National Service Framework NSF sets out 12 standards covering the following areasNSF sets out 12 standards covering the following areas –Reducing heart disease in the population –Preventing CHD in high-risk patients –Acute coronary syndromes –Stable angina –Revascularisation –Heart failure –Cardic rehabilitation

National Service Framework Standard 1Standard 1 –NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease Standard 2Standard 2 –NHS and partner agencies should contribute to a reduction in smoking in the local population

National Service Framework Health Improvement Programme (HiMP)Health Improvement Programme (HiMP) –Reduce smoking, promote healthy eating, increase physical activity, reduce overweight –Co-ordinated by HA –Clear lines of action and accountability –Structure, process and outcome measures by which local delivery judged to be specified

National Service Framework Standard 3Standard 3 –GPs and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks Standard 4Standard 4 –GPs and primary care teams should and primary care teams should identify all people at significant risk of cardiovascular disease but have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks

National Service Framework If established vascular diseaseIf established vascular disease –Smoking advice including nicotine replacement –Other risk factor advice (exercise, diet, alcohol, weight) –BP below 145/85 –Aspirin 75mg –Statins to get chol<5 or 30% reduction –ACEI if LV dysfunction –Beta-blockers if previous MI –Warfarin or aspirin if A fib and over 60 –Tight glucose and BP control in diabetics

National Service Framework Without vascular disease but CHD risk greater than 30% over 10 yearsWithout vascular disease but CHD risk greater than 30% over 10 years –Smoking advice including nicotine replacement –Other risk factor advice (exercise, diet, alcohol, weight) –BP below 145/85 –Statins to get chol<5 or 30% reduction –Tight glucose and BP control in diabetics

National Service Framework By April % of heart attack patients should be on proven effective medicines (aspirin, beta-blockers, statins)By April % of heart attack patients should be on proven effective medicines (aspirin, beta-blockers, statins)

National Service Framework Standard 5Standard 5 –People with symptoms of possible MI should receive help from appropriately trained person with a defibrillator within 8 minutes Standard 6Standard 6 –Possible MI patients should be assessed professionally and, if indicated, receive aspirin and thrombolysis within 60 minutes of the call for help Standard 7Standard 7 –NHS Trusts should have protocols so MI patients receive proven cost-effective treatments

National Service Framework Aspirin 300mg followed by 75mg odAspirin 300mg followed by 75mg od Beta-blockers for at least 1 yearBeta-blockers for at least 1 year ACEI reviewed after 4-6 weeksACEI reviewed after 4-6 weeks Keep BP < 140/85Keep BP < 140/85 Statins to get chol<5 or 30% reductionStatins to get chol<5 or 30% reduction Tight glucose and BP control in diabeticsTight glucose and BP control in diabetics Risk factor adviceRisk factor advice Arrange rehabilitationArrange rehabilitation Assess potential benefit from revascularisationAssess potential benefit from revascularisation

National Service Framework For UNSAFor UNSA –Aspirin, heparin –Beta-blockers, nitrates, calcium antagonists –Interventions as for MI

National Service Framework By April 2001 –Ambulance response time of under 8 minutes for at least 75% of category A calls –At least 75% of A+E departments able to provide thrombolysis

National Service Framework By April 2002 –Door to needle time of under 30 minutes in 75% of eligible cases By April 2003 –Door to needle time of under 20 minutes in 75% of eligible cases

Standard 8Standard 8 –People with syndromes of angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events National Service Framework

InvestigationsInvestigations –Hb, glucose, cholesterol –Assess myocardial ischaemia TreatmentTreatment –S/L nitrates, Beta-blockers, Oral nitrates, Ca antagonists, Aspirin –Risk factor advice and treatment EducationEducation –What to do about possible MI Assess benefits of revascularisationAssess benefits of revascularisation National Service Framework

By April 2001By April 2001 –50 rapid-access chest pain clinics nationally –Agreed hospital protocol for investigation and management of suspected angina By April 2002By April 2002 –100 rapid-access chest pain clinics nationally National Service Framework

Standard 9Standard 9 –People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently Standard 10Standard 10 –NHS Trusts should have a care system so patients with confirmed CAD receive timely and appropriate investigation and treatment to relieve symptoms and improve prognosis

AngiographyAngiography –Extensive ischaemia on non-invasive testing –Persisting angina in spite of medical Px Quantitative assessment of priorityQuantitative assessment of priority –System for stratification (immediate/urgent/soon) CABG or PTCACABG or PTCA Secondary preventionSecondary prevention and rehabilitationand rehabilitation National Service Framework

Increase number of revascularisations by 3000 by April 2002Increase number of revascularisations by 3000 by April 2002 Aim for at least 750 PTCAs per million population and 750 CABGs per millionAim for at least 750 PTCAs per million population and 750 CABGs per million Maximum waiting timesMaximum waiting times –GP to specialist for new onset CP (2 weeks) –GP to consultant for routine First stage 13 weeksFirst stage 13 weeks Second stage 4 weeksSecond stage 4 weeks

