1. Heart Disease in the Acute Hospital
Will Orr
Consultant Cardiologist

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

3. What is a heart attack?

4. approx 20% of all UK deaths

5. 30% of all male premature deaths

6. 22% of all female premature deaths

7. half of all deaths occur before reaching hospital

8. …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)

9. Improving outcomes for heart attack

11. CVD Death rates

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

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

14. How good have we been at treating heart attack historically?

15. 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

16. UK Primary PCI October 2008

17. How important is time?
60 minute Isochrones
Oxford & Southampton

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

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

20. How is mortality affected by delay?
% Mortality in NIAP
NIAP

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

24. 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

25. 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

26. monthly MINAP Audit meeting

30. 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

31. 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

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

34. medicines make an important difference too

35. Statins

36. 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 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 patients (0.05 – 0.1%)
IT’S YOUR CHOICE!!

37. 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

39. 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