myocardial ischaemia - national audit project [minap] 2011 - ucl
TRANSCRIPT
How
the NH
S cares for patients with heart attack
MIN
AP Tenth P
ublic Report 2011
Myocardial IschaemiaNational Audit Project
Myocardial IschaemiaNational Audit Project
myocardial ischaemia national audit project [minap]
How the NHS cares for patients with heart attack
Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group
NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH
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heart attacks recorded in minap in 2010/11This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11.
Report prepared by: Lucia Gavalova, Project co-ordinator MINAP
With assistance from:Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinatorLynne Walker, MINAP Programme managerProfessor Tom Quinn, MINAP Steering Group memberProfessor Adam Timmis, Chairman MINAP Academic GroupMrs Sirkka Thomas, MINAP Patient/carer representativeMr David Geldard, MINAP Patient representative
Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap
For further information about this report, contact:
Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes ResearchInstitute of Cardiovascular ScienceUniversity College London175 Tottenham Court RoadLondon W1T 7NU
Tel: 0203 108 3931 Email: [email protected]
University College London (media enquiries)Media Relations Manager Ruth Howells Tel: 020 3108 3845Email: [email protected]
Acknowledgements
Department of Health Enquiries to the Department should be directed to the Customer Service CentreTel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform
In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS
Welsh Assembly Government Ms Cathy WhiteHead of Adult & Children’s HealthMedical DirectorateDepartment for Health, Social Services & ChildrenWelsh GovernmentCathays Park,Cardiff CF10 3NQ
Tel: 029 20826108Email: [email protected]
Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/HomePage.aspx
The MINAP team would like to thank all the hospitals and ambulance services that have collected data.
This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.
The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.
MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk.
This report may not be published or used commercially without permission.
Designed and published by:
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3MINAP Tenth Public Report 2011
contents
By the National Director for Heart Disease and Stroke
1. Background to heart attacks 7
1.1 ST elevation myocardial infarction 7 and non ST elevation myocardial infarction
1.2 Aims of management 7
1.3 Reperfusion therapy 8
2. Background to MINAP 8
2.1 A look back 8
2.2 Organisation of MINAP 10
2.3 How the data are collected 10
2.4 Security and patient confidentiality 10
2.5 Case ascertainment 10
2.6 Data quality 10
3. Improving quality, improving outcomes 11
3.1 Use of MINAP data to inform the British 11 Cardiovascular Society working group on the use of the cardiac care unit
3.2 Use of primary angioplasty 11
3.3 Access to coronary angiography 12 for patients with non ST elevation myocardial infarction
3.4 International comparisons 13
4. MINAP: a patient’s perspective 14
1. Characteristics of patients with heart attack 16 in 2010/11
2. Hospitals that perform primary angioplasty 18
3. Hospitals using thrombolytic treatment 19
4. Angiography for ST elevation infarction 20 patients not having primary angioplasty
5. Reperfusion treatment by hospital 20
6. Ambulance service performance 21
7. Use of secondary prevention medication 21
8. Cardiac networks 21
9. Care for patients with non ST elevation infarction 22
10. Change in mortality of heart attack patients 23
11. Results by hospitals, ambulance services 24 and cardiac networks
Table 1 Primary angioplasty in hospitals in 24 England, Wales & Belfast
Table 2 Thrombolytic treatment in hospitals 28 in England
Table 3 Thrombolytic treatment in hospitals 36 in Wales & Belfast
Table 4 Ambulance services in England & Wales 37
Table 5 Secondary prevention medication 38 in England
Table 6 Secondary prevention medication 50 in Wales & Belfast
Table 7 Cardiac networks in England & Wales 52
Table 8 Care of patients with non ST elevation 54 infarction in England
Table 9 Care of patients with non ST elevation 66 infarction in Wales & Belfast
12. Difference in performance in England 68 and Wales
Implementing a Primary PCI service in Oxford 69
MINAP, promoting prevention 70
Establishing a primary angioplasty service in 71 Lincolnshire
Improvement in call-to-balloon times at London 72 Chest Hospital, Barts & the London NHS Trust
Using data from MINAP to model a PPCI Service 73 in the Chesire & Merseyside network area
Use of MINAP data to analyse and improve 74 the PPCI service
1. MINAP Academic Group - 5 year overview 75
2. Use of MINAP data to evaluate the impact of 75 acute coronary syndrome care by patient age
3. Enriching MINAP through linkage to primary 76 care & investigator led cohorts
4. Management of hyperglycaemia in acute 76 coronary syndromes
foreword 4
executive summary 5
part two: results 16
part five: appendices 78
part four: research use of 75 minap data
part three: case studies 69
part one: introduction 7
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4 MINAP How the NHS cares for patients with heart attack
This is quite an achievement and reflects on the hard work of staff across the NHS both in the ambulance services and in hospitals supported by the improvement programmes led by NHS Improvement and implemented locally by cardiac networks.
As more patients with heart attack have primary angioplasty these reports increasingly will also rely on information from the British Cardiovascular Intervention Society’s (BCIS) database, and future reports are likely to include analyses from this source.
We would like to thank all those that have been involved.
Professor Sir Roger Boyle, CBE, FRCP
National Director for Heart Disease and Stroke [to August 2011]
foreword
This year we celebrate the 11th anniversary of the initial roll out of MINAP in October 2000. During this time, we have witnessed a series of transformations in the management of heart attack which have long-term benefits for individual patients and the NHS as a whole. In the first few years we saw thrombolytic treatment provided with high levels of expertise, timeliness and efficiency by hospitals and by ambulance services. Over the last four years primary angioplasty has rapidly replaced thrombolytic treatment as the preferred treatment for heart attack, centralising acute care in specialist heart attack centres. At present, over 80% of heart attack patients receive primary angioplasty which is associated with shorter hospital stays, is safer and provides better outcomes. The chances of survival after heart attack have improved year on year despite an ageing population so that the outcomes in this country match the best in the world. Data show that death rates after heart attack have fallen faster in the UK than in any other European country.
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This is the tenth annual MINAP Public Report. It presents analyses from all hospitals and ambulance services in England and Wales that provided care for patients with suspected heart attack between April 2010 and March 2011 (2010/11). For the first time we present data from hospitals in Belfast. The report also presents some data from previous years. Its purpose is to inform the public about the quality of local care for heart attack patients.
Heart attack is common and remains a major cause of death and ill health. Importantly, prompt and appropriate treatment reduces the likelihood of death and recurrent heart attack. Good treatment coupled with cardiac rehabilitation promotes optimal recovery. Heart attack, or myocardial infarction, is part of the spectrum of conditions known as acute coronary syndromes (ACS). This term includes both ST elevation myocardial infarction (STEMI), for which emergency reperfusion treatment with primary angioplasty or thrombolytic drugs is beneficial, and non ST elevation myocardial infarction (nSTEMI), which represent the majority and for which a different approach is required.
Initial treatment of patients with ST elevation myocardial infarction
High quality care for STEMI includes early diagnosis and rapid treatment to re-open the blocked coronary artery responsible for the heart attack. Two forms of treatment are available; primary angioplasty, where the artery is re-opened mechanically using a balloon catheter inserted into the blocked artery, and thrombolytic treatment, where the clot is dissolved by a drug given by ambulance or hospital staff. Delay to providing either treatment is associated with poorer outcomes.
Patients who received primary angioplasty for ST elevation myocardial infarction
Primary angioplasty is the preferred treatment if it can be provided promptly. Once a patient is recognised as having a heart attack, ambulance staff take the patient directly to the catheter laboratory of the nearest heart attack centre, often bypassing smaller hospitals and the Accident and Emergency (A&E) department.
� This year, in England, 82% of patients who received any reperfusion treatment received primary angioplasty compared to 63% in 2009/10. In Wales the increase was from 22% to 30%. In the Belfast hospitals 99% of patients who received any reperfusion treatment received primary angioplasty compared to 59% in 2009/10.
� This year 90% of eligible patients in England, 68% in Wales and 87% in Belfast were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre.
� 81% of eligible patients in England, 75% in Wales and 90% in Belfast were treated with primary angioplasty within 150 minutes of calling for professional help.
� Access to primary angioplasty is variable. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5% and 93%; in 6 cardiac networks fewer than 50% of patients received primary angioplasty.
� 75% of patients that were treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in the Belfast hospitals.
executive summary
The Myocardial Ischaemia National Audit Project (MINAP) is a national clinical audit of the management of heart attack. It supplies participating hospitals, ambulance services and commissioners with a record of their management and compares this with nationally and internationally agreed standards. MINAP provides comparative data to help clinicians and managers monitor and improve the quality and outcomes of their local services.
5MINAP Tenth Public Report 2010
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Patients who received thrombolytic treatment for ST elevation myocardial infarction
As the number of patients having primary angioplasty has increased, the number having thrombolytic treatment, either before or on arrival at hospital, has fallen.
� 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help in England; 53% in Wales. Thrombolytic treatment is not used in the Belfast hospitals.
� 69% of patients who received thrombolytic treatment or who had no reperfusion treatment had, or were later referred for, coronary angiography in England; 83% in Wales and 50% in Belfast.
Thrombolytic treatment given by paramedics before the patient reaches hospital
For many ambulance services, the focus has shifted from provision of early pre-hospital thrombolytic treatment to identifying those patients with a heart attack who might benefit from primary angioplasty, and transferring these patients rapidly to a heart attack centre. This means that for many ambulance services the number of patients receiving pre-hospital thrombolytic treatment has declined.
� 824 patients received pre-hospital thrombolytic treatment in England in 2010/11 compared to 1633 in 2009/10, a decrease of 50%. In Wales 219 patients received pre-hospital thrombolytic treatment compared to 250 in 2009/10. Pre-hospital thrombolytic treatment is not used in Belfast.
Care of patients with non ST elevation myocardial infarction
Patients with nSTEMI have a lower early risk of death (within the first month), but appear to be at similar or even greater long-term risk than patients with STEMI. Perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to cardiac care units and are not always cared for by cardiologists. However, specialist involvement has been shown to lead to better outcomes. The performance of angiography and coronary intervention soon, within the first 2-4 days, is an
important facet of treatment for the majority of these patients. Ideally, admission should be to a cardiac facility where nursing staff have cardiac expertise and there is easy access to cardiological advice. This year:
� 50% of nSTEMI patients were admitted to a cardiac unit or ward in England, 59% in Wales and 81% in Belfast.
� 91% of nSTEMI patients were seen by a cardiologist or member of their team in England, 84% in Wales and 99% in Belfast. However the Welsh data are incomplete as 4/18 hospital did not enter data on their nSTEMI patients.
Prescription of secondary prevention medication
Taking secondary prevention drugs after the acute event (for both STEMI and nSTEMI patients) reduces the risk of death and further heart attack. The proportion of patients in England, Wales and Belfast who are suitable for treatment and in whom secondary prevention medication is prescribed on discharge from hospital continues at over 90% for each of the 5 drug classes monitored.
Falling mortality
There has been a year on year fall in the percentage of patients with STEMI and nSTEMI who die within 30 days of admission to hospital.
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If ischaemia is sufficiently prolonged or complete, death of heart muscle results. This is myocardial infarction and is confirmed if evidence of heart muscle cell death is found on blood testing. Such evidence may take some hours to appear and, to be most effective, treatment must start before the results of such tests are available. Ischaemia is suggested by characteristic symptoms (for example central chest discomfort, sweating, breathlessness) and abrupt changes in blood pressure, heart rate and heart rhythm (sometimes leading to collapse or sudden death). Features of ischaemia often can be seen as electrical alterations on the electrocardiogram (ECG). At the onset of symptoms it is uncertain whether the ischaemia will be transient and of no long-term consequence, or whether it will progress to infarction and consequent failure of the heart to pump strongly. So all patients require urgent treatment to reverse ischaemia and prevent infarction.
