There’s good research showing that people are more likely to survive heart attacks if they’re treated quickly with PPCI. Studies suggest that between 30 and 40 lives would be saved for every 1,000 patients treated with PPCI instead of thrombolytic drugs providing they get the procedure within a couple of hours of calling for help.

PPCI is the best treatment for some kinds of heart attack. The NHS in the East Midlands can save lives by using PPCI instead of the next-best treatment (injections of clot-busting drugs, known as thrombolysis).

For every 1,000 patients treated with PPCI instead of thrombolysis:

  • 30 or 40 more people will be alive five years later

  • More than 40 people will avoid a further heart attack in the next three years

  • 10 to 20 people will avoid a stroke in next six months.

 

PPCI is more successful when performed in specialist hospitals by experienced staff. Research shows that, to get the best results each consultant should carry out a minimum of 75 procedures a year, but aim to increase to 150 per year.

 

How we made our decisions

In a major review during 2007, as part of a national review of the NHS, NHS East Midlands asked around 4,500 members of the public and 500 health and social care staff about the healthcare issues that mattered to them. There was strong support for specialised services dealing with heart attacks and strokes.

The details of our proposals  were developed with local doctors and the people responsible for commissioning healthcare. A clinical summit was held in September 2008 to review current stroke and heart attack services across the region, and to discuss the development of a new service model. Clinical Advisory Groups were set up as a result of this summit, and met regularly to develop the service model and the minimum standards of care that should be on offer.

We also sought views on the proposed changes from patients, carers and their representatives during a series of small workshops in November and December 2008. During the summer and autumn of 2009 we held a series of engagement events around the region to seek the views of patients and the public on our more detailed proposals.

How we decided which hospitals should offer specialist heart care

We collected data on past heart attacks, where and when they tend to happen, and the population in each area, to help us anticipate how many people will need care across the region. We also looked at how long ambulance journeys take in different areas, and we reviewed the strengths and weaknesses of current services.

Our sources included East Midlands Ambulance Service, East Midlands Public Health Observatory, the performance intelligence unit of the Strategic Health Authority (SHA), and the Nottingham Stroke Unit. The accuracy of this data was checked with the health community.

In July 2009, all NHS hospitals in the East Midlands that offer emergency care were invited to apply to provide a specialist PPCI centre and/or a level of care for heart attacks and chest pain that meets new quality guidelines.

A panel of independent experts, including doctors from within and outside of the region, have now assessed these proposals. They visited each hospital to review the care they provide at the moment and discussed with clinicians and managers how they would deliver the new services.

We then put together our final recommendations for creating our new regional system of care for heart attacks, including where the specialist centres should go. In February 2010, these recommendations were presented to our local primary care trusts (PCTs) who  are responsible for commissioning the new services for the people in their area. They agreed to fund the new specialist centres.

The hospitals which have been accredited as specialist centres are now working hard to implement the new services as quickly as possible so patients start to get the benefits.

heart monitor

Other useful links: 

Your views about heart attack care

Check out how heart attack services are performing on quality through the East Midlands Quality Observatory

NHS Improvement - HEART

East Midlands Cardiac and Stroke Network