National Service Framework Maximum waiting timesMaximum waiting times –Decision to investigate to angiography First stage 6 monthsFirst stage 6 months Second stage 3 monthsSecond stage 3 months –Decision to operate to PTCA First stage 12 monthsFirst stage 12 months Second stage 3 monthsSecond stage 3 months –Decision to operate to CABG First stage (urgent inpatient, high risk 3 months, others 12 months)First stage (urgent inpatient, high risk 3 months, others 12 months) Second stage (urgent inpatient, high risk 3 months, others 6 months)Second stage (urgent inpatient, high risk 3 months, others 6 months)

National Service Framework Standard 11Standard 11 –Suspected heart failure patients should be offered appropriate investigations (ECG, ECHO) to confirm/refute diagnosis. In confirmed cases treatments most likely to relieve symptoms and reduce mortality should be offered

National Service Framework ACEIACEI DiureticsDiuretics Beta-blockers (advise specialist initiation)Beta-blockers (advise specialist initiation) Nitrates/hydralazine for ACEI intolerantNitrates/hydralazine for ACEI intolerant DigoxinDigoxin Lifestyle/risk factor adviceLifestyle/risk factor advice Control BPControl BP Flu vaccineFlu vaccine Tight BP and glucose control in diabeticsTight BP and glucose control in diabetics

National Service Framework Outreach follow-up by specialist nursesOutreach follow-up by specialist nurses Multidisciplinary community support including palliative careMultidisciplinary community support including palliative care Heart failure clinics (nurse practitioners or doctors, primary or secondary care)Heart failure clinics (nurse practitioners or doctors, primary or secondary care) Clear protocolsClear protocols Easy/open access echocardiographyEasy/open access echocardiography

National Service Framework Standard 12Standard 12 –NHS Trusts should put in place agreed protocols so patients admitted suffering from CHD are invited into secondary prevention protocols and rehabilitation

St Mary’s response to the NSF Standard 7 (proven treatments offered)Standard 7 (proven treatments offered) –Secondary prevention nurse Standards 9 and 10 (revascularisation)Standards 9 and 10 (revascularisation) –Standards largely in place Standard 11 (heart failure)Standard 11 (heart failure) –Open access echo in place –Heart failure clinic Standard 12 (rehabilitation)Standard 12 (rehabilitation) –Programme in place

St Mary’s response to the NSF Standard 6 (thrombolysis)Standard 6 (thrombolysis) –Triage ECG room –Chest pain specialist nurse Standards 8 (new onset/stable angina)Standards 8 (new onset/stable angina) –Rapid assessment unit –Chest pain specialist nurse

Chest Pain Services at St Marys Refer high risk patients with potential MI or unstable angina to the on-call cardiologist (bleep 1216) for assessment in casualtyRefer high risk patients with potential MI or unstable angina to the on-call cardiologist (bleep 1216) for assessment in casualty Patients potentially at moderate riskPatients potentially at moderate risk –Recent onset chest pain (within 3 months) –Worsening chest pain of possibly ischaemic origin can be referred to the Rapid Assessment Unit ( )

Rapid assessment unit nurse review Suspected myocardial infarction or unstable anginaSuspected myocardial infarction or unstable angina –Transfer to casualty resuscitation –ECG immediately in resuscitation –Contact cardiologist immediately –Insert IV cannula –Give soluble aspirin 300mg po or aspirin 300mg po chewed

Investigations arranged by RAU staff Cardiovascular observationsCardiovascular observations ECGECG Routine bloodsRoutine bloods BMstix if known or suspected diabeticBMstix if known or suspected diabetic CXRCXR Exercise treadmill test if possible ischaemic painExercise treadmill test if possible ischaemic pain Echo and spirometry if shortness of breathEcho and spirometry if shortness of breath

Cardiologist assessment After patient already worked upAfter patient already worked up –Admission –Diagnosis of stable angina with appropriate drug treatment and follow up –Reassurance CommunicationCommunication –Faxed report on the same day of referral

Summary Patients with probable MI/UNSA to on-call cardiologistPatients with probable MI/UNSA to on-call cardiologist Patients with recent onset/worsening chest pain of possible ischaemic origin to RAU ( )Patients with recent onset/worsening chest pain of possible ischaemic origin to RAU ( ) If in doubt ring the RAU to discussIf in doubt ring the RAU to discuss

Summary Easy accessEasy access Same day assessment with full non-invasive work upSame day assessment with full non-invasive work up Same day communication of resultsSame day communication of results

Summary Early risk stratificationEarly risk stratification –Prevent potential disaster of missed diagnosis Targeting of high risk patientsTargeting of high risk patients –Reduce morbidity/mortality Some reduction in pressure on A+E and routine outpatientsSome reduction in pressure on A+E and routine outpatients