1.1 ST elevation myocardial infarction and non ST elevation myocardial infarction
Based upon the ECG, patients are categorised into those with, and those without, ST segment elevation – leading to the final diagnosis of those with ST elevation myocardial infarction (STEMI) and those with non ST elevation myocardial infarction (nSTEMI). ST elevation usually indicates complete blockage of a coronary artery and warrants specific immediate treatment to re-open the artery – see Section 1.3 Reperfusion therapy. The absence of ST elevation usually indicates that any coronary thrombosis is only partially occluding the artery.
Although those with STEMI are at greater early risk, the medium to long-term outcome (in terms of recurrent heart attack or death) is similar, if not worse, for those with nSTEMI. Within the last two years the National Institute for Health and Clinical Excellence (NICE)1 has published guidelines for the management of patients with nSTEMI. NICE have a STEMI guideline and Quality Standard in development.2
1.2 Aims of management
The aims of management of acute coronary syndrome are presented in Figure 1 together with examples of some interventions that have been shown to be associated with better outcomes for patients and have therefore been included in various guidelines. Not all patients require all the interventions and some interventions are unsuitable – contraindicated – in some patients. Therefore, clinicians involved in providing care do not blindly follow protocols of treatment but must use their clinical judgement to determine when particular treatments should be used, and when best avoided, in individual patients.
Aims Examples of interventions
Prompt recognition of symptoms
Public education
Education of professionals
Provision of heart monitoring & resuscitation
Ambulance ‘999’ response
Hospital Cardiac Care Units
Restoration of coronary blood flow
Reperfusion treatment
� Primary angioplasty
� Thrombolytic therapy
Nitrates
Elective angioplasty/surgery
Prevention of further coronary thrombosis
Anticoagulants
Antiplatelet agents
Reduction & reversal of ischaemia
Reperfusion treatment
Anti-anginal drugs
e.g. beta blockers, nitrates
Stabilisation of coronary artery Statins
Optimise healing ACE inhibitors
Prevention of future myocardial infarction
Secondary prevention drugs
Lifestyle changes
Education & support, promotion of healthy lifestyles
Hospital cardiac nurse specialists
Cardiac Rehabilitation classes
Patient support groups
Fig 1. Aims of management of acute coronary syndrome
part one: introduction
1. Background to heart attacks
The term ‘heart attack’, while used widely in discussions between clinicians and their patients, and therefore in this public report, is too imprecise to define the clinical condition that is the subject of this national audit. The preferred term is acute coronary syndrome. This covers the symptoms and clinical features that occur when there is an abrupt reduction in the blood supply to a segment of heart muscle. Usually this is a consequence of a gradual build-up of fibro-fatty material (atheroma) within the wall of the coronary artery, which may have happened over years and often without symptoms, followed by sudden disruption of the internal artery wall at this site. This causes blood to clot within the artery – a coronary thrombosis – and leads to a state of myocardial ischaemia, in which the demands of the effected heart muscle for oxygen-rich blood exceed the supply of such blood down the clot-containing artery.
1. www.nice.org.uk/guidance/CG94
2. http://guidance.nice.org.uk/CG/WAVE25/8
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1.3 Reperfusion therapy
These are treatments that re-open the blocked coronary artery that is causing the ACS; thereby reducing the amount of heart damage. If re-opening the artery is to be of benefit it needs to happen as quickly as possible, before all the heart muscle at risk has been damaged. These therapies are therefore used in the immediate management of those with STEMI (see above). If patients delay too long after the start of their symptoms reperfusion therapy may be of no value and would not then be advised.
Two forms of treatment exist, primary angioplasty (percutaneous coronary intervention (PCI) – where the artery is opened mechanically using a balloon catheter and a stent is then left in the artery to prevent re-occlusion – and thrombolytic therapy – where the clot is dissolved by a drug. Thrombolytic therapy is given by intravenous injection and can therefore be delivered rapidly, preferably even before arriving at hospital. While the drug can be given quickly its effect on the blood clot is not immediate and varies from person to person – in some failing to re-open the artery at all. Primary angioplasty requires specialised equipment and highly-trained clinical staff within the hospital. Patients tend to wait longer for primary angioplasty than they would for thrombolytic treatment, but the final results are more reliable in terms of complete restoration of coronary blood flow, see Fig 2.
Advantages Disadvantages
Thrombolytic drugs
Established treatment
Simple administration (intravenously)
Potentially available in all hospitals
Pre-hospital use by ambulance paramedics
Fails in at least 20%
Risk of bleeding and stroke
Primary angioplasty
Successful in at least 95%
Lower stroke risk
Allows visualisation of all coronary arteries
Cardiologist necessarily involved in care of all patients
Randomised trials suggest primary angioplasty more effective than thrombolytic therapy
Not available in all centres
Treatment must be delayed until arrival at hospital
Risk of bleeding
Fig 2. Reperfusion therapy in ST elevation myocardial infarction
2. Background to MINAP
2.1 A look back
It is only by collecting data and using them that you get senseWilliam Osler, 1928
The publication of the tenth annual report of MINAP provides an opportunity to reflect on the development of the audit project, and to consider its future role in supporting and assuring good quality care for patients with ACS.
The concept of collecting a common dataset of
information on geographically distinct groups of people with heart attack was proposed by the European Regional Office of the World Health Organisation in 1968, and led to the promotion of Myocardial Infarction Community Registers, (and later to the WHO MONICA research project). In Britain, early community registers were developed in Oxford, Edinburgh and Tower Hamlets.
The primary purpose of such registers was ‘educational’ – to more precisely report the incidence of coronary events in a community; both within and without hospital, to describe the manifestations of heart attacks and to allow a comparison of fatality rates between localities. Little information was collected about the care provided within hospital. To be of more practical use to clinicians and the general population a change of emphasis was needed. As Hugh Tunstall Pedoe commented in 1978.
“The collection of information for its own sake is of doubtful value unless it is acted upon. Community registers should not become the equivalent of village war memorials.” 3
He also recognised that such information could be used in “monitoring the effects of treatment” and ensuring that it was “reaching those who needed it”. Here was recognition that data collection could be used to assure appropriate treatment; to go beyond a register toward an audit function.
Clinicians have for many years maintained hospital-based cardiac care unit registers. Perhaps the most enduring is the Nottingham Heart Attack Register, which began in simple form in 1972, and has collected more definitive data since 1982 4.
3. Tunstall Pedoe H. Uses of coronary heart attack registers. Br Heart J 1978;40:510-5.
4. Rowley JM, Mounser P, Harrison EH, et al. Management of myocardial infarction: implications for current policy derived from the Nottingham Heart Attack Register. Br Heart J 1992;67:255-62.
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Such registers have been of great value in showing variation over time in the presentation and outcome of patients with heart attacks. Being unique to each hospital, they are of limited value in revealing and quantifying variation between hospitals.
By the end of the 1980s large randomised trials, in carefully selected groups of patients, confirmed the effectiveness of clinical treatments of heart attack, and provided robust evidence upon which to base recommendations for best management. In particular, the recognition that thombolytic drugs had substantial benefits when given early after the onset of symptoms led to the realisation that it also mattered how and when a treatment was given as well as whether it was given. Measurable standards for treatment, such as door-to-needle time and call-to-needle time appeared in national guidelines, together with advice that hospitals “should provide audit data of delays to treatment” (against agreed standards)5.
Some cardiologists actively lobbied for a common audit in which all hospitals would participate. They believed that a truly national audit would lead to a more rapid implementation of evidence-based clinical practice and thus to improved outcomes for patients with heart attack. Beginning with paper records and later using portable pre-programmed Psion organisers, these cardiologists formed the Myocardial Infarction Audit Group and began, from 1992, to share their (anonymised) data, providing evidence of significant variation in practice6. A regionwide comparative audit conceived by Dr John Birkhead and Professor Rod Griffiths, the West Midlands Thrombolysis Project, reported significant improvement in call-to-needle time as a result of this approach7 . Around this time certain significant advances facilitated the aspiration of the group. Anthony Rickards and David Cunningham conceived and developed the Central Cardiac Audit Database (CCAD) to which data from all participating hospitals could be sent electronically, with automatic encryption8.
Government policy emphasised the potential gain to health from the optimum management of heart attack. Setting, delivering and monitoring standards became an imperative, resulting in much professional and public engagement in describing both potential health outcome indicators9 and the standards of care expected by patients with coronary disease10. This latter document, a National Service Framework (NSF), mandated every acute hospital to have available clinical audit data that was no more than 12 months old and suggested that “where relevant” these should be “derived from participation in national audits”.
The Myocardial Infarction (later, Ischaemia) National Audit Project (MINAP) was established in 1999. It was founded on the following propositions:
� The audit should be a complete record of care rather than a snapshot – all (rather than a sample of) patients being included
� The audit should be prospective – information being collected as soon after treatment as possible
� Participating hospitals should agree both common definitions of clinically important variables and common standards of good quality care against which to audit their practice
� Standards of care should be chosen that have a proven link to improved outcome – i.e. those aspects of care being audited, whilst capable of being expressed as measures of process or performance, should link directly to better patient outcomes
� The practices of individual hospitals should be aggregated into a national figure – a hospital could audit against agreed standards and compare against the national aggregate
� Sufficient data should be recorded to allow for case-mix adjustment and other techniques for investigating differences in outcomes between hospitals,
� The dataset should be revised periodically to account for the introduction of newer treatments
� The audit should maintain its credibility and validity by being guided and supported by relevant professional and patient groups and be managed by a small project team
� A publicly accessible report should be published annually.
The standards presented in the NSF became the standards against which care was compared and a core dataset was prepared for participating hospitals11. Data collection began in October 2000 and by mid-2002 all acute hospitals in England and Wales were participating in the audit.
5. Weston CFM, Penny WJ, Julian DG. Guidelines for the early management of patients with myocardial infarction. BMJ 1994;308:767-71.
6. Birkhead JS. Thrombolytic treatment for myocardial inraction: an examination of practice in 39 United Kingdom hospitals. Myocardial Infarction Audit Group. Heart 1997;78:28-33
7. Quinn T, Allan TF, Birkhead J et al. Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project. Eur J Cardiovasc Nurs 2003 Jul;2(2):131-9.
8. Rickards A, Cunningham D. From quantity to quality: the Central Cardiac Audit Database Project. Heart 1999;82:II18-II22.
9. Birkhead J, Goldacre M, Mason A, et al. Health Outcome Indicators: Myocardial Infarction. Oxford, Centre for Health Outcomes Development, 1999.
10. National Service Framework for Coronary Heart Disease. Modern standards and service models. Accessed on 25 June 2011 at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf
11. Birkhead JS. Responding to the requirements of the National Service Framework for coronary disease: a core data set for myocardial infarction. Heart 2000;84:116-7.
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2.2 Organisation of MINAP
MINAP is one of 7 national cardiac clinical audits that are now managed by the National Institute for Cardiovascular Outcomes Research (NICOR) which is part of the Institute for Cardiovascular Science at University College London (UCL).
