Archived decisions

Briefing Note for Joint HOSC members: Treatment of Heart Attacks with Primary Angioplasty

This briefing note has been prepared as a source of information for HOSC members when considering proposals from the NHS to improve access to primary angioplasty services (sometimes referred to as PPCI). The information has been taken from the Department of Health website and the National Guidance that has been produced to support this work (see web link ). Key questions and draft comments from the Isle of Wight are attached at Annexe One.

Approximately 110,000 people in England suffer a heart attack each year. The main treatment for heart attack is the administration of clot dissolving drugs (thrombolysis) which help to restore blood supply in the coronary arteries to the affected part of the heart. An increasing number of mainly urban centres offer angioplasty as the first treatment for heart attacks.

What is a heart attack?

A heart attack is said to have occurred when the myocardium (heart muscle) is

damaged as a result of impaired blood supply. This is known as a myocardial

infarction. The amount of damage is greatest when the blood supply to part of the

heart is cut off altogether as a result of a thrombus (blood clot formation) within one

of the coronary arteries ( blood vessels) supplying that area of the heart. Under these

circumstances, the electrocardiogram (ECG) recorded after the onset of occlusion will

usually show an abnormality termed `ST elevation'. Patients suffering from this

condition are said to have sustained `ST elevation myocardial infarction', abbreviated to STEMI. The report and proposals relate only to the management of STEMI.

Primary angioplasty

Angioplasty is a technique for unblocking arteries carrying blood to the heart muscle. A small balloon at the tip of a catheter tube is inserted via an artery in the groin or arm and guided to the blocked heart artery. It is then inflated and removed, leaving in place a 'stent' - a rigid support which squashes the fatty deposit blocking the artery, allowing blood to flow more easily. Primary angioplasty is the use of this technique as the main or first treatment for patients suffering a heart attack.

The key to improving outcomes after heart attack is to re-establish coronary artery flow as quickly as possible and limit damage to the heart muscle.

There have been numerous studies addressing the relative benefits of primary angioplasty as against thrombolysis as a treatment for heart attack. Evidence for the longer-term benefits of primary angioplasty had been steadily growing. The main conclusions are :

· Primary angioplasty reduces mortality, and improves longer-term outcome compared to thrombolysis when both treatments can be undertaken within a similar time frame.

· The advantage of primary angioplasty over thrombolysis decreases with increasing delay in undertaking the procedure. Whilst much debate still surrounds this issue it is thought that the benefit of primary angioplasty may be lost, or considerably reduced, if it takes more than 90 minutes longer to undertake the procedure than it would to administer thrombolysis.

· More patients are potentially suitable for primary angioplasty than thrombolysis, and primary angioplasty is associated with fewer strokes and recurrent heart attacks during the hospital admission.

· However the greatest delay in providing effective treatment is often the time taken for patients to recognise that they have a problem and call or help.

Lower mortality rate in Primary Angioplasty patients

Overall, in-hospital mortality for all the patients undergoing Primary Angioplasty was 5.2%. For those given thrombolysis it was 7.1%. While this is not directly comparable, as the research was not set up to compare PCI and thrombolysis, this mortality in the thrombolysed patients is the same as the rate recorded nationally for all patients receiving thrombolysis in other research databases over the same time period.

Treatment is defined in terms of the time it takes from the patients calling for professional help to the time when primary angioplasty is delivered (Call to Balloon or CTB). Acceptable times are achievable by direct or indirect admission to a primary angioplasty centre but the ideal is undoubtedly direct admission to the catheter laboratory at the centre.

Patients were tracked by NHS number using the Office for National Statistics,

allowing mortality during follow-up to be assessed (see Table1)

.

Table 1 - Mortality (%)

Effects of time to treatment

Analysis of CTB times in relation to patient follow-up data showed that:

· mortality at all time periods (in-hospital, 30 days, one year) was lower when CTB times were shorter

· mortality during follow-up was noted for all CTB times except the cohort with CTB times under an hour in whom there was no later mortality (3.3% at one year); and

· at one year the mortality for those with longer CTB increased (see Table 2) and most noticeably diverged when the CTB time was greater than 120 minutes.

