24/7 Heart Attack Care by the NHS

A recent article in the Guardian implies that the treatment of heart attacks outside working hours is below an acceptable standard. It suggests that "the principle of 'office hours only' applies as much to emergency medicine as it does to your local fishmongers".

 

The article quotes a meta-analysis of heart attack patients published in the British Medical Journal. 48 studies published between 2001 and 2013 were pooled for analysis. Most data was old (pre-2005 and some even from the 1990s) and only two studies looked at UK patients. The researchers 'concluded' that worldwide mortality rates for heart attacks (STEMIs) were higher outside normal working hours (and that North Americans fared better).

 

How does this data apply to the treatment of heart attacks in the UK now? For details on how we treat heart attacks in the UK see my earlier blog here. The majority of STEMI patients in the UK are now treated by primary angioplasty, the gold standard of heart attack treatment, and the speed with which this has been successfully implemented is shown by this graph.

 

ALL patients in the UK regardless of their background, location, age and clinical condition receive an equal and excellent standard of heart attack care 24 hours a day, 7 days a week, and delivered by a consultant. A network of designated 24/7 regional heart attack centres in the UK ensures that ALL patients get the appropriate treatment as soon as possible (and yes, to all those outside the UK, it is free at the point of delivery!). This is ONLY possible because the NHS delivers truly universal healthcare across the country and NHS ambulances work closely with NHS heart attack centres 24/7 to deliver the best care for patients.

 

All this data is very carefully audited and available to the general public. The MINAP (Myocardial Infarction National Audit Project) 2014 report is available here. BCIS, the British Cardiovascular Intervention Society, produces annual public reports (see here). Again the UK is unique in the way it audits and publishes data of ALL interventional cardiology units.

 

The general public in the UK should know that if they have a heart attack, they will receive the best possible care (at the very highest of international standards) 24 hours a day, 7 days a week. Any suggestion in the media to the contrary is misleading at best and scaremongering at worst.

 

Vinod Achan

Vinod Achan is a Consultant Cardiologist and the Clinical Lead for Primary Angioplasty at the Surrey Heart, Stroke and Vascular Centre, Frimley Park Hospital NHS Foundation Trust. Frimley Park Hospital NHS Foundation Trust is an award winning 24/7 regional Heart Attack Centre, performing over 1000 coronary angioplasties a year and delivering emergency cardiac care to a population of one million people.

Recent BBC Radio Interview

Q and A on Angina and Heart Attacks

 

The human heart pumps six litres of blood per minute around the body for an entire lifetime (and up to 18 litres per minute during exercise and pregnancy), maintaining the delivery of oxygen and nutrients to all body tissues. Three (and in some people, four) major coronary arteries (running on the surface of the heart) supply blood to the heart muscle and slowly narrow with age due to the accumulation of fat and inflammatory cells in the wall. This process known as atherosclerosis is accelerated by smoking, diabetes, high blood pressure and high cholesterol levels.

What is Angina?

As the arteries narrow beyond 60%, blood flow to the heart muscle is restricted during exercise and can produce symptoms of stable angina during physical activity. In most people, this is a central chest discomfort (described as a weight on the chest or a tight band across the chest) radiating to the shoulders and/or neck and associated with shortness of breath. Others may only experience breathlessness, jaw pain or upper back discomfort. These symptoms typically resolve with rest. Occasionally there may be no warning symptoms whatsoever.

What is a Heart Attack?

A complete blockage of a coronary artery results in a heart attack which is potentially fatal. Heart attacks are the most common cause of death in the developed world and the risk of death following a heart attack is 40% if untreated. The symptoms of a heart attack are the same as those described above but more severe and typically associated with sweating, feeling faint, vomiting and sometimes collapse. Interestingly, 25% of heart attacks do not produce any recognizable symptoms or are ‘silent’.

How do we treat Heart Attacks?

Thirty years ago, heart attack patients would spend at least two weeks in hospital and, with no specific treatment available, the probability of leaving hospital (having survived the initial attack) was only 80%. Over the last thirty years, ‘clot busting’ drugs improved survival rates to 90% but patients spent a week in hospital, often suffered significant muscle damage and often developed heart failure.