MINAP is overseen by a Steering Group that represents key stakeholders including professional bodies, national government and patient representation, in conjunction with the British Cardiovascular Society (Appendix 1). MINAP is commissioned by the Healthcare Quality Improvement Partnership (HQIP) who hold commissioning and funding responsibility for MINAP and other national clinical audits. An academic group, which reports to the Steering Group, has been established to facilitate research use of the data, see part 4.
2.3 How the data are collected
The current dataset v9.1 contains 122 fields and includes information on pre- and in- hospital treatment, patient demographics and previous medical history. The dataset is revised every 2 years to meet the requirements of users and to respond to developments in the management of ACS. The dataset is available on the MINAP web pages12.
Data are collected by nurses and clinical audit staff and entered in a dedicated data application (either on-line or web based). Alternatively hospitals can also use commercial software that is able to collect the data. The project uses a highly secure electronic system of data entry, transmission and analysis developed by the CCAD team that is now part of NICOR. The audit has been running continuously since 2000 and all hospitals in England and Wales that admit patients with ACS contribute data.
Participating hospitals are requested to enter all patients with suspected myocardial infarction. About 90,000 records are created annually and in June 2011 the database contained over 873,000 records.
2.4 Security and patient confidentiality
All data uploaded by hospitals are encrypted on transmission and stored encrypted on the CCAD servers. CCAD manages access control to the servers via user IDs and passwords. All patient identifiable data are pseudonymised by CCAD before release to NICOR via a secure drop box on the CCAD server. Data held within NICOR are managed within a secure environment for storage and processing provided by the UCL network and within the UCL information governance and security policy.
The national cardiac audit data held by CCAD are registered under the Data Protection Act. NICOR has support under section 251 of the National Health Service (NHS) Act 2006. (Ref: NIGB: ECC 1-06 (d)/2011).
In addition, NICOR staff recognise that confidentiality is an obligation and regularly undergo information governance training to ensure understanding of the duty of confidentiality and how it relates to patient data.
2.5 Case ascertainment
In practice MINAP records the great majority of patients having STEMI in England and Wales. However it is accepted that a number of hospitals do not enter all their nSTEMI patients mainly due to lack of resources. The true number is difficult to establish as it is not possible to compare MINAP data with Hospital Episode Statistics (HES), the only possible comparator, except in aggregate. Although HES reports approximately 105,000 hospital admissions annually with myocardial infarction, it is not possible to separate this number into the clinical categories used within MINAP. MINAP records about 30,000 STEMIs, but only about 50,000 nSTEMIs annually. From internal data we consider that approximately 80,000 nSTEMIs per year would be an appropriate number.
Where all patients with ACS are admitted to the same ward or area it is easy to identify patients. It is much harder where patients are not all cared for in one area, and are looked after in several wards. Under-reporting of nSTEMIs varies between hospitals and reflects variation in resources allocated to data collection. Many hospitals do not have the resource to identify and record all nSTEMIs as these may not be admitted to a cardiac facility. Instead, patients with nSTEMI may be cared for in many areas in a hospital, and identification is difficult.
2.6 Data quality
Assessment of data completion and validation is presently based on patients with nSTEMI. The completeness of 20 key fields is continually monitored and is available to hospitals in an online view. Currently these fields are 99% complete.
MINAP performs an annual data validation study to assess the agreement of data held on the CCAD servers with data re-entered from the case notes. Hospitals are required to re-enter data from case notes in 20 key fields in 20 randomly selected nSTEMI records using an online data validation tool. Agreement between the original and the re-entered data is assessed for each variable and for each record. Reports
12. www.ucl.ac.uk/nicor/audits/minap
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showing the agreement of each variable compared to national aggregate data
are sent to hospitals to allow them to
identify and act on areas of weakness with
respect to data collection and entry. 97.5% of eligible
hospitals in England and Wales participated in this year’s data
validation study. The median score for 2009/10 was 94.8% (IQR 90.0-
97.8). However the data are only as good as the data provided by hospitals
and there is no independent validation.
The MINAP data application contains error checking routines, including range and
consistency checks, designed to minimise common errors and online help. MINAP provides
detailed guidelines for data entry and provides a dedicated helpdesk to support problems regarding
data entry and clinical definitions.
3. Improving quality, improving outcomes
3.1 Use of MINAP data to inform the British Cardiovascular Society working group on the use of the cardiac care unit.
MINAP data continue to be used at local level and nationally to inform the development of cardiac services. MINAP data have recently been used to provide a report to the British Cardiovascular Society’s (BCS) working group on the future of the cardiac care unit (CCU).
Cardiac or coronary care units have been in existence since the early 1960s –almost 50 years – and in that time the management for heart attack has evolved in a fashion that would be unrecognisable to those working at that time. Coronary care units, to use the term originally applied, were primarily for the care of STEMI, a group of infarctions with a high early mortality. Death was, in the main, due to primary ventricular fibrillation (VF), a lethal condition treatable by immediate electrical cardioversion. It made sense therefore to admit all patients with STEMI, at high risk of VF, to a CCU. For other ACS, the majority, who were at lesser risk of early sudden death it was not thought necessary to admit to a CCU. CCUs were expensive to staff, and tended to be small in size, with 4 - 8 beds being typical. Units changed little over the next 40 years, and continued to provide excellent care for the limited number of patients that could be managed there.
Pressure for change has recently come from a number of directions. The first has been the rapid development of primary angioplasty performed in a limited number of hospitals for a number of surrounding hospitals. CCUs are no longer admitting the patients with STEMI that they had cared for over more than 40 years. At the same time there has been increased awareness of the opportunities for care for nSTEMI, previously often cared for in general medical facilities and by non-specialist physicians. In addition the value of specialised nursing and medical management for cardiac arrhythmias and severe forms of heart failure has long been apparent. However, a short term financially driven view of a CCU that no longer admits the patients for which it was designed almost 50 years ago is to close it, and deploy nursing staff elsewhere. This disturbing approach has been noted in a number of parts of the country.
It was in the light of reports of pressures to close CCUs, and an awareness that the facilities of existing CCUs might potentially be put to very good use that led to the setting up of the working group of the BCS. MINAP was invited to comment to the working group, and produced a report based on MINAP data for the care of patients with nSTEMI. This report, the contents of which will inform part of the report of the working group, indicated very clearly the benefits of admission of patients with nSTEMI to a CCU in terms of more appropriate care, the economic benefit of a shortened length of stay, and improvement in early mortality.
3.2 Use of primary angioplasty
The number of patients having STEMI who receive reperfusion treatment has declined slightly in the last few years. This decline appears to be associated with the increased use of primary angioplasty and, on reflection, might have been expected as primary angioplasty is preceded by a detailed radiographic examination of the coronary arteries.
When thrombolytic treatment was the reperfusion treatment of choice for STEMI the decision to use thrombolytic treatment was based on clinical findings and crucially on the appearances of the ECG. The appearances of the ECG do not always allow for a clear cut treatment decision; sometimes the appearances on which thrombolytic treatment is based are borderline and the clinician must make a judgement on the available evidence. This approach can potentially result in a small number of patients receiving thrombolytic treatment where clinical benefit is unlikely. By contrast all patients having primary angioplasty undergo a coronary angiogram as part of the procedure, and this provides detailed information on the presence of a coronary artery occlusion, it’s site, and likely impact on outcome. An additional benefit to patients admitted for primary angioplasty is that they come under the care of a consultant cardiologist almost immediately.
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MINAP data allow an analysis of what procedure was ultimately performed for patients who present with ECG appearances of STEMI and who are therefore considered suitable candidates for primary angioplasty.
In 2010/11 MINAP data show that 8.6% of patients for whom it was intended to perform primary angioplasty did not receive it. Of those, 6.4% received an angiogram after which it was decided not to proceed to angioplasty. The commonest reasons for this was that the infarct related vessel had re-opened spontaneously or, that the coronary disease was too severe for angioplasty and that coronary artery bypass grafting was a more suitable treatment option. Another 1.8% of patients were not thought to require an angiogram.
Thus, the adoption of primary angioplasty, now provided for more than 80% of the population of England has resulted in reperfusion treatment for STEMI being more accurately tailored to those who might benefit most.
3.3 Access to coronary angiography for patients with non ST elevation myocardial infarction
In 2010 NICE published a guideline on the management of patients with nSTEMI13. A significant part of this report was written based on data from MINAP. One of the recommendations was that patients having infarctions of moderate severity, and those in whom it is possible to demonstrate residual ischaemia
on testing (evidence of persisting narrowing of a coronary artery) should have a coronary angiogram within 96 hours of admission, in order to determine the need for further treatment, typically coronary angioplasty or in a minority of cases, coronary artery bypass grafting.
During the last 10 years there has been a very substantial expansion of the number of catheterisation laboratories, with 141 hospitals in England (133) and Wales (8) having catheter laboratories compared with 86 in England and 2 in Wales 10 years ago.14
Since 2004, the percentage of patients with a final diagnosis of nSTEMI (broadly reflecting the NICE classification of moderate or greater severity) who have angiography during the admission has increased from just under 45% in 2004 to 71% in 2010. It should be recognised that angiography is not appropriate for all patients with nSTEMI. The average age of patients having a first nSTEMI is 70 years, and where performance of angiography is unlikely to alter longer term outlook because of co-morbidity, it may not be appropriate to perform it.
The improved access to angiography for patients with nSTEMI has resulted in a significant fall in the median length of stay for patients having angiography from 7.4 days in 2004/5 to 5.5 days in 2010/11. Over the same time the length of stay of patients not having angiography has fallen from 7.1 to 6.6 days.
13. The early management of unstable angina and non-ST-segment-elevation myocardial infarction. CG 94. National Institue for Health and Clinical Excellence. London 2010.
14. Birkhead J, Pearson J and Walker L. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians 2007. ISBN 978-1-86016-314-2.
Coronary angiogram of blocked left anterior descending artery before PCI Coronary angiogram of left anterior descending artery after PCI
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3.4 International comparisons
Outcomes from heart attack have been a source of controversy in the ongoing debate about proposals for NHS reform in England. The Prime Minister has stated that “Someone [in this country] is twice as likely to die from a heart attack as someone in France”15. Statements from other Ministers have subsequently given a similar message.
The comparison with France appears to have been based on an Organisation for Economic Co-operation and Development (OECD) report using data from 200616 and includes the whole of the UK, rather focusing on than the NHS in England. MINAP has demonstrated in this and previous reports that mortality for both main types of heart attack –STEMI and nSTEMI- has fallen significantly in recent years in England and Wales, not least because of the success of the NSF for coronary heart disease17, the rapid introduction of primary angioplasty services with around 80% of the population of England now having access to this ‘gold standard’ treatment, and better uptake of evidence-based therapies for secondary prevention. Others, including the highly respected Kings’ Fund have suggested that the rate of improvement in outcomes from heart attack has been the fastest in Europe18.
Comparing outcomes between different countries is a complex undertaking, with evidence of miscoding and misclassification of the cause of death, variation in the entry criteria for national registries and completeness of data19 20. An international consensus on the definition of a heart attack is expected to improve the quality of comparison for the future.21
The MINAP team are working with our international partners in heart attack registries and professional societies to provide more robust international comparisons for the future, to help inform ongoing debate about the quality of cardiovascular care.
