1. Blue light to the East of England Heart Attack Centres Dr Sarah Clarke Consultant Cardiologist And Clinical Director Cardiac Services Papworth Hospital

2. Objectives Review the current PPCI service at Papworth hospital Discuss HAC centres planned in East of England Roger Boyle view on PPCI in East of England Update on configuration of HAC in the East of England and delivery PPCI

3. Background In 2005 the Myocardial Infarction Audit Project (MINAP) identified the “use of PPCI as a treatment for heart attack is increasing rapidly and is set to increase further.’ Dr Roger Boyle (2006) made the clinical case for re- configuration in the context of heart disease and stroke services, stating that local accident and emergency units may not always be the best place to treat heart attack and stroke victims. National coverage of primary angioplasty services would prevent around 500 deaths, around 1,000 further heart attacks and around 250 strokes (Mending Heart and Brains, DoH 2006). Lord Darzi states in his interim report “we are beginning to lag behind other countries in treating heart attack patients with primary angioplasty”.

4. Thrombolysis Best outcome if delivered early esp in the first hour onset chest pain- the ‘golden hour’ However: –Majority do not call in the golden hour –30% not eligible to receive it –it does not always work and 20 - 30% given thrombolysis re-occlude shortly after and have a further heart attack –only dissolves the thrombus and does not remove the plaque –Risk of bleeding eg stroke

5. PPCI >22% heart attacks in UK now have ‘primary angioplasty’ or PPCI PPCI removes the thrombus and treats the plaque to keep the artery open Lower risk of re-occlusion and bleeding PPCI gives superior outcomes if delivered quickly

6. The importance of time to treatment National standards: – Thrombolysis should be given within 60 minutes call or within 30 minutes arrival in hospital (‘call to needle’ or ‘door to needle’) –PPCI should be delivered within 120 minutes of patients call for help (‘call to balloon’) (NIAP 2008)

7. First Heart Attack Centre (HAC) in the East of England Opened Monday 22 September 2008 at 9am 999 call heart attacks at home or in hospital from ambulance catchment area around –Peterborough –Hinchingbrooke –Addenbrookes Hospitals Admitted directly to Papworth Hospital Catheter Laboratory for ‘Primary Angioplasty’ or PPCI Open 24/7 90 PPCI cases to date Biweekly open review meetings, bimonthly steering group meetings Review of first 3 months, 5 February 2009 Papworth Heart Attack Centre (PHAC)

9. Where next? PPCI for all Hybrid approach (based on travel time. See ERPHO service maps)

10. Where next in E of E? Roger Boyle communication 5 December 2008 –The 120 minute time from call is an aspiration rather than a target. –The Europeans start the clock from ‘first medical contact’ not the first ring to the ambulance service, so in proposing 120 minutes we are being more demanding than most other nations –The Danes run a service spread across their difficult landscape in only 5 centres and the Czechs in only 2 –DANAMI showed benefit for PCI vs. thrombolysis even when transfers took 3 hours or more

11. –We know that achieving rapid call to treatment times is something that needs focus and takes time to deliver (cf experience with thrombolysis) –I am concerned about the viability of small volume pre-hospital thrombolysis in more rural areas with longer trial times –I am much more in favour of setting up 100% PPCI services even if this means longer transfers and some patients taking more than 120 minutes in the first instance.

12. –..there will be an inverse relationship between travel time and door to balloon time –..and I believe that the ambulance arrival to departure time can also be reduced with attention to detail

13. –From this you will see that I need some convincing that hybrid services in Suffolk and North East Essexare worth considering –I would also need convincing that there is sufficient critical mass between Colchester and Ipswich to consider providing an angioplasty solution locally

14. SHA review emergency services: Service standards for PPCI centre Compliance with BCIS criteria for providing PCI service Provision 24/ 7 PPCI service Located to maximise probability of achieving max 150 minute call to balloon with centres covering the EoE geographically Sufficient interventional cardiologists for rota (not less than 1 in 6) Catheter laboratory staffed by multi-disciplinary team 24/7 Suitable back-up support for intensive patients Provision robust follow-up and rehabilitation pathways Audit

16. ERPHO: travel times 90 minutes

21. Complete coverage

22. What does this tell us? Regional coverage for PPCI can be achieved with target travel times of 90 minutes to 3 HACs (Papworth, Norfolk and Norwich and Basildon) – plus Harefield Target of 30 minutes first medical contact (paramedic) to start of journey and door to balloon of 30 minutes gives maximum times of 150 minutes for minority of patients. The upper time limit for PPCI’s clinical benefit is at least 165 minutes

23. Wider clinical group – 8/12 Single model for PPCI – no PHT No small volume centres No part-time centres EoE target 120 mins CTB, stating with 265 mins Specialist Commissioning Group to agree proposals Centres operational from April 2009

24. 2b3a not to be pursued as line of preferred treatment at present Model based on road ambulance Establish PPCI Steering Group Agree metrics, protocols and audit across EoE Discuss with Overview and Scrutiny Committee

25. EoE Management Board Specialist Commissioning Group Towards the Best Together Steering Group Acute Programme Board PPCI Steering Group Overview & Scrutiny Committees

26. Thank you