Now there is substantial evidence that the best treatment for heart attack patients is an emergency (or primary) coronary angioplasty delivered as quickly as possible. An interventional cardiologist, with the help of his or her team, performs an angiogram by passing a narrow plastic tube (called a catheter) into the circulation (through a small tube in the groin or wrist) and to the heart, obtaining detailed x-ray images of the coronary arteries. The artery responsible for the heart attack is then identified and reopened with a fine wire, balloon and a stent (a wire mesh tube to keep the artery open). Other devices to aspirate clot from the arteries may also be used in conjunction with drugs injected directly into the blocked artery. Survival rates are greater than 96% and patients leave hospital after two or three days with a lower risk of heart failure.

Heart attacks require emergency treatment and delays can result in death. At designated ‘24/7’ regional heart attack centres like Frimley Park NHS Foundation Trust, we have a ‘Door to Balloon’ target (namely, the time between the patient entering the hospital via ambulance or helicopter and having their blocked artery reopened) of 60 minutes (and in practise we average 40 minutes).

What should I do if I think I have Angina?

When symptoms are stable, in other words symptoms develop with activity but resolve with rest, urgent advice should be sought from your GP and then a cardiologist. Your cardiologist will arrange a treadmill test, an ultrasound study of your heart and possibly an angiogram before deciding on the best treatment for you. Symptoms developing at rest should be regarded as ‘unstable’ and treated as urgently as possible.

The ideal situation would be to avoid a heart problem altogether. Avoiding cigarettes, regular moderate exercise, weight control, blood pressure control and a healthy diet (in particular avoiding sugar and controlling fat intake) can help reduce your risk of developing heart problems. However a number of unidentified factors (including genetic factors) mean that no one is immune from heart disease and symptoms should always be taken seriously.

Vinod Achan

Vinod Achan is a Consultant Cardiologist and the Clinical Lead for Primary Angioplasty at the Surrey Heart, Stroke and Vascular Centre, Frimley Park Hospital NHS Foundation Trust. Frimley Park Hospital NHS Foundation Trust is an award winning 24/7 regional Heart Attack Centre, performing over 1000 coronary angioplasties a year and delivering emergency cardiac care to a population of one million people.

Recent BBC Radio Interview

(Explanation of figure: A. Blocked coronary artery. B. Stent being deployed. C. Reopened coronary artery.)

The Quantified Self: A Clinician's Perspective

Digital health was a hot topic at Social Media Week London (#SMWLDN) this week and I was lucky to be involved with a session called The Next Stage of Digital Engagement: The Quantified Self (hosted by CIPR). The session was voted runner-up by MarketMeSuite in (take a breath) The Most Slightly Terrifying and Yet Apprehensively Exciting Talk Award category.

Our chairman was Drew Benvie, founder/MD of Battenhall and author of Body Data: Applied Thinking in Quantified Self and Wearable Technology . My co-panellists were David Clare, Digital Consultant at Hotwire and author of OneMoreLifeHack, and Steve Davies, Director of Ruder Finn UK and author of Bionic.ly.

We all gave our very own and different perspectives on The Quantified Self (QS). This is the concept of self tracking body data and sharing this via social media. It also concerns the application of the web, apps and wearable tech to personal health and productivity.

Steve spoke about how he and others in the QS community are monitoring their bodily functions, blood biochemistry and genetic makeup to learn about their health. By 2023, the computing power of an iPhone will fit into a red blood cell raising all sorts of exciting possibilities for invasive body monitoring.

David spoke of how the rise of the QS movement is being driven by an explosion in DIY digital health technologies, how businesses (including the pharma industry) might tap into this body data to tailor products more appropriately, and how the QS community is growing from a small hacker community to a mainstream phenomenon.

I spoke about how patient body data is monitored and transmitted between ambulances and hospitals during the treatment of heart attacks, how cardiologists are using implantable devices in patients which can be monitored remotely, and how the QS movement may provide us with healthy body data that allows us to predict and therefore prevent illness.

During the interactive session, we touched on the concerns regarding data privacy, the dangers of over-testing and medicalization of healthy people, and much more.