15. BBC News 16 March 2011 http://www.bbc.co.uk/news/uk-politics-12760865
16. Organisation for Economic Cooperation and Development. Health data 2010—October. www.ecosante.org/index2.
17. Department of Health. Evaluation of the Coronary Heart Disease National Service Framework. 2010 http://www.dh.gov.uk/en/FreedomOfInformation/Freedomofinformationpublicationschemefeedback/FOIreleases/DH_126679
18. Appleby J. Does poor health justify NHS reform? BMJ 2011; 342: d566
19. Lozano R, Murray CJL, Lopez AD, et al. Miscoding and misclassification of ischaemic heart disease mortality. Global Programme on Evidence for Health Policy Working Paper No 12. World Health Organisation; 2001. p. 1-19
20. Widimsky P, Wijns W, Fajadet J, et al European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J. 2010 31(8):943-57
21. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525-38
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4. MINAP: a patient’s perspective
Sirkka Thomas, Cardiac nurse, Health visitor, Cardiac carer and patient, member of Patient Network for London Cardiovascular Project 2011, member South West London Cardiac and Stroke Network and member of Healthcare Quality Improvement Partnership Patient Panel
MINAP has become a major influence in my life in my demanding passage of nurse, carer, and finally cardiac patient. I turned to Cardiac nursing and trained at the Royal Brompton Hospital because I was inspired by the efforts of my native country Finland in managing such high incidence of heart conditions and I wanted to join the campaign against Britain’s greatest killer disease.
That knowledge was to help me so much when my husband suffered a heart attack 14 years ago followed by heart failure and the need for an Implantable Cardioverter Defibrillator (ICD). I was able to support him, medically as a nurse and psychologically as a carer.
It is only being a close partner that one can understand the problems of a patient with a serious illness. Doctors are highly qualified to diagnose and give treatment and my husband and I have received first class therapy. However, it is our view that only the patient and close partner know the pain, physical and psychological, and the stress of their illness. That is when a carer’s understanding presence is so vital.
We first became aware of MINAP when my husband recovered sufficiently to join the MINAP Steering Group, as he put it, “to repay in some way the high class cardiac treatment I had received from so many branches of the NHS”. MINAP was no magic remedy but it did provide a recovery incentive for me as a carer and for my husband as a patient.
MINAP is not a Government target for heart treatment. But it is an encouragement for hospitals and ambulance services to demonstrate their performances in standards for coronary artery disease as set out by the National Service Framework of 2000.Those standards include the time from onset of heart symptoms until appropriate treatment, clot-busting drugs and now primary angioplasty, is received. They also include the use of secondary medication on hospital discharge.
It was so important for my husband and me to learn from MINAP about hospital performances, the speed of immediate treatment and the attention given to the prescribing of drugs on discharge.
Mortality rates due to coronary heart disease have been falling since the 1970s. Surely MINAP has helped in some way with its pursuit of excellence. MINAP has definitely contributed with its
data to encourage speed of treatments and guidance to improve drug provision on discharge, (see the data in this 10th Report).
Unfortunately, I turned from carer to patient two years ago, having experienced a non-STEMI which has required a pacemaker. Fortunately, I had MINAP to lift me up, along with that wonder treatment for heart patients, a caring, understanding husband.
David Geldard, MINAP Patient representative and Steering Group member, past president Heart Care Partnerships (UK)
At a recent national conference, Celebrating Leadership in Heart Disease and Stroke in London on 4th July, 2011, MINAP was frequently mentioned in the context of developing standards of care in the treatment of people with heart disease. Equally pleasing, and for the tenth year running, this Report is a record of steady change and improvement.
With the advent of primary angioplasty as the preferred treatment for people suffering an ST elevation myocardial infarction, the need to treat these people at centres where round-the-clock equipment and appropriately trained staff are available is paramount. This shift in treatment from localised Accident and Emergency facilities, to heart attack centres that can provide 24/7 response is often a cause of concern to communities that feel they are losing a vital and local resource. People want the best treatment, but they also want it at their local hospital, and that is no longer realistic. This Report will do much to allay concerns. This year, with the assistance of NHS Improvement Heart, and the thirty two cardiac networks in England and Wales, and of Heart Care Partnership (UK), the patient arm of the British Cardiovascular Society, copies of this Report will be sent to local patient representatives at the time of publication. In this way patient representatives will be able to examine how things are going
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in their locality. Hopefully they will see improvement, and this will provide them with evidence to dispel local anxieties. They will discover many causes for passing on congratulations, and some, but not too many, “could do betters”. These local patient representatives will be the local banner bearers for their local heart attack services.
Despite the success of hounding smoking and smoke from public places, tobacco smoking is still a significant contributing factor to poor health and heart attack. This report also provides evidence that shows how some heart attack victims and their companions are misjudging the event and neglecting to seek assistance in timely fashion. The success of primary angioplasty in hastening the recovery of victims has an unusual side effect in that many patients quickly seem to forget the seriousness of their condition and the responsibility they owe to themselves and their families to pay heed to the advice they receive concerning their future lifestyle, their medication, and their cardiac rehabilitation. It is extraordinary that nearly three times as many cardiac surgery patients participate in cardiac rehabilitation as do heart attack patients.
On the bright side, it is ten years after the first Public Report and it is wonderful to observe the continuing commitment of the ambulance services, the hospital services, primary care and the rehabilitation services, along with the those of the central support of Professor Sir Roger Boyle, National Clinical Director for Heart Disease and Stroke and his team, and all those colleagues on the front line and behind the scenes, for they have all gone “above and beyond” in their service to people who have suffered heart attack.
It is through audit that one can objectively observe the success or otherwise of any activity, and it is to John Birkhead, the pioneer of MINAP, and the MINAP team who now bring it all together, that the heart patient community owes such a warm vote of thanks.
I encourage all patient representatives for people with heart disease to read this Report carefully, and to share their joy and their aspirations; it is a good news story, in fact it is a great news story, and with their help it can get even better.
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202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
25
30
35
40
45
50%
55
60
65
70
Fig 5. Hypertension in patients having first heart attack.
Females
Males
The number of records eligible for analysis from each hospital is shown in the tables. Where a hospital reports less than 20 cases for the year analyses may not be meaningful. The number of cases are shown but not the percentages. There are several reasons why hospitals may report less than 20 patients.
� In hospitals providing a primary angioplasty service, most patients receive primary angioplasty rather than thrombolytic treatment. Different audit standards apply for timeliness of treatment with primary angioplasty and thrombolytic treatment, and delays for the two treatments cannot be combined.
� Hospitals that do not provide primary angioplasty may report few, if any, cases having thrombolytic treatment, as patients from their area will be admitted directly to a primary angioplasty centre.
� About 18% patients make their own way to hospital without involving either the ambulance service or their GP. These patients are excluded from analyses of call-to-needle time and may account for small numbers in some hospitals.
� Smaller hospitals manage few heart attack patients.
� Hospitals may have only recently started a primary angioplasty service or have performed primary angioplasty on an occasional basis.
1. Characteristics of patients with heart attack in 2010/11
In 2010/11, 89,511 records in England and Wales were submitted to the MINAP database and 79,863 were records of patients with a final diagnosis of myocardial infarction. Of these some 40% had STEMI. [Fig 3] MINAP recognises that not all patients having nSTEMI are entered into the database and that the true ratio for nSTEMI to STEMI should be at least 2:1.
The average age for patients having a first heart attack in England and Wales was 69 years, for men 66 years and for women 74 years. Heart attack is more common in men, with two men having a heart attack for every woman. STEMI tends to present in younger age groups than nSTEMI. The average age for a first STEMI is 65 years, while that of nSTEMI is 70 years. Overall more than 52% of all heart attacks recorded in MINAP were in people over 70 years of age [Fig 4].
part two: results
All hospitals in England and Wales that treat heart attack patients submit data to MINAP. This year we also present data from 3 Belfast hospitals. The 204 hospitals in England and 18 hospitals in Wales are listed alphabetically in Tables 1-3, 5, 6, 8 and 9 with the location of the hospital alongside its name.
79863 admissions with heart attack
31765 (40%) STE MI
48098 (60%) nSTEMI
8859 (28%) had no reperfusion treatment
660 (2%) treatment option not clear
18042 (57%) referred for pPCI
4204 (13%) had thrombolytic treatment
1110 (27%) had thrombolytic treatment in an ambulance
3094 (73%) had thrombolytic treatment in hospital
Fig 3. Hearts attacks recorded in MINAP in 2010/11
There was a total of 89511 records, the others having either another confirmed diagnosis or chest pain of uncertain cause.
Fig 4. Frequency distribution of STEMI and nSTEMI in financial year 2011
0
5
10
15
25
20
30
%
Years
<30 >9030-39 40-49 50-59 60-69 70-79 80-89
STEMI
nSTEMI
Fig 4. Frequency distribution of STEMI and nSTEMI in 2010/11
STEMI is more common in younger age groups, while more than 60% of nSTEMI occur after age 70.
102003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
11
12
13
14
15
16%
17
18
19
20
Fig 6. Frequency of diabetes in patients having first heart attack
Females
Males
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202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
25
30
35
40
45
50%
55
60
65
70
Fig 5. Hypertension in patients having first heart attack.
Females
Males
Fig 5. Hypertension in patients having first heart attack
Patients with final diagnosis of AMI treated for hypertension at the time of admission.
Among those admitted with heart attack there is a continuing increase over time in the frequency of previously diagnosed hypertension and diabetes. The upwards trend for hypertension continues for females, but may be levelling out for males.[Fig 5] The increase in the frequency of diabetes on admission for first heart attacks continues in both males and females. Further analysis shows that the increase is limited to those having type 2 diabetes (non-insulin dependent diabetes) [Fig 6]. It is not clear to what extent this represents a real increase, or whether this in part reflects improved recognition of type 2 diabetes in primary care. The proportion already prescribed cholesterol lowering drugs (usually statins) at the time of admission may now be becoming constant at about 30% of those presenting with a first heart attack [Fig 7]. This may reflect more efficient recognition and treatment in primary care of those at risk.
Cigarette smoking remains a major contributor to heart attacks in younger people, being a risk factor present in more than half of men and women under 55 years of age having a first heart attack. While the smoking rate in younger males is stable or falling slightly, that in females of less than 55 years continues to increase [Fig 8].
102003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
11
12
13
14
15
16%
17
18
19
20
Fig 6. Frequency of diabetes in patients having first heart attack
Females
Males
Fig 6. Frequency of diabetes in patients having first heart attack
The large majority of the increase in frequency of diabetes is in type 2 (non-insulin dependent) diabetics.
02003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
5
10
15
20%
25
30
35
Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission
Hyperlipidaemia having treatment
Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission
Fig 8. Current smoking amongst patients admitted with heart attack.
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
Females
60
50
40
30
20
10
0
20-54 yrs
55-64 yrs
65-74 yrs
›75 yrs
Males
20-54 yrs
55-64 yrs
65-74 yrs
›=75 yrs
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
60
50
40
30
20
10
0
Fig 8. Current smoking amongst patients admitted with heart attack
Smoking amongst females presenting with first heart attack under 55 years continues to increase, against the generally decreasing trend for smoking rates.
Fig 8. Current smoking amongst patients admitted with heart attack.
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
Females
60
50
40
30
20
10
0
20-54 yrs
55-64 yrs
65-74 yrs
›75 yrs
Males
20-54 yrs
55-64 yrs
65-74 yrs
›=75 yrs
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
60
50
40
30
20
10
0
Fig 8. Current smoking amongst patients admitted with heart attack.
