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A new NICE guideline aims to improve the outcomes for people who have suffered the most severe type of heart attack
NICE publishes guideline for treating people with acute heart attack
London, UK (July 10, 2013) – If you’ve had or are having a heart attack, time is of the essence.
Professor Huon Gray, Consultant Cardiologist and National Clinical Director for Heart Disease, NHS England, who chaired the independent guideline development that produced NICE’s guideline on treating people who have had a heart attack, said: “Time is muscle. Nearly half of potentially salvageable heart muscle is lost within one hour of the coronary artery being blocked, and two-thirds is lost within three hours. The more heart muscle that is lost, the poorer the outcome for the patient. Apart from resuscitation if your heart stops, restoring blood flow to the heart as quickly as possible is the most important priority.”
The NICE guideline makes recommendations about the treatment that should be given immediately after a person has had a type of heart attack (myocardial infarction, or MI) called ST-segment-elevation myocardial infarction (STEMI). The name comes from the pattern seen on an ECG. This is the most severe type of heart attack and happens when blood flow to the heart is completely blocked by a blood clot, usually on a background of fatty materials accumulating in the walls of arteries taking blood to the heart, a condition known as coronary heart disease.
The number of people dying in hospital after a heart attack has fallen from around one in five in the early 1980s to nearer one in 20 now. This has been attributed to various factors, including improved drug therapy and speed of access to effective treatments. Although the number of people suffering these severe heart attacks has been falling over the past 20 years, they still account for around 35,000 hospital admissions in England and Wales each year.
In recent years coronary angioplasty, thrombus extraction catheters and stenting (collectively known as primary percutaneous coronary intervention’ [PPCIi]) have replaced fibrinolysis (the use of clot-busting drugs)ii as the best way quickly to unblock the coronary artery and restore adequate blood flow (coronary reperfusion) for people with STEMI. It is estimated that around 95% of the population in England and Wales now have access to a PPCI treatment, however some people, particularly those living in more rural areas, will still receive fibrinolysis if PPCI cannot be given within a specified timeframe.
The timeliness of PPCI is a crucial factor in improving outcomes for patients with a STEMI and it therefore forms a key part of this guideline. As its starting point, the guideline recommends that all people with STEMI are immediately assessed for their eligibility for coronary reperfusion. The guideline also covers the use of antiplatelet and antithrombiniii drugs, and improving outcomes for the minority of people still receiving fibrinolysis.
Key recommendations for clinicians in the guideline include:
Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if:
presentation is within 12 hours of onset of symptoms and
primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiographyiv (with follow-on PPCI if indicated).
Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.
When commissioning PPCI services for people with acute STEMI, be aware that outcomes are strongly related to how quickly PPCI is delivered, and that they can be influenced by the number of procedures carried out by the PPCI centre.
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “The guideline development group has carefully weighed all the current evidence and have come up with a set of recommendations that have at their core the need to ensure that wherever they live there should be a single reperfusion strategy for people with STEMI, that should work consistently and be reproducible for all people, 24 hours a day, seven days a week. A great deal has been done to improve outcomes for people who have had an acute STEMI heart attack; this guideline identifies how outcomes can be improved even further.”
Professor Huon Gray added: “There is evidence that as many as 30% of people who have had a STEMI heart attack do not receive reperfusion treatment to remove the blockage in the coronary artery to restore blood flow. This is usually for good clinical reasons but the expert group felt some of these people may be eligible for this treatment, but this needs further investigation. Every minute counts and this guideline stresses the importance of immediate assessment of a person’s suitability for reperfusion treatment and then its delivery as quickly as possible.”
Rob Henderson, Consultant Cardiologist, Nottingham University Hospitals and Deputy Chair of the guideline development group, said: “There have been substantial developments in the management of STEMI over recent years and a NICE review of what works and what is cost-effective is therefore timely. The guideline highlights the need to deliver reperfusion therapy to eligible patients with STEMI as quickly as possible and confirms that PPCI is the preferred reperfusion strategy, provided that it can be delivered within the recommended timeframes. The guideline also provides up-to-date guidance on other important aspects of STEMI management, including the treatment of patients who remain unconscious after cardiac arrest, the use of radial artery access for PPCI, and the use of fibrinolysis for the small proportion of patients with STEMI who will still be eligible for this reperfusion therapy. The guideline should be of great interest to anyone involved in the management of patients with acute STEMI.”