The session was streamed live and is available to watch here (there are some issues with sound overlay at the start, so you may want to fast forward to the start of Steve's talk at 04:00. My talk starts at 14:00) :

http://new.livestream.com/smwlondon/events/2394741/videos/30811376

Photo of panel courtesy of @ManeeshJuneja

  

London's First Health Tech Forum Meet

The London chapter of the Health Technology Forum (HTF) met for the first time earlier this month and I was fortunate to speak at the event. The HTF is the brainchild of Silicon Valley health tech enthusiast and deal maker, Pronoy Saha, who has created an international network of HTF chapters based in the US, Singapore, India and now the UK. Pronoy hopes that this network of HTF chapters will answer the following question: How can technology be used to narrow the healthcare gap between rich and poor?

 

He believes that by bringing entrepreneurs, technologists, futurists, and clinicians together, answers to this and similar questions will be found in the health tech space. A feature of these meetings is the involvement of clinicians who play a vital role in the adoption of healthcare technologies.

My impressive co-speakers were Battenhall founder Drew Benvie, MedCrunch's Ben Heubl, and telehealth expert Charles Lowe. For me the talk of the evening was Drew Benvie's vision of the Quantified Self and how this will apply to digital health in the future. Continuous harvesting of personal data for maintaining personal fitness, disease prediction/avoidance and management of chronic illness is an exciting prospect. Applying these technologies to healthcare will no doubt lead to more personalised treatments during illness.

 

I spoke about how several technologies are being applied to the emergency treatment of heart attacks. These include technologies used during treatment (drug coated coronary stents, a variety of other invasive technologies, genetically engineered monoclonal antibody based drugs and so on) as well as for communication between ambulances (or helicopters) and coronary care units. A recent radio interview where I describe such a case can be heard here. Implantable devices which can be monitored remotely are routinely used in cardiology departments.

 

I also emphasised the role of the UK's National Health Service (NHS) in future digital health. The NHS is uniquely placed to apply new technologies to cost effective, patient centred healthcare. A nationwide healthcare system with comprehensive data capture has the ability to apply new treatments effectively, safely and rapidly to a huge number of patients, as it has done in the treatment of heart attacks.

 

Details regarding the London chapter of HTF are available here. Another review of this meet is available here.

The Stenting of George W Bush: Why the Controversy?

 

A coronary artery stenting procedure performed last week on former US President George W Bush has generated controversy. After an abnormal treadmill test (done as part of a routine screening programme), he had a CT coronary angiogram which demonstrated a coronary artery stenosis. He was then transferred to an interventional cardiology centre where a stent was inserted into the coronary artery via the femoral artery. Two physicians (neither a cardiologist) claimed that the stent was unnecessary in the Washington Post. Larry Husten writing in Forbes asked a similar question. Burt Cohen writing for Angioplasty.Org gives a more balanced view. Meanwhile, on Fox News, Professor Marc Siegel struggled to get a stent out of its packaging with his teeth on live TV ('Pull the flap at the back,' I could hear many of us screaming). If nothing else, watch the video for a really good laugh.

 

 

The simple truth is that it is not possible to make any comment about this case without knowing all the details. And those details are private between the patient and his cardiologist. 
 

The debate about routine screening tests is not the focus of this post. Briefly, routine screening treadmill tests in the ABSENCE of symptoms are not recommended in the UK, but they do happen (for example, in athletes). I learnt last week that in France all men aged 65 years are offered an appointment with their cardiologist (which I suspect might lead to a treadmill test; can anyone confirm?). It is entirely possible that Bush said something to trigger concern, despite his excellent level of fitness.

In symptomatic patients, treadmill tests are not a 'rule out' test. In other words, a normal result does NOT rule out coronary artery disease. But treadmill tests are cheap, often immediate, and an abnormal result can guide further investigation. In some patients who have no obvious symptoms, a treadmill test can be used to unmask these. The value of treadmill testing (compared to more expensive tests for which patients may wait several weeks) is still being debated.

 

Once the treadmill has been performed, changes on the ECG (or EKG) can indicate ischaemia, in other words reduced blood flow to the heart muscle. Minor ECG changes may have quite reasonably led to a CT angiogram ('I think that this is normal but I want to be sure'). Major ECG changes would have led directly to an invasive angiogram.