· treatment 30 days 1 year 18 months

Table 2 - Mortality (%)

The effect of patient delay in calling for help

For patients with short delays (time from symptom onset to arrival in hospital of less

than 60 minutes), the mortality was 3.0% at hospital discharge and 6.1% at

18 months. For those with long delays (more than six hours), rates were 5.9% and

14.9% respectively. Thus, delay is associated with increased mortality and this

association is even more pronounced later, presumably due to the cumulative adverse

effects of greater heart damage over time. This highlights the importance of patients

seeking help as early as possible if they suspect a heart attack; early defibrillation by

ambulance crews can also avoid death from ventricular fibrillation caused by

heart attack.

Routes of admission

Patients having Primary Angioplasty who were admitted directly to the catheter laboratory, bypassing accident and emergency departments or wards, had the lowest mortality rates of all the routes of admission (in-hospital mortality was 3.5%; 18-month mortality, 7.0%).

Patients assessed first in the accident and emergency department within a Primary Angioplasty hospital not only had longer times to treatment but this was associated with higher mortality rates (6.0% and 11.8% respectively).

Complications following treatment

Complications were low for patients receiving Primary Angioplasty. The overall in-hospital stroke rate was 0.8% for Primary Angioplasty patients and 1.3% for those receiving thrombolysis. The overall in-hospital rate of major bleeding was 3.5% in the Primary Angioplasty group and 6.2% in those receiving thrombolysis.

Length of hospital stay

The median length of stay for all groups increased with age but was lower for each age cohort for Primary Angioplasty patients (3-5 days) compared with those receiving thrombolysis (5-9 days).

Patients and Carers

A survey and interviews were conducted with patients and their carers to assess their

views of care. It was found that:

· there was overall a high level of satisfaction with both treatment options (Primary Angioplasty and thrombolysis);

· patients rated time waited and the efficiency of treatment with a Primary Angioplasty service more highly than the thrombolysis sites;

· carers had concerns when travel to a Primary Angioplasty centre, distant to their own local hospital, was required because of the distance and problems with parking etc. However, they accepted this requirement in the context of the clinical circumstances and the potential for better treatment;

· satisfaction levels were lower for treatment by PPCI than for thrombolysis, with respect to discharge planning, aftercare advice and services, and arrangements for cardiac rehabilitation. Some patients felt that the process was so fast that insufficient time was allowed to reflect on events and discuss next steps.

Possible lines of questioning/discussion

· what account has been taken of the way in which hospitals on the periphery of South Centrals borders can contribute to providing primary angioplasty services for our population

· what mapping has been done of travel times and what areas would sit outside the 120 minute `CTB' target

· what community services would need to be in place to support patients leaving hospitals within 3 days of having a heart attack

· what work has been done with the ambulance service to ensure that they could meet the target timeframes

· what public information programmes will complement these changes

· what staff and technology implications are there if the proposals proceed.

Annexe One: Key Questions and draft comments from Isle of Wight HOSC

PPCI (coronary angioplasty) consultation

Questions

1. How many people (including visitors to the Island) having heart attacks on the Island per year would be suitable for PPCI?

2. What percentage of Island heart attack patients would be likely to reach a PPCI centre at Southampton or Portsmouth within the 2 hour deadline, assuming that they travel by air ambulance during daytime only?

3. Has the Island population been included in the calculations for the Portsmouth and Southampton PPCI centres?

4. Has the increase in population of the Island during the summer and festival occasions been included when calculating likely patient numbers?

5. What is the feasibility of having a `mini PPCI centre' at St Mary's, which could perhaps be staffed using Island and mainland staff in rotation to ensure that they maintain their skill base?

6. What would be the cost of providing a centre at St Mary's for PCI and PPCI treatment?

7. What is the cost of keeping someone in hospital for recovery following thrombolysis? How does this compare with the cost of keeping someone in hospital for only 3 days following PPCI?

8. How many patients need to be transferred to a PPCI centre at Southampton or Portsmouth for PCI treatment following thrombolysis at St Mary's?

9. For those patients who receive thrombolysis as they cannot reach a PPCI centre within the 2 hour deadline, how effective is subsequent PCI treatment on the mainland?

10. How much does it cost the PCT to use PPCI centres at Southampton or Portsmouth for each PCI and PPCI treatment?

11. What is the cost to the PCT of using the air ambulance for each transfer from the Island to a PPCI centre in Portsmouth or Southampton?