Mark Whitbread, Consultant Paramedic, London Ambulance Service and member of the guideline development group, said: “We’ve been taking heart attack patients in London direct to specialist centres since 2006 giving them the best chance of survival and recovery. Ambulance crews are trained to diagnose a heart attack using a 12-lead ECG and they are making the decision to go immediately to a specialist hospital, often by-passing the local A&E, for the best possible care.”
Gerry Robinson, patient/carer representative on the guideline development group, said: “This guideline will help to ensure that people who have had a STEMI, will receive the same high standard of care wherever they are admitted to hospital. I believe the lay version of the guideline will be an important tool in ensuring that both patients and clinicians are aware of the standards of care to which the health service should be working.
“It has been a privilege to sit on the guideline development group and I have been impressed by the rigour and inclusiveness of NICE’s process, and by the collegiate approach of everyone on the Group with the sole objective of improving treatment and care for people who have had a STEMI.”
Notes to Editors
References and explanation of terms
i. Mechanical techniques as a means of widening acutely blocked coronary arteries, thereby restoring coronary flow. They include balloon coronary angioplasty, stent insertion (where a short wire-mesh tube is inserted into an artery to allow blood to flow more freely through it), and thrombus extraction catheters.
ii. Fibrinolysis is the use of drugs to break down blood clots (also termed thrombolysis).
iii. Antiplatelet drugs are agents which decrease platelet aggregation and inhibit thrombus (blood clot) formation. Drugs in this class include aspirin, clopidogrel and glycoprotein IIb/IIIa inhibitors. This group of drugs is different from those called anticoagulants, such as heparin, bivalirudin and warfarin.
iv. An invasive procedure that uses a special dye (contrast material) and x-rays to see how blood flows through the arteries in the heart. A catheter (tube) is inserted through an artery and moved up to the heart. Once the catheter is in place, dye is injected into the coronary arteries and X-ray images taken to see how the dye (blood) moves through the artery. The dye helps highlight any blockages in blood flow.
About the guidance
The guideline will be available on the NICE website from 00:01 on 10 July 2013.
NICE has produced three different versions of the guideline: a full version; a summary version, known as the “NICE guideline”; and a version for people who have had a STEMI, their family and carers, and the public. All these versions, as well as a pathway and a suite of tools to help implement the guideline, are available from the NICE website from 00:01 on 10 July 2013.
About myocardial infarction with ST-segment-elevation
The process by which arteries become stiff and thickened is termed arteriosclerosis, and is the most common form of cardiovascular disease (CVD). It is the consequence of a number of predisposing risk factors, such as advancing age, smoking, hypertension, diabetes, raised cholesterol, impaired renal function, obesity, inactivity and family history.
When coronary arteriosclerosis impairs blood supply to heart muscle (myocardium), the person affected may suffer exertional chest pain relieved by rest, a condition known as stable angina.
When myocardial blood flow is acutely impaired (ischaemia), and often not provoked by exertion, a person will commonly suffer more prolonged pain; this is referred to as an acute coronary syndrome (ACS).
ACS involves the erosion or sudden rupture of an atheroscerotic plaque within the wall of a coronary artery. Exposure of the circulating blood to the cholesterol-rich material within the plaque stimulates blood clotting (thrombosis), which obstructs blood flow within the affected coronary artery.
ACS encompass a range of heart conditions from unstable angina to myocardial infarctions (heart attacks). Where the blood supply to the heart is impaired, but there is no evidence of actual damage to the heart muscle, the clinical syndrome is described as unstable angina.
When the ischaemia causing infarction is either short-lived or affects only a small territory of myocardium the ECG will often show either no abnormality or subtle changes. This syndrome is termed non-ST-segment-elevation myocardial infarction (NSTEMI).
When the ischaemia causing infarction is prolonged the affected person will usually experience more severe and sustained chest pain, often together with breathlessness, nausea and sweating. Symptoms can be atypical, particularly in women, the elderly, and people with diabetes. Not only will cardiac troponin be released, but the ECG will usually show ST-segment elevation, resulting in this being termed ST-segment-elevation myocardial infarction (STEMI).
As soon as the coronary blood supply is interrupted, myocardial damage begins and the longer the blood supply is occluded the greater the amount of heart muscle lost – nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds is lost within 3 hours.
The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.
Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).
Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.
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This page was last updated: 09 July 2013
National Institute for Health and Care Excelence (NICE), 10.07.2013 (tB).