Heart Disease in the Acute Hospital Will Orr Consultant Cardiologist

Will Orr Consultant Cardiologist Primary Angioplasty to Improve Heart Attack Survival - The importance of joined-up care for our patients Will Orr Consultant Cardiologist

What is a heart attack?

approx 20% of all UK deaths

30% of all male premature deaths

22% of all female premature deaths

half of all deaths occur before reaching hospital

…but there is some good news of those who survive the initial heart attack: 75% alive at 5 years 67% alive at 10 years (and walking for 30 mins every day halves your risk of having a first or another heart attack)

Improving outcomes for heart attack

CVD Death rates

How do we treat heart attack? thrombolysis (clot-busting drugs)

Absolute mortality reduction per 1000 Pre-Hospital Thrombolysis Boersma et al : Lancet 1996; 348:771-775 Absolute mortality reduction per 1000 treated patients 80 60 40 20 3 6 9 12 15 18 21 24 Treatment delay (h) Early thrombolysis

How good have we been at treating heart attack historically?

Why did we need to change what we were doing? Keely. Lancet 2003;361:13-20 % mortality Primary Angioplasty Thrombolysis heart attack mortality 1 additional life saved for every 44 patients treated with PPCI 25% reduction in mortality

UK Primary PCI October 2008

How important is time? 60 minute Isochrones Oxford & Southampton

How important is time? CTB Time In-hospital 30 days 1 year % Mortality in NIAP CTB Time In-hospital 30 days 1 year 60-120 minutes 2.7 2.9 5.1 120-180 minutes 4.5 4.9 8.7 % increase in mortality at 120-180 mins 67% 69% 71% National Infarct Angioplasty Project. DOH October 2008

How is mortality affected by delay? % Mortality in NIAP CTB Time In-hospital 30 days 1 year 60-120 minutes 2.7 2.9 5.1 120-180 minutes 4.5 4.9 8.7 Greater than 180 minutes 11.4 12.2 15.9 % increase in mortality at 120-180 minutes 67% 69% 71% % increase in mortality at >180 minutes 320% 212% NIAP 2008. www.dh.gov.uk/publications

How is mortality affected by delay? % Mortality in NIAP NIAP 2008. www.dh.gov.uk/publications

How is mortality affected by delay? % Mortality in NIAP CTB Time In-hospital 30 days 1 year 60-120 minutes 2.7 2.9 5.1 120-180 minutes 4.5 4.9 8.7 Greater than 180 minutes 11.4 12.2 15.9 % increase in mortality at 120-180 minutes 67% 69% 71% % increase in mortality at >180 minutes 320% 212% NIAP 2008. www.dh.gov.uk/publications

Primary Angioplasty for ST-elevation MI MINAP RBH % CTB 150 mins % CTB 120 mins n Eng 2009 38 78 83 2010 144 79 96 2011 147 81 95 59 89 2012 166 62 90 2013 186 82 99 60 2014 150 94 2015 92* MINAP = Myocardial Ischaemia National Audit Project, RBH = Royal Berkshire Hospital, CTB = Call-to-Balloon time

How is mortality affected by delay? % Mortality in NIAP if 111 don’t pass the call on to SCAS for 10’, the chances of the patient dying increase by 10% if the paramedic doesn’t pre-alert when the diagnostic ECG is done, but waits until they’re en route 20’ later, the chances of the patient dying may increase by 20% if the team don’t recognise a STEMI, or the Cardiologist blocks the decision to activate the PPCI team out-of-hours, and this doesn’t happen until arrival at hospital, there may be a 30’ delay & a 30% increased risk of dying NNT to save 1 life = 50  SCAS-RBH Heart Attack Team saves an additional 4 lives per year Risk of Death increases by 1% per minute delay

monthly MINAP Audit meeting

Out-of-Hospital Cardiac Arrest (OOHCA) OHCA Oct 2012 – May 2015 OOHCA Survival to Discharge n % England 79618 6672 8.4 South Central Ambulance Service 3428 595 17.4* Royal Berkshire Hospital 493 96 19.5* ** *p<0.001 v England **p=ns v SCAS MINAP data for SCAS & RBH

Summary Primary Angioplasty saves lives and prevents long-term disability if it is done well The quality & effectiveness of Primary Angioplasty is dependent on ALL members of the Heart Attack Team consistently doing their job well and constantly seeking further improvement The faster it is done, the more likely that the patient will survive, and survive without disability

Walking briskly for 30 mins on 5 days of the week halves your risk of heart attack, stroke or death

medicines make an important difference too

Statins

IT’S YOUR CHOICE!! Patients with known vascular disease Lancet 8th Sept 2016 Patients with known vascular disease prevent 1 heart attack/stroke/death for every 10 treated Patients at risk of developing vascular disease - prevent 1 heart attack/stroke/death for every 20 treated Side Effects in 10 000 patients treated for 5 years true muscle inflammation in 5 patients (0.05%) (reversible) muscle aches/weakness in 50 – 100 patients (0.5 – 1%) new diabetes in 50 – 100 patients (0.5 – 1%) haemorrhagic stroke 5 - 10 patients (0.05 – 0.1%) IT’S YOUR CHOICE!!

Statins stabilise plaques lipid core STATIN THERAPY Many individuals who develop vascular disease do not have particularly elevated cholesterol Trials have demonstrated statin benefits on increased regression and reduced progression of atheromatous plaques Meta analysis of 14 trials has shown a 19% reduction in progression of plaques with statins. LDL Targets significantly lower to achieve favourable plaque modulation (LDL reduction >45%) Statins stabilise plaques lipid core

Conclusions Heart Disease remains Britain’s biggest killer Rates of survival without long-term disability continue to improve year-on-year Our emergency treatment of heart disease is the best in the world (especially locally!) Prevention is the best option