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
Females
60
50
40
30
20
10
0
20-54 yrs
55-64 yrs
65-74 yrs
›75 yrs
Males
20-54 yrs
55-64 yrs
65-74 yrs
›=75 yrs
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
%
60
50
40
30
20
10
0
Females
Males
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2. Hospitals that perform primary angioplasty
National and international guidance22 23 24 recommend that in the emergency treatment of patients with STEMI, primary angioplasty should be performed within 90 minutes of arrival at the angioplasty site (door-to-balloon time) and within 150 minutes of a patient’s call for help (call-to-balloon time). Results are presented against these best practice standards in Table 1.
The use of primary angioplasty continued to increase in 2010/11. This year in England, 15,817 patients in England were treated by primary angioplasty compared to 12,505 in 2009/10, an increase of 26%. In Wales 301 patients were treated compared to 232 in 2009/10, an increase of 30%. Of patients who received reperfusion treatment in 2010/11, 82% of patients in England, 30% in Wales and 99% in Belfast received primary angioplasty. The overall median time from arrival at hospital to primary angioplasty was 43 minutes in 2010/11. In 25% of records this interval was less than 30 minutes and for 75% the interval was less than 64 minutes.
This year, 68 hospitals in England performed primary angioplasty. In Wales 3 hospitals performed primary angioplasty. Hospitals performing primary angioplasty may provide this for their own patients only or may do so for groups of other hospitals. Of 62 hospitals in England reporting that they were performing primary angioplasty on a routine basis, 43 provided the service throughout the 24 hour period. A small number shared a night time rota on an alternate basis. An additional 10 hospitals have started to provide a 24/7 service from April 2010. In Wales two hospitals perform primary angioplasty with 24 hour availability. In Belfast, two hospitals performed primary angioplasty.
The provision of primary angioplasty is complex and involves close collaboration between ambulance, portering, nursing, medical, and radiographic teams. This is particularly important for out of hours working. The percentage of patients with an admission diagnosis of STEMI who receive primary angioplasty within 90 minutes of arrival at the heart attack centre has increased from 52% in 2003/4 to 89% in 2010/11 and is a reflection of this close collaboration [Fig 9]. In particular direct transfer of the patient from ambulance to the catheter lab without involvement of other departments or wards, has reduced delays.
In Belfast the Royal Victoria Hospital essentially provided a city wide service in 2010/11. In Northern Ireland routine use of primary angioplasty is presently limited to the Belfast area. Outside Belfast thrombolytic treatment is understood to be the primary reperfusion treatment of choice for STEMI, though primary angioplasty is occasionally available in some hospitals. The Northern Ireland cardiac network is currently developing a national strategy for the management of STEMI. We look forward to the other hospitals in Northern Ireland joining MINAP before long.
Door-to-balloon time
In England this year, 90% of eligible patients were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre compared to 89% in 2009/10. In Wales 68% of eligible patients were treated within 90 minutes compared to 71% in 2009/10. In Belfast 87% of eligible patients were treated within 90 minutes compared to 53% in 2009/10.
Call-to-balloon time
This reflects the interval from a call for professional help to the time that the primary angioplasty procedure is performed. This involves ambulance crews making an accurate diagnosis, including skilled interpretation of the ECG. Ideally all patients with a diagnosis of STEMI confirmed by a paramedic crew should then be taken to a heart attack centre. This however is not always possible, particularly where there is diagnostic uncertainty, or in remoter parts of the country. In 2010/11 75% of patients treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in Belfast.
22. http://www.improvement.nhs.uk/heart/?TabId=66
23. Van de Werf F, Ardissino D et al. (2003) Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 24(1): 28–66.
24. Antman EM, Hand M, Armstrong PW et al. (2008) 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008; 51: 210–247.
Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital in E&W.
0
10
20
30
50
60
70
80
40
90100
%
2003-4 2010-112004-5 2005-6 2006-7 2007-8 2008-9 2009-10
52.856.5 58
72.3
79.784.5
88.2 89.3
Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital
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In England, 81% of all eligible patients were treated within 150 minutes of calling for professional help compared to 80% in 2009/10. In Wales 75% of patients were treated within 150 minutes compared to 76% in 2009/10. In Belfast 90% of patients were treated within 150 minutes compared to 77% in 2009/10.
In England, 88% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help compared to 49% of patients taken first to a local hospital and then transferred to a heart attack centre. In Wales 76% of such patients were treated within 150 minutes. In Belfast 89% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help.
The proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help continues to improve [Fig 10]. There is a limit to how rapidly ambulance services can assess patients and transfer them safely to hospital. The scope for further improvement in this interval may be limited.
3. Hospitals using thrombolytic treatment
Thrombolytic treatment is now used for a rapidly diminishing number of patients. At present approximately 15% of those eligible for reperfusion treatment have thrombolytic treatment, and this occurs mainly in a few areas where timely access
to a heart attack centre is not yet available. This number is expected to fall further over the next 12 months.
The national standard for thrombolytic treatment is for this to be given within 60 minutes of a call for professional help. This is a joint responsibility of acute hospital trusts and ambulance services. Performance against this standard continues to be monitored as an existing commitment within the NHS Operating Framework for England in 2010/11. The aim is for at least 68% of cases to achieve this standard in England, and 70% in Wales.
Tables 2 and 3 show hospital thrombolytic treatment analyses for 2009/10 and 2010/11 for England and Wales respectively. The Belfast hospitals did not report use of any thrombolytic treatment in 2010/11.
Door-to-needle time
In England, 75% of eligible patients received thrombolytic treatment within 30 minutes of arrival at hospital compared to 79% in 2009/10. In Wales 62% of eligible patients received treatment with 30 minutes compared to 67% in 2009/10.
Call-to-needle time
As more patients have primary angioplasty fewer receive thrombolytic treatment. However, the percentage of patients receiving thrombolytic treatment who do so within 60 minutes of a call for help is essentially unchanged. In England 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help compared to 69% in 2009/10. In Wales 53% of eligible patients received treatment within 60 minutes compared to 55% in 2009/10.
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Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help
50
55
60
65
70
75
80
85
90
%
Financial year
2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help
The sudden improvement between 2005/6 and 2006/7 is likely to be due to the rapid increase in new cardiac units performing angioplasty and the influence of the National Infarct Angioplasty Project (NIAP)
Normal coronary angiogram
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4. Angiography for STEMI patients not having primary angioplasty
It is recognised that despite timely thrombolytic treatment some patients are at early risk of further heart attack. This risk is reduced by performance of angiography to determine the extent and severity of disease in coronary arteries, and where appropriate, angioplasty to the affected artery. The performance of angiography for STEMI patients not having primary angioplasty is now considered to be routine, whereas in 2003/4 only about one third of patients had angiography for this indication (Fig 11).
Due to a database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the MINAP web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11.
In 2010/11, 69% of STEMI patients in England, 83% in Wales, and 50% in Belfast who received thrombolytic treatment, or who had no reperfusion treatment were referred for coronary angiography or, in a minority, had this arranged to take place after discharge.
5. Reperfusion treatment by hospital
Rates of reperfusion treatment by hospital have become difficult to present and interpret as so many patients who would previously have been treated with thrombolytic treatment in a local hospital now receive primary angioplasty in a heart attack centre, and may not even return to the local hospital after treatment. Performance of individual hospitals is not shown for 2010/11.
There has been a small increase in the number of patients with STEMI who do not receive reperfusion treatment, from about 25% in 2005/6 to 28.5% in 2010/11. The commonest reason why no reperfusion treatment is given is that the patient presents too late for treatment, which typically is not given more than 12 hours after onset of symptoms because of limited benefit by this time. In a small number of cases severe co-morbidity such as advanced malignancy or severe dementia may make reperfusion treatment inappropriate. These features do not change significantly over time. However, the performance of angiography before an intended primary angioplasty may demonstrate features that indicate that primary angioplasty is not required or is not feasible. These features can only be determined by angiography. Thus, angiography allows treatment to be offered only to those for whom benefit can be expected, and enables clinicians to exclude those where benefit is not anticipated. Trends in reperfusion treatment since 2003/4 are shown in Fig 12.
As the intention is to treat patients by primary angioplasty as quickly as possible, those initially referred to a hospital without facilities for primary angioplasty are assessed rapidly for possible onwards transfer to the interventional hospital (heart attack centre), and will not be admitted. If patients are not formally admitted to the non-interventional hospital before onward transfer they do not appear in MINAP analyses for the non-interventional hospital. Only those patients that are formally admitted to a non-interventional hospital, a small minority, are included in the columns referring to transfer elsewhere for primary angioplasty.
Fig 12. Use of reperfusion treatment for patients with a final diagnosis of STEMI
0
10
20
30
40
50
60
%
70
80
90
100
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
In-hospital lysis
Pre-hospital lysis
Primary angioplasty
Fig 12. Use of reperfusion treatment for patients with a final diagnosis of STEMI
Primary angioplasty makes up more than 80% of reperfusion treatment.
Fig 11. Use of angiography for patients having STEMI who did not receive primary angioplasty, but instead received receiving thrombolytic treatment or had no reperfusion treatment
0
10
20
30
40
50
60
%
70
80
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10
31.1
45.550.1
55.658.6
63.3
70.173.2
Fig 11. Use of angiography for patients having STEMI who do not receive primary angioplasty, but instead received thrombolytic treatment or had no reperfusion treatment.
Where angiography is thought inappropriate because of co-morbidity or the patient refused, these are excluded from analysis. All age groups are included.
MINAP Public Report Part 1 and 2 blue.indd 20 16/08/2011 14:03
21MINAP Tenth Public Report 2011
6. Ambulance service performance
Ambulance services collaborate closely with receiving hospitals and networks to improve care. For many, the focus has shifted from provision of pre-hospital thrombolytic treatment to identifying those patients with heart attack who might benefit from primary angioplasty, and transferring them rapidly to a heart attack centre. So, for many ambulance services, the number of patients receiving pre-hospital thrombolytic treatment has declined.
Table 4 shows ambulance service performance in England and Wales. In England in 2010/11, 824 patients received pre-hospital thrombolytic treatment compared to 1,633 in 2009/10. In Wales 219 patients received pre-hospital thrombolytic treatment compared to 250 in 2009/10.
7. Use of secondary prevention medication
Use of secondary prevention medication after the acute event is proven to improve outcomes for patients. These benefits apply after both STEMI and nSTEMI.
NICE guidance25 recommends that all patients who have had an acute heart attack should be offered treatment with a combination of the following drugs:
� ACE inhibitor
� aspirin
� beta blocker
� statin.
Tables 5 and 6 show the percentage of patients prescribed secondary prevention medication on discharge by hospital in England, Wales and Belfast in 2010/11. For each hospital those patients surviving to be discharged home from that hospital are included but those transferred to another hospital and those patients in whom such drugs were contraindicated are excluded. Historically, we have used the NSF audit standard of 80% for aspirin, beta blockers and statins treatment. There are no national standards for the prescription of ACE inhibitors, Clopidogrel/thienopyridine inhibitors and newer antiplatelet agents.
Use of secondary prevention medication at discharge from hospital is very satisfactory, continuing to exceed the national standards, and there is little room for further improvement [Fig 13]. In England prescription of aspirin was 99%, beta blockers 96%, statins 97%, ACE inhibitors 94% and Clopidogrel/thienopyridine inhibitors 95%. In Wales prescription of aspirin was 98%, beta blockers 95%, statins 95%, ACE inhibitors 91% and Clopidogrel/thienopyridine inhibitors 92%. In the Belfast hospitals prescription of aspirin was 99%, beta blockers 99%, statins 99%, ACE inhibitors 97% and Clopidogrel/thienopyridine inhibitors 98%.
