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Is the NHS failing those who have suffered a heart attack?

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    A blog considering the results of a recent study carried out in relation to the adequacy of care provided to patients following heart attack in NHS hospitals in England and Wales.

    By Kerstin Kubiak

I have been reading recently about a study looking at patients who have suffered a heart attack and the treatment they received as a result. This study was funded by the British Heart Foundation (BHF) and the National Institute for Health Research and it was carried out by a number of researchers from various institutions, to include the University of Leeds and University College London.

This cohort study (a type of medical research used to investigate the causes of disease, establishing links between risk factors and health outcomes) was undertaken to determine whether the best care and advice was being given to individuals who had suffered a certain type of heart attack.

In response to this study, Professor Peter Weissberg, Medical Director at the BHF has stated “This study shows that many people in the UK are receiving suboptimal care after a heart attack and that lives are being lost as a consequence.”

What is a heart attack?

A heart attack is a form of acute coronary syndrome (ACS), where there is a significant blockage in the coronary arteries. Each heart attack can be classified by a measurement know as the ST segment, an electrical measurement recorded by an ECG and it corresponds to the level of damage inflicted on the heart.

There are three main types of ACS: first, and the most serious is ST segment elevation myocardial infarction (STEMI) – this occurs as a result of a total blockage to a coronary artery causing a long interruption to the blood supply and extensive damage to the heart; second, non-ST segment elevation myocardial infarction (NSTEMI) – this occurs when there is a partial blockage and so less damage is caused; and third, unstable angina, the least serious type, although still categorised as a medical emergency.

What data did the study use?

The clinical data was obtained from the UK National Heart Attack Register from 247 hospitals between 1 January 2003 to 30 June 2013 in England and Wales looking at 390,000 patients (with an average age of 70 years) who had experienced a NSTEMI heart attack. The study did not include individuals who had died in hospital, where pharmacological therapies were uncertain, or if there was missing data on death.

The researchers used guidelines for the management of NSTEMIs from the European Society of Cardiology and a total of 13 guidelines were considered.

What were the results?

The conclusion from the researchers was that “The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality (death). Greater attention to the provision of guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.”

Staggeringly, researchers found that 86.9% of the patients had not received one or more of the recommended interventions/ necessary advice, to include:

1. Advice to quit smoking;
2. Cardiac rehabilitation;
3. Coronary angiography;
4. Statins (drugs aimed to lower cholesterol);
5. Cardiac rehabilitation;
6. P2Y12 inhibitors (drugs which decrease the ability of a blood clot);
7. Dietary advice.

Of the 13 missed interventions, 1-4 from the list above were deemed to be the most effective in avoiding death.

In summary, if all of the eligible patients in the study had received all of the guideline-indicated interventions available to them, 32,765 deaths may have been prevented.

How much can we rely on this study?

Whilst the reported statistics from this study are very worrying, it is also important to note that all medical research has both strengths and weaknesses. The main advantage of this study is that it included a large amount of data over a period of 10 years specifically looking at one type of heart attack. On the other hand, a key limitation which has been reported is the question over why the researchers compared UK practice against the European guidelines instead of the National Institute for Health and Care Excellence (NICE). Further, it has been noted that, in addition to the guidelines, there are a number of other factors which could have an impact on survival. Lastly, on occasion there were reasons to explain why a particular treatment was not given, for example, patient refusal and the study did not take this into account.

How can this study help patients in the future?

A heart attack is considered to be one of the most common reasons why an individual would require emergency medical treatment and due to the significant impact it can have on such a vital organ it is paramount that adequate treatment and advice is given. It is reported that if an individual survives more that 28 days after suffering a heart attack then their recovery dramatically improves. Whilst the results of the study may not be as stark as they seem, I hope that this study will prompt closer consideration of all treatments available to patients following heart attack, to maximise their chances of a good recovery.

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