12. It is understood that air ambulance transfers frequently also require the use of coastguard and other emergency service personnel. What is the average cost of these per transfer?

13. What plans are there to provide the necessary modifications to enable the air ambulance to fly at night?

14. What percentage of time is the air ambulance service available for IOW residents?

15. What is the timescale for the provision of a helipad at Southampton hospital?

16. When is a helipad likely to be constructed at St Mary's?

17. Who will make the decision about using thrombolysis or transfer to a PPCI centre? If this is the role of the paramedic what plans are there to ensure that every ambulance has a paramedic on board?

18. What training will be given to ambulance staff in deciding whether to use thrombolysis or transfer to a PPCI centre?

19. What arrangements will be made for continuity of care for patients transferring between PPCI centres and St Mary's?

20. What financial assistance can be given to relatives towards the cost of travel to the mainland to visit patients at the PPCI centres?

21. What percentage of Island heart attack patients are aged over 50?

Draft comments

1. The proposed changes to the emergency heart attack treatment aim to make sure that "no matter where you live you can get this gold standard treatment any time of the day or night". Failure to provide a PPCI centre on the Isle of Wight will mean that a significant proportion of heart attack patients will not receive this gold standard treatment as they will not be able to reach a mainland PPCI centre within the 2 hour deadline.

2. It is understood that:

· More patients are potentially suitable for PPCI than thrombolysis.

· PPCI saves more lives and has better long-term results than thrombolysis.

· There is a 50% increase in mortality in patients having traditional thrombolysis over those receiving timely PPCI.

Islanders are therefore significantly disadvantaged without access to a PPCI centre.

3. The two hour deadline severely limits the number of Island heart attack patients who can use mainland PPCI centres due to the need to cross the Solent.

4. Option 1 is unacceptable as it does not provide a centre at Portsmouth.

5. Options 2 and 3 are preferred, and the PCT is urged to provide a PPCI centre on the Island.

6. The PPCI criteria should be relaxed to enable Islanders to benefit from a centre on the Island.

7. The air ambulance is not equipped for night flying, thereby limiting the use of mainland PPCI centres for Island patients.

8. It is understood that all proposed options will provide cost savings over the current provision. It is suggested that some of these savings should fund a PPCI centre on the Island.

9. The equality impact assessment acknowledges that "Portsmouth, Milton Keynes and the Isle of Wight will have the largest growth in population between 2006 and 2031" and that "Milton Keynes, Southampton City and the Isle of Wight will have the largest growth in males aged 40-74". The Island has an above average level of elderly residents at 25% and this proportion is growing. It is understood that males and the elderly are at greater risk of heart attack than other sections of the population. This is likely to result in an increasing number of heart attacks on the Island.

10. The number of holiday visitors to the Island is increasing and in holiday periods the number of heart attacks is likely to grow. The Island population also rises several times a year due to various festivals.

11. Angioplasty (PCI) treatment is not currently available at St Mary's for those at risk of having a heart attack. A PPCI centre on the Island could be used for such patients, thereby saving the costs of transfer to and treatment on the mainland.

12. The quicker recovery time for patients receiving PPCI on the Island over thrombolysis (and possibly a subsequent PCI treatment) would provide significant cost savings.

13. A centre at St Mary's would significantly reduce the expense, time, anxiety and inconvenience to family and friends visiting patients.

14. The existence of a centre at St Mary's would mean that the expensive air ambulance service would not be required, thus leading to a significant cost savings.

15. The cost of the coastguard and other emergency service personnel could also be saved if patients access a PPCI centre on the Island.

16. The air ambulance service should give priority to transfers from the Island over mainland journeys which could be made by ambulance within the 2 hour limit.

17. There are likely to be few occasions when ferry transport to Portsmouth or Southampton is viable (i.e. the total journey can be undertaken within the 2 hour limit). For the occasions that such a journey is viable agreement should be reached with the ferry companies that patient transfers should be given priority.

18. The recent Care Quality Commission report on the IoW PCT stated that the target for the management of heart attacks and CPA follow ups was under achieved. It is suggested that a PCI centre at St Mary's would help to improve this performance.

16/10/09