8.Cardiac networks
Cardiac networks (also known as ‘heart and stroke networks’ since they also now facilitate improvements in stroke care) are local NHS organisations that seek to improve the way that services are planned and delivered. Bringing together clinicians, managers, commissioners and patients, and aware of the entire ‘cardiac pathway’, the networks can provide a powerful voice in the local health economy to enable frontline staff to secure the changes needed to deliver best care. They provide a forum through which the public can influence their services. Some cardiac networks have patient carer representatives providing a voice among the professionals.
Table 7 shows the performance of the call-to-needle and call-to-balloon targets and the percentage of patients that received pre-hospital thrombolytic treatment, in-hospital thrombolytic treatment, primary angioplasty and no reperfusion treatment by cardiac network. The two cardiac networks in Wales are shown separately.
Countrywide access to primary angioplasty remains incomplete, although the picture is changing rapidly. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5-93% and in 6 cardiac networks less than 50% of their patients received primary angioplasty.
Fig 13. Use of secondary prevention medication.
All heart attacks, [transfers, deaths, contraindicated and patient refused are all excluded.]
Fig 13. Use of secondary prevention medication for myocardial infarction
Aspirin
Statin
Beta blocker
ACEI/ARB
Clopidogrel/thienopyridine inhibitors
2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-1050
55
60
65
70
75%
80
85
90
95
100
25. http://guidance.nice.org.uk/CG48/QuickRefGuide/pdf/English
MINAP Public Report Part 1 and 2 blue.indd 21 16/08/2011 14:03
22 MINAP How the NHS cares for patients with heart attack
National audit lends itself to the demonstration of variation in practice and outcome. The MINAP Public Reports repeatedly have shown this. Variation in practice is an expected phenomenon in healthcare, and there is a difficulty determining whether such variation is simply the ‘play of chance’ or whether it represents some systematic difference in performance. One of the methods being considered, to more clearly describe such variation is the funnel plot.
Funnel plots were first introduced26 27 in 1984 as a means of estimating bias in meta-analysis of clinical trials that contained varying numbers of subjects. In essence, each individual value is compared to the overall mean, and the control limits around that mean diminish as the number of subjects (or admissions) increases (as one would expect). A value which falls outside the ‘funnel’ is considered an outlier, and can represent abnormally high performance as well as abnormally low performance.
The width of the control limits is determined by the statistical significance level from which they are calculated. To diminish the risk of a false positive ‘outlier’ we use +/- 3 standard deviations, which means that the chance of an outlier happening ‘accidentally’ (i.e. by random chance) is no more than 0.4%.
9. Care for patients with non ST elevation infarction
For some years the focus of heart attack management has been upon the early provision of reperfusion treatment to those patients presenting with STEMI, and MINAP Public Reports have reflected this. Patients with nSTEMI have a lower early risk of death and perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to CCUs, nor always cared for by cardiologists. However, specialist involvement is important, and it is recognised that performance of angiography and coronary intervention within the first 4 days is an important facet of treatment for the majority. Ideally admission should be to a cardiac facility where nursing staff have a cardiac background, and there is easy access to cardiological expertise.
As mentioned above the numbers of nSTEMI reported in MINAP are incomplete, and in particular it is likely that patients who are not admitted to a CCU are omitted. Failure to enter all cases often reflects a lack
26. RJ Light, DB Pillemer. Summing up: The Science of Reviewing Research. Cambridge, Massachusetts.: Harvard University Press. 1984. ISBN 0674854314.
27. Egger M, Smith GD, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 1997; 315:629–634.
Fig 13. Use of secondary prevention medication for myocardial infarction
UCL 99.6% LCL 99.6%
GMCN
South WalesNorth Wales
West Yorkshire
SE London
CTN60%National Average
100 200 300 400 500 6000
10
20
30
40
50%
60
70
80
90
100
Admissions
Fig 13. Use of secondary prevention medication for myocardial infarction
North EnglandCMCN
NEYNLLancs/Cumbria
NE London
NW LondonSE London
Kent
Peninsula
West Yorkshire
200 400 600 800 1000 120040
50
60
%70
80
90
100
PeninsulaPeninsula
NEYNLNEYNLLancs/Cumbria
Admissions
UCL 99.6% LCL 99.6% Avg of CTB150National Average
Fig 13. Use of secondary prevention medication for myocardial infarction
North England
SW LondonKent
Cov Warks
NC London West Yorkshire
50 100 150 200 250 300 350 400 450
40
30
20
10
0
60
50
70
80
%
Admissions
90100
UCL 99.6% LCL 99.6% Avg of CTB150National Average
Fig 14. Call-to-needle within 60 minutes by cardiac network
Fig 15. Call-to-balloon within 150 minutes for direct admissions only by cardiac network
Fig 16. Call-to-balloon within 150 minutes for inter-hospital transfers by cardiac network
MINAP Public Report Part 1 and 2 blue.indd 22 16/08/2011 14:03
23MINAP Tenth Public Report 2011
of resources, but it remains the case that the quality of care for patients not entered into MINAP remains unknown. In addition the variable nature of recording nSTEMI between hospitals may distort some analyses.
Table 8 shows the percentage of nSTEMI patients that were admitted to a cardiac unit or ward and the percentage of nSTEMI patients seen by a cardiologist or member of their team, by hospital, in 2009/10 and 2010/11. The same analyses for hospitals in Wales and Belfast are shown in Table 9. In England in 2010/11, 50% of nSTEMI patients were admitted to a cardiac unit or ward compared to 47% in 2009/10. In Wales 59% of patients were admitted to a cardiac unit or ward compared to 55% in 2009/10. In the Belfast hospitals, 81% of patients were admitted to a cardiac unit or ward compared to 82% in 2009/10.
In England in 2010/11, 91% of nSTEMI patients were seen by a cardiologist or member of their team compared to 89% in 2009/10. In Wales 84% of nSTEMI patients were seen by a cardiologist or member of their team compared to 74% in 2009/10. In the Belfast hospitals 99% of nSTEMI patients were seen by a cardiologist or member of their team compared to 100% in 2009/10.
The frequency with which patients are referred for angiography for nSTEMI also continues to increase, [Fig 17]. Due to a database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11. In 2009/10, 63% of nSTEMI patients in England were referred for angiography after nSTEMI, and 70% in 2010/11. In Wales 74% were referred in 2009/10, and 81% in 2010/11. In Belfast 82% were referred in 2009/10 and 85% in 2010/11.
10. Change in mortality of heart attack patients
Mortality data are obtained from the NHS Central Register by CCAD. The percentage of patients having STEMI and nSTEMI who die within 30 days of admission to hospital has fallen annually from 2003/4-2010/11 [Figs 18, 19].
Fig 17. Use of angiography for patients with a diagnosis of non ST segment elevation MI. [Inappropriate of refused (small numbers) excluded. All age groups.]
0
10
20
30
50
60
70
80
40%
2003-4 2010-112004-5 2005-6 2006-7 2007-8 2008-9 2009-10
35.1
44.847.8 49.6 51.6
54.4
64.1
71
Fig 17. Use of angiography for patients with a diagnosis of non ST segment elevation MI.
Inappropriate or refused (small numbers) excluded. All age groups.
Fig 19.
14
13
12
11
10
9
8
7
6
%
Financial year
2004-52003-4 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
Fig 19. 30 day mortality (with 95% confidence limits) for nSTEMI.
The data for 2010/11 are provisional and may be revised.
Fig 18.
14
13
12
11
10
9
8
7
%
Financial year
2004-52003-4 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
Fig 18. 30 day mortality, (with 95% confidence limits) for all patients having STEMI.
The data for 2010/11 are provisional and may be revised.
MINAP Public Report Part 1 and 2 blue.indd 23 16/08/2011 14:03
table
1 pr
imar
y an
giop
last
y in
hos
pita
ls i
n england, wales and belfast
Pri
mar
y an
giop
last
y w
ithin
90
min
s of
arr
ival
at
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
fo
r pa
tient
s w
ith
dire
ct a
dmis
sion
to
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
for
pat
ient
s tr
ansf
erre
d to
in
terv
entio
nal
cent
re
% o
f pat
ient
s w
ith d
irect
ad
mis
sion
to
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
90
min
s of
arr
ival
at
inte
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tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp
Pri
mar
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giop
last
y w
ithin
150
min
s of
cal
ling
for
help
fo
r pa
tient
s w
ith
dire
ct a
dmis
sion
to
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tiona
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ntre
Pri
mar
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last
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150
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s of
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for
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for
patie
nts
tran
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to
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l ce
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% o
f pat
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s w
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to
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l ce
ntre
Year
20
09/1
020
10/1
1
%n
%n
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%%
n%
n%
n%
n%
24 MINAP
25MINAP
11. R
esul
ts b
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spit
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am
bula
nce
serv
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and
car
diac
net
wor
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perc
enta
ges
are
not s
how
n fo
r le
ss th
an 2
0 ca
ses
Engl
and
nati
onal
ave
rage
89%
11466
80%
10012
86%
8336
45%
1689
75%
90%
14545
81%
12868
88%
10713
49%
2157
75%
Bar
ts &
the
Lond
on, L
ondo
n80%
533
56%
500
78%
297
23%
203
56%
96%
485
80%
418
95%
330
25%
8868%
Bas
ildon
Hos
pita
l, B
asild
on97%
396
85%
347
86%
335
1484%
96%
609
84%
589
90%
457
61%
132
75%
Bas
ings
toke
& N
orth
Ham
pshi
re H
ospi
tal,
Bas
ings
toke
93%
8293%
6793%
670
81%
94%
104
95%
8595%
850
83%
Bir
min
gham
Hea
rtla
nds
Hos
pita
l, B
irm
ingh
am83%
278
77%
264
86%
192
50%
7269%
84%
262
85%
249
90%
209
58%
4080%
Bri
stol
Roy
al In
firm
ary,
Bri
stol
85%
328
70%
318
84%
241
27%
7873%
90%
559
74%
535
82%
415
48%
120
74%
Cas
tle H
ill H
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tal,
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l83%
139
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125
77%
122
393%
89%
348
89%
300
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1583%
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Che
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3685%
3388%
321
90%
93%
7486%
7386%
730
99%
City
Hos
pita
l, B
irm
ingh
am90%
6296%
5696%
560
91%
78%
6788%
5288%
520
79%
Con
ques
t Hos
pita
l, St
Leo
nard
s on
Sea
87%
6075%
5375%
530
88%
90%
6182%
5582%
550
91%
Der
rifo
rd H
ospi
tal,
Ply
mou
th83%
6984%
6484%
640
93%
81%
136
77%
136
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136
0100%
Dor
set C
ount
y H
ospi
tal,
Dor
ches
ter
86%
2219
190
95%
92%
2580%
2580%
250
96%
East
Sur
rey
Hos
pita
l, R
edhi
ll88%
4891%
4591%
450
94%
94%
5290%
5090%
491
94%
Pri
mar
y a
ngio
plas
ty w
ithi
n 90
min
utes
of a
rriv
al re
flec
ts t
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ovid
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Pri
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refl
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rman
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of t
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y se
rvic
es in
iden
tify
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I and
tak
ing
the
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ent
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terv
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onal
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tre
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ay n
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Not
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ents
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ken
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ctly
to
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terv
enti
onal
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tre,
esp
ecia
lly w
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the
re is
dia
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tic
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nty.
Thi
s in
evit
ably
tak
es lo
nger
tha
n di
rect
tra
nsfe
r, bu
t ca
nnot
be
avoi
ded
in s
ome
case
s.
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
24
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8/20
11
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3
25MINAP
East
bour
ne D
GH
, Eas
tbou
rne
73%
3073%
3072%
291
97%
61%
3871%
3171%
310
84%
Free
man
Hos
pita
l, N
ewca
stle
99%
835
86%
750
96%
570
54%
181
68%
98%
765
90%
672
98%
527
62%
145
69%
Fren
chay
Hos
pita
l, B
rist
ol7
55
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22
20
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Frim
ley
Par
k H
ospi
tal,
Frim
ley
72%
5082%
3883%
353
70%
76%
140
81%
127
86%
9467%
3369%
Gle
nfiel
d H
ospi
tal,
Leic
este
r70%
215
67%
181
68%
180
186%
84%
267
85%
232
87%
227
585%
Ham
mer
smith
Hos
pita
l, Lo
ndon
91%
324
71%
286
86%
192
38%
9461%
90%
318
74%
284
89%
176
49%
108
63%
Har
efiel
d H
ospi
tal
99%
508
88%
421
90%
414
1293%
75%
408
85%
379
91%
329
48%
5081%
Jam
es C
ook
Uni
vers
ity H
ospi
tal,
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dles
boro
ugh
93%
542
83%
500
92%
404
42%
9675%
95%
549
87%
476
92%
413
49%
6376%
John
Rad
cliff
e H
ospi
tal,
Oxf
ord
93%
224
75%
212
87%
148
48%
6465%
93%
347
78%
331
93%
244
38%
8770%
Ken
t & S
usse
x H
ospi
tal,
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ridg
e W
ells
11
10
100%
33
30
100%
Ket
teri
ng G
ener
al H
ospi
tal,
Ket
teri
ng71%
2871%
2471%
240
89%
83%
102
87%
9388%
921
93%
Kin
g's
Col
lege
Hos
pita
l, Lo
ndon
64%
270
64%
238
65%
235
393%
65%
316
68%
239
68%
239
090%
Leed
s G
ener
al In
firm
ary,
Lee
ds88%
833
80%
661
86%
503
61%
158
63%
85%
985
64%
793
75%
625
22%
168
66%
Linc
oln
Cou
nty
Hos
pita
l, Li
ncol
n0
00
011
1111
0100%
List
er H
ospi
tal,
Stev
enag
e96%
7490%
7097%
5812
77%
94%
7893%
6995%
636
81%
Live
rpoo
l Hea
rt &
Che
st H
ospi
tal,
Live
rpoo
l98%
400
84%
387
97%
217
68%
170
54%
98%
670
82%
601
98%
359
57%
243
53%
Man
ches
ter
Roy
al In
firm
ary,
Man
ches
ter
91%
341
77%
194
89%
140
46%
5441%
89%
326
74%
247
89%
169
42%
7853%
Med
way
Mar
itim
e H
ospi
tal,
Gill
ingh
am0
00
010
1010
0100%
New
Cro
ss H
ospi
tal,
Wol
verh
ampt
on89%
447
80%
369
90%
311
26%
5873%
91%
498
81%
385
89%
324
34%
6170%
Nor
folk
& N
orw
ich
Uni
vers
ity H
ospi
tal,
Nor
wic
h95%
365
85%
353
87%
329
54%
2491%
96%
402
86%
389
89%
357
53%
3289%
Nor
tham
pton
Gen
eral
Hos
pita
l, N
orth
ampt
on83%
3685%
2685%
260
75%
92%
3696%
2896%
280
78%
Nor
ther
n G
ener
al H
ospi
tal,
Shef
field
83%
289
70%
274
79%
217
39%
5764%
88%
606
75%
581
84%
422
51%
159
70%
Nor
thw
ick
Par
k H
ospi
tal,
Har
row
11
10
100%
33
30
100%
Not
tingh
am C
ity H
ospi
tal,
Not
tingh
am92%
9883%
9284%
893
92%
96%
188
86%
176
87%
173
393%
Pap
wor
th H
ospi
tal,
Cam
brid
ge97%
409
74%
372
87%
279
40%
9768%
98%
419
76%
413
90%
293
40%
120
70%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
25
16/0
8/20
11
14:1
3
26 MINAP
27MINAP
Pri
mar
y an
giop
last
y w
ithin
90
min
s of
arr
ival
at
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
fo
r pa
tient
s w
ith
dire
ct a
dmis
sion
to
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
for
patie
nts
tran
sfer
red
to
inte
rven
tiona
l ce
ntre
% o
f pat
ient
s w
ith d
irect
ad
mis
sion
to
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
90
min
s of
arr
ival
at
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
fo
r pa
tient
s w
ith
dire
ct a
dmis
sion
to
inte
rven
tiona
l ce
ntre
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
for
patie
nts
tran
sfer
red
to
inte
rven
tiona
l ce
ntre
% o
f pat
ient
s w
ith d
irect
ad
mis
sion
to
inte
rven
tiona
l ce
ntre
Year
20
09/1
020
10/1
1
%n
%n
%n
%n
%%
n%
n%
n%
n%
Que
en A
lexa
ndra
Hos
pita
l, P
orts
mou
th95%
6395%
6195%
610
97%
88%
193
81%
176
92%
136
43%
4070%
Que
en E
lizab
eth
Hos
pita
l, B
irm
ingh
am99%
9962%
8463%
822
80%
68%
124
74%
109
76%
106
386%
Roy
al B
erks
hire
Hos
pita
l, R
eadi
ng94%
145
96%
137
96%
136
193%
96%
147
95%
134
95%
134
092%
Roy
al B
ourn
emou
th G
ener
al H
ospi
tal,
Bou
rnem
outh
90%
9395%
7894%
699
76%
92%
7296%
6895%
635
88%
Roy
al C
ornw
all H
ospi
tal,
Trur
o12
1010
092%
97%
3394%
3394%
321
97%
Roy
al D
erby
Hos
pita
l, D
erby
93%
2892%
2592%
250
89%
89%
6287%
5587%
550
89%
Roy
al D
evon
& E
xete
r H
ospi
tal,
Exet
er86%
196
86%
147
86%
147
091%
91%
176
79%
141
79%
141
089%
Roy
al F
ree
Hos
pita
l, Lo
ndon
93%
161
92%
155
93%
148
792%
93%
186
91%
184
91%
183
197%
Roy
al S
usse
x C
ount
y H
ospi
tal,
Bri
ghto
n71%
6378%
5878%
580
91%
94%
190
86%
176
86%
176
093%
Roy
al U
nite
d H
ospi
tal B
ath,
Bat
h100%
27100%
26100%
260
96%
92%
5192%
4891%
471
91%
Rus
sells
Hal
l Hos
pita
l, D
udle
y0
00
01
11
0100%
Sand
wel
l Dis
tric
t Hos
pita
l, W
est B
rom
wic
h75%
102
83%
8083%
800
79%
77%
9592%
7692%
760
80%
Sout
ham
pton
Gen
eral
Hos
pita
l, So
utha
mpt
on86%
166
82%
150
88%
138
1283%
91%
194
89%
170
91%
162
978%
St G
eorg
e's
Hos
pita
l, Lo
ndon
84%
303
87%
278
88%
269
993%
89%
342
90%
306
89%
218
91%
8867%
St P
eter
's H
ospi
tal,
Che
rtse
y16
1111
069%
96%
2796%
2696%
260
96%
St T
hom
as H
ospi
tal,
Lond
on61%
109
51%
101
62%
7127%
3068%
83%
132
73%
120
83%
8748%
3365%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
26
16/0
8/20
11
14:1
3
27MINAP
Sund
erla
nd R
oyal
Hos
pita
l, Su
nder
land
43
30
75%
22
20
89%
Taun
ton
& S
omer
set H
ospi
tal,
Taun
ton
94%
6693%
5692%
488
72%
99%
156
98%
145
98%
124
100%
2180%
The
Gre
at W
este
rn H
ospi
tal,
Swin
don
1814
140
89%
97%
3397%
2997%
290
88%
Torb
ay H
ospi
tal,
Torq
uay
85%
8988%
7388%
730
89%
87%
7793%
7093%
700
95%
Uni
vers
ity C
olle
ge H
ospi
tal,
Lond
on94%
154
55%
117
86%
5824%
5938%
93%
168
65%
126
85%
8818%
3853%
Uni
vers
ity H
ospi
tal C
oven
try,
Cov
entr
y86%
329
90%
274
90%
273
194%
88%
330
85%
304
85%
292
1291%
Uni
vers
ity H
ospi
tal o
f Nor
th S
taffo
rdsh
ire,
St
oke-
on-T
rent
83%
289
84%
240
86%
231
981%
89%
341
73%
282
85%
225
26%
5767%
Vict
oria
Hos
pita
l, B
lack
pool
77%
173
88%
144
88%
144
083%
87%
154
95%
140
96%
139
190%
Wat
ford
Gen
eral
Hos
pita
l, W
atfo
rd92%
6092%
6092%
600
100%
90%
4888%
4288%
420
87%
Wex
ham
Par
k H
ospi
tal,
Slou
gh3
22
050%
83%
4195%
3995%
390
93%
Will
iam
Har
vey
Hos
pita
l, As
hfor
d0
00
0100%
88%
519
75%
425
74%
381
84%
4475%
Wor
cest
ersh
ire
Roy
al H
ospi
tal,
Wor
cest
er0
00
0100%
1111
101
93%
Wor
thin
g H
ospi
tal,
Wor
thin
g19
1717
089%
77%
2219
190
86%
Wyc
ombe
Gen
eral
Hos
pita
l, H
igh
Wyc
ombe
90%
3172%
2972%
290
85%
93%
3090%
2190%
210
69%
Wyt
hens
haw
e H
ospi
tal,
Man
ches
ter
91%
257
78%
205
89%
122
60%
8350%
92%
312
73%
245
82%
201
36%
4467%
Bel
fast
ave
rage
53%
7277%
4775%
443
65%
87%
160
90%
124
89%
8960%
Bel
fast
City
Hos
pita
l16
77
044%
10
00
0%
Roy
al V
icto
ria
Hos
pita
l59%
5680%
4078%
373
71%
87%
159
90%
124
89%
8960%
Wal
es n
atio
nal a
vera
ge71%
215
76%
180
76%
178
285%
68%
283
75%
225
76%
221
479%
Gla
n C
lwyd
DG
H T
rust
, Bod
elw
ydda
n3
22
075%
43
30
80%
Mor
rist
on H
ospi
tal,
Swan
sea
72%
180
76%
159
76%
157
288%
76%
190
79%
159
81%
155
481%
Uni
vers
ity H
ospi
tal o
f Wal
es, C
ardi
ff72%
3219
190
69%
52%
8967%
6367%
630
75%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
27
16/0
8/20
11
14:1
3
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Year
2009
/10
2010
/11
%n
%n
%n
%n
table
2 th
romb
olyt
ic t
reat
ment
in
hosp
ital
s in england
28 MINAP
29MINAP
Engl
and
nati
onal
ave
rage
79%
2984
69%
3522
75%
1526
68%
1790
Aire
dale
Gen
eral
Hos
pita
l, St
eeto
n1
31
4
Arro
we
Par
k H
ospi
tal,
Wir
ral
89%
8977%
7518
17
Bar
nsle
y D
istr
ict G
ener
al H
ospi
tal,
Bar
nsle
y85%
2015
11
Bar
ts &
the
Lond
on, L
ondo
n1
11
1
Bas
ildon
Hos
pita
l, B
asild
on18
87%
391
77%
26
Bas
setl
aw D
istr
ict G
ener
al H
ospi
tal,
Not
tingh
am14
100%
250
3
Bed
ford
Hos
pita
l, B
edfo
rd7
93
1
Bir
min
gham
Hea
rtla
nds
Hos
pita
l, B
irm
ingh
am0
02
2
Bra
dfor
d R
oyal
Infir
mar
y, B
radf
ord
1212
55
Cal
derd
ale
Roy
al H
ospi
tal,
Hal
ifax
44
21
Cas
tle H
ill H
ospi
tal,
Hul
l70%
3076%
543
2
Cha
ring
Cro
ss H
ospi
tal,
Lond
on1
11
0
Che
ltenh
am G
ener
al H
ospi
tal,
Che
ltenh
am11
190
2
Che
ster
field
Roy
al, C
hest
erfie
ld86%
4476%
886
9
The
sm
all n
umbe
rs h
avin
g th
rom
boly
tic
trea
tmen
t re
flec
ts t
he d
omin
ance
of p
rim
ary
angi
opla
sty
as t
he re
perf
usio
n tr
eatm
ent
of c
hoic
e fo
r STE
MI.
In 2
009/
10 6
2 ho
spit
als
gave
thr
ombo
lyti
c tr
eatm
ent
to 2
0 or
mor
e pa
tien
ts, a
nd in
201
0/11
thi
s ha
d fa
llen
to 2
8. F
urth
er fa
lls c
an b
e an
tici
pate
d.
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
28
16/0
8/20
11
14:1
3
29MINAP
Cho
rley
Hos
pita
l, C
horl
ey77%
3183%
2379%
2819
Col
ches
ter
Gen
eral
Hos
pita
l, C
olch
este
r11
191
1
Con
ques
t Hos
pita
l, St
Leo
nard
s on
Sea
812
87
Cou
ntes
s of
Che
ster
Hos
pita
l, C
hest
er77%
4876%
4510
88%
24
Cou
nty
Hos
pita
l Her
efor
d , H
eref
ord
64%
2276%
2980%
3582%
45
Cum
berl
and
Infir
mar
y, C
arlis
le75%
4051%
4770%
3770%
53
Dar
ent V
alle
y H
ospi
tal,
Dar
tfor
d85%
3478%
322
3
Dew
sbur
y D
istr
ict H
ospi
tal,
Dew
sbur
y4
25
5
Dia
na, P
rinc
ess
of W
ales
Hos
pita
l, G
rim
sby
75%
2090%
2972%
2574%
31
Don
cast
er R
oyal
Infir
mar
y, D
onca
ster
79%
2495%
401
1
Dor
set C
ount
y H
ospi
tal,
Dor
ches
ter
1750%
3416
15
East
Sur
rey
Hos
pita
l, R
edhi
ll81%
3175%
2073%
3016
East
bour
ne D
GH
, Eas
tbou
rne
80%
2082%
2212
5
Epso
m H
ospi
tal,
Epso
m63%
2411
147
Fair
field
Gen
eral
Hos
pita
l, B
ury
86%
4378%
2715
12
Free
man
Hos
pita
l, N
ewca
stle
00
11
Fren
chay
Hos
pita
l, B
rist
ol2
51
1
Frim
ley
Par
k H
ospi
tal,
Frim
ley
82%
2214
01
Furn
ess
Gen
eral
, Bar
row
-in-
Furn
ess
100%
2763%
2718
77%
22
Geo
rge
Ellio
t Hos
pita
l, N
unea
ton
00
11
Gle
nfiel
d H
ospi
tal,
Leic
este
r14
74%
782
90%
52
Glo
uces
ters
hire
Roy
al H
ospi
tal,
Glo
uces
ter
1112
21
Gra
ntha
m &
Dis
tric
t Gen
eral
, Gra
ntha
m17
57%
21100%
2218
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
29
16/0
8/20
11
14:1
3
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Year
2009
/10
2010
/11
%n
%n
%
n%
n
30 MINAP
31MINAP
Har
efiel
d H
ospi
tal
00
11
Hill
ingd
on H
ospi
tal,
Uxb
ridg
e0
01
1
Hin
chin
gbro
oke
Hos
pita
l, H
untin
gdon
00
22
Hop
e H
ospi
tal,
Man
ches
ter
00
10
Hor
ton
Gen
eral
Hos
pita
l, B
anbu
ry2
20
1
Hud
ders
field
Roy
al In
firm
ary,
Hud
ders
field
87
11
Jam
es C
ook
Uni
vers
ity H
ospi
tal,
Mid
dles
boro
ugh
00
11
John
Rad
cliff
e H
ospi
tal,
Oxf
ord
00
11
Ken
t & C
ante
rbur
y H
ospi
tal,
Can
terb
ury
81%
3696%
241
0
Ket
teri
ng G
ener
al H
ospi
tal,
Ket
teri
ng18
81%
4710
19
Kin
g's
Col
lege
Hos
pita
l, Lo
ndon
32
19%
310%
26
Kin
gs M
ill H
ospi
tal,
Not
tingh
am88%
5169%
6875%
6772%
76
Leed
s G
ener
al In
firm
ary,
Lee
ds9
74
4
Leic
este
r R
oyal
Infir
mar
y, L
eice
ster
62%
2926%
232
2
Leig
hton
Hos
pita
l, C
rew
e84%
3258%
4386%
4373%
49
Linc
oln
Cou
nty
Hos
pita
l, Li
ncol
n92%
3965%
6384%
3171%
51
Mac
cles
field
Dis
tric
t Gen
eral
, Mac
cles
field
65%
2652%
2118
15
Mai
dsto
ne G
ener
al H
ospi
tal,
Mai
dsto
ne79%
3389%
272
1
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
30
16/0
8/20
11
14:1
3
31MINAP
Man
ches
ter
Roy
al In
firm
ary,
Man
ches
ter
21
22
Med
way
Mar
itim
e H
ospi
tal,
Gill
ingh
am91%
4393%
452
1
New
Cro
ss H
ospi
tal,
Wol
verh
ampt
on2
32
2
New
ark
Hos
pita
l, N
ewar
k14
103
4
Nor
folk
& N
orw
ich
Uni
vers
ity H
ospi
tal,
Nor
wic
h2
40
7
Nor
th D
evon
Dis
tric
t Hos
pita
l, B
arns
tabl
e18
74%
359
13
Nor
th M
anch
este
r G
ener
al H
ospi
tal,
Man
ches
ter
00
32
Nor
th M
iddl
esex
Hos
pita
l, Lo
ndon
00
11
Nor
tham
pton
Gen
eral
Hos
pita
l, N
orth
ampt
on88%
2582%
5712
90%
31
Nor
ther
n G
ener
al H
ospi
tal,
Shef
field
11
10
Not
tingh
am C
ity H
ospi
tal,
Not
tingh
am76%
2166%
4416
52%
23
Pap
wor
th H
ospi
tal,
Cam
brid
ge1
100
8
Pet
erbo
roug
h C
ity H
ospi
tal,
Pet
erbo
roug
h0
80
2
Pilg
rim
Hos
pita
l, B
osto
n79%
3967%
5287%
3963%
46
Pin
derfi
elds
Gen
eral
Hos
pita
l, W
akefi
eld
65
42
Pon
tefr
act G
ener
al In
firm
ary,
Pon
tefr
act
64
21
Poo
le H
ospi
tal,
Poo
le77%
2281%
2770%
2059%
27
Pri
nces
s R
oyal
Hos
pita
l, H
ayw
ards
Hea
th16
136
4
Pri
nces
s R
oyal
Hos
pita
l, Te
lford
88%
2475%
281
1
Que
en's
Hos
pita
l, B
urto
n-up
on-T
rent
80%
3081%
213
3
Que
en A
lexa
ndra
Hos
pita
l, P
orts
mou
th77%
8348%
8475%
2853%
30
Que
en E
lizab
eth
Hos
pita
l, B
irm
ingh
am1
11
1
Que
en E
lizab
eth
the
Que
en M
othe
r, M
arga
te78%
3217
44
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
31
16/0
8/20
11
14:1
3
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Year
2009
/10
2010
/11
%n
%n
%
n%
n
32 MINAP
33MINAP
Que
en's
Hos
pita
l, R
omfo
rd0
01
1
Roc
hdal
e In
firm
ary,
Roc
hdal
e98%
4693%
2816
13
Roy
al A
lber
t Edw
ard
Infir
mar
y, W
igan
96%
8567%
7294%
8488%
72
Roy
al B
erks
hire
Hos
pita
l, R
eadi
ng0
21
1
Roy
al B
lack
burn
Hos
pita
l, B
lack
burn
83%
115
74%
129
81%
9869%
95
Roy
al B
olto
n H
ospi
tal,
Bol
ton
89%
9574%
8085%
6667%
55
Roy
al B
ourn
emou
th G
ener
al H
ospi
tal,
Bou
rnem
outh
82%
5677%
5279%
2880%
35
Roy
al C
ornw
all H
ospi
tal,
Trur
o59%
4671%
104
68%
3467%
82
Roy
al D
erby
Hos
pita
l, D
erby
86%
3681%
7389%
4469%
74
Roy
al D
evon
& E
xete
r H
ospi
tal,
Exet
er0
02
2
Roy
al L
anca
ster
Infir
mar
y, L
anca
ster
69%
3958%
4577%
3055%
29
Roy
al O
ldha
m H
ospi
tal,
Old
ham
80%
5965%
4670%
2017
Roy
al P
rest
on H
ospi
tal,
Pre
ston
84%
4371%
3577%
4892%
38
Roy
al S
hrew
sbur
y H
ospi
tal,
Shre
wsb
ury
1465%
265
3
Roy
al S
urre
y C
ount
y H
ospi
tal,
Gui
ldfo
rd18
145
4
Roy
al S
usse
x C
ount
y H
ospi
tal,
Bri
ghto
n100%
2095%
210
2
Roy
al U
nite
d H
ospi
tal B
ath,
Bat
h79%
3354%
503
5
Roy
al V
icto
ria
Infir
mar
y, N
ewca
stle
33
11
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
32
16/0
8/20
11
14:1
3
33MINAP
Salis
bury
Dis
tric
t Hos
pita
l, Sa
lisbu
ry90%
3159%
3715
45%
20
Sand
wel
l Dis
tric
t Hos
pita
l, W
est B
rom
wic
h0
01
1
Scar
boro
ugh
Gen
eral
Hos
pita
l, Sc
arbo
roug
h89%
2857%
3018
18
Scun
thor
pe G
ener
al H
ospi
tal,
Scun
thor
pe18
85%
3418
89%
36
Sout
hend
Hos
pita
l, W
estc
liffe
on
Sea
1493%
272
2
Sout
hpor
t & F
orm
by D
istr
ict G
ener
al, S
outh
port
94%
3379%
297
7
St M
ary'
s H
ospi
tal,
New
port
87%
2374%
3812
84%
25
St P
eter
's H
ospi
tal,
Che
rtse
y94%
31100%
2390%
2014
St R
icha
rd's
Hos
pita
l, C
hich
este
r61%
3169%
2618
18
Step
ping
Hill
Hos
pita
l, St
ockp
ort
310
13
Stok
e M
ande
ville
Hos
pita
l, Ay
lesb
ury
129
107
Tam
esid
e G
ener
al H
ospi
tal,
Asht
on U
nder
Lym
e0
02
2
Taun
ton
& S
omer
set H
ospi
tal,
Taun