 

An anatomically severe narrowing of the coronary artery is likely to have been stented. While 'ad hoc' stenting is frowned upon by some in the elective/stable setting, the interventional cardiologist may already have had evidence of ischaemia. The treadmill test was abnormal. Alternatively the interventional cardiologist may have performed a pressure wire study, measuring what is known as an FFR (fractional flow reserve) across the stenosis. This would have indicated whether the narrowing was functionally important.

Much attention is being paid to the COURAGE trial in this debate. This study (published in 2007) recruited 2300 patients between 1999 and 2004. Patients who had a 70% coronary stenosis AND objective ischaemia (<10% in most patients) or angina were randomised to PCI (Percutaneous Coronary Intervention; stenting) or optimal medical therapy (For more on randomised trials, click here). PCI did not provide a mortality benefit over 4.6 years.

In this study, less than one third of the patients had significant (>10%) ischaemia and so to me it is not surprising that the study did not demonstrate a benefit. It is probably reasonable to ask why patients with no angina and no significant (>10%) ischaemia were having angiograms in the first place. 38% of patients had had a previous heart attack and 85% of the PCI procedures were elective (planned). This does not reflect current clinical practice in the UK where only 30% of PCI procedures are elective (the remainder are emergency or urgent) and all patients with heart attacks are treated urgently.

We know that FFR guided PCI improves clinical outcomes in patients (11% were asymptomatic) from the FAME II trial. We now await the results of the ISCHEMIA trial where patients are being randomised BEFORE angiography. The results of this trial are therefore more likely to reflect current clinical practice.

In conclusion, I think that it is impossible (and perhaps even rash) to say that Bush's stenting procedure was unnecessary. Perhaps a more pertinent question should be this. Why was the PCI performed via the femoral artery? In the UK, 60% of PCI is performed via the radial artery.


Vinod Achan is an interventional cardiologist and clinical lead for primary angioplasty at the Surrey Heart Attack Centre. Listen to his recent interview on BBC radio regarding the treatment of heart attacks and cardiac arrests.

 

 

 

Is Relentless Media Attack on NHS Justified?

The UK's National Health Service has been under a blistering media attack. First, Charles Moore in the Telegraph describes the NHS as the “worst in the Western world” (1). According to him, “the NHS cannot look at the whole patient and meet his/her medical needs”. On Twitter, his editor Tony Gallagher describes the article as “really good”, and he is praised by Douglas Carswell MP. Next, in The Independent on Sunday, Ian Birrill describes the NHS as “a toxic institution”, one where “myopic worship has fostered a culture of complacency that kills patients” (2). Again he has been praised on Twitter by Jane Merrick (political editor of the IoS), Charlotte Leslie MP (MP for BristolNW) and Lord Ashcroft.

What is going on? It would appear that at least two of the above have had bad personal experiences of the NHS with care of relatives or themselves. Could that justify such vitriol in the national press?

Now might be a good time to clear up a few things. Firstly, the NHS is not the CQC (Care Quality Commission). We need a powerful regulator of hospitals in both public and private sectors, and the CQC has failed us in that. But do not tar the NHS with the same brush. Secondly, there are pockets of excellence within the NHS just as there are pockets of abject failure. To use examples of failure as a rod with which to strike all NHS staff demoralises them and fails to recognise their vital role in society.

The NHS is the backbone of healthcare in the UK. It is who we turn to when we are really sick. It doesn’t matter how sick you are, the NHS takes you in and does its best to fix you.  It also trains all our doctors and nurses. Yes, even those who now work in the private sector. Of course, the NHS is not perfect. But it does its utmost to deliver healthcare as a basic human right. It certainly is not complacent.

Funding cuts, staff shortages and increasing patient expectations are putting a strain on the NHS. See how our funding compares to other systems:

 

 

Is it the worst healthcare system in the world as Charles Moore and Ian Birrill would have us believe? Three years ago patient satisfaction with the NHS was the highest it had ever been. Research clearly demonstrates that the NHS provides the most cost efficient, high quality healthcare when compared to all other healthcare systems in the developed world (3). A report by The Commonwealth Fund (4) puts the UK in the top two for safe care, effective care, efficiency and equity (see chart).

 

 

 

We scored poorly on patient centred care (communication, continuity, feedback and patient preferences), and that may have been the price we paid for delivering the most cost-effective universal healthcare system in the world. For most of us in the NHS, this shines a light on where we must focus our efforts next. No complacency there.

How do we persuade the media to stop this unjustified attack on the NHS as a whole? What are their motives?

Please participate in the Twitter debate using #stopNHSattack.

References:

3. Comparing the USA, UK and 17 Western countries’ efficiency and effectiveness in reducing mortality (C Pritchard, M Wallace), J R Soc Med Sh Rep 2011

4. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally (K Davis, C Schoen, K Stremikis), 2010 Update

 

Effective Data Transparency: Cloudier Than You Might Think

 

 

Data transparency, the development of a safe and open culture of data sharing between clinicians and patients, is a noble aspiration. I have no doubt that it will improve the quality of data collection and lead to improvements in clinical care. Tim Kelsey, NHS National Director for Patients and Information, says that data transparency is the future of the people's NHS (1). It is one of the core strategic principles of NHS England. As part of this drive to improve data transparency, outcome data for nine surgical specialities AND interventional cardiology are being published this summer. An important issue that has not been discussed is how this data will be presented and interpreted by the public.

Jeremy Hunt says that patients will see which surgeons apparently have the best outcomes (2). Patients will be able to choose the best surgeons. Really? Cardiac surgery is cited as an example of how this model can drive improvement. Cardiac surgeons have published their outcome data since 2004 and mortality rates have apparently dropped to half those in Germany and a fifth of those in Portugal. What is often not discussed is how this may have led to risk avoidance amongst some surgeons.

MACCE (major adverse cardiovascular and cerebrovascular events) data for all interventional cardiologists in England will be published shortly. This is not a bad thing. However, we should exercise caution when looking at the data and bear in mind the effect this may have on many cardiologists. BCIS (British Cardiovascular Interventional Society) explicity states that you CANNOT compare the performance of cardiologists on the basis of the data. This is unlikely to be the view of government and the public.

For one thing, the data does not discriminate between cardiologists working in high volume heart attack centres and those only doing planned (elective) cases. Cardiologist A in a high volume heart attack centre will have a high volume of complex emergency work (usually 1/3rd of his/her cases) of which a proportion will be of extremely high risk. Patients following cardiac arrest who have been intubated and ventilated (and possibly on a Lucas chest compression device) have a high risk of death even if their angioplasty is successful, but are not considered separately in the data. Cardiologist B may only perform low risk elective cases or avoid taking high risk patients to the operating theatre (known as a catheterisation laboratory or 'cath lab'). While Cardiologist A has an elective mortality of 0%, his/her overall mortality may be 5%. Cardiologist B may have an elective mortality of 1%, and yet appear better overall.

Imagine the following clinical scenario (imagined but based on cases we frequently treat). A 50 year old man has a cardiac arrest at home and receives CPR from his wife. An ambulance crew arrives within 5 minutes and shocks him out of ventricular fibrillation. He is intubated on the scene, airlifted to a Heart Attack Centre by an air ambulance where a specialist interventional cardiology team reopens his blocked coronary artery within 15 minutes of him landing on top of the hospital.

The interventional cardiologist who takes full responsibility for treating this man considers many factors. One, that he may already be brain dead and that saving his heart may not save his life. Two, although the situation appears futile, there is a real chance that this man’s life may be saved. To adopt a non-interventional treatment strategy is to guarantee death (3). Three, the best chance of saving this man’s life depends on an immediate angioplasty and cooling. This is evidence based. Four, the man’s wife, an ambulance crew and an air ambulance crew have fought hard to this point to save his life. Is it fair that the cardiologist may deny potentially life-saving interventional treatment when the patient arrives at the door of his/her 'cath lab'?

Now there is a further consideration, namely the effect that taking on this extremely high risk case may have on the cardiologist's published outcome data. Many of us will swiftly put this consideration to one side and get on with the urgent job in hand.

Data transparency and publication of outcomes are here to stay in a patient centred NHS. But as patients use complex data to make comparisons between cardiologists, will some cardiologists begin to avoid high risk emergency work? How do we help patients to navigate the jungle of data they will be faced with?

Vinod Achan is a Consultant Cardiologist and Lead Consultant for Primary Angioplasty at the Surrey Heart Attack Centre, Frimley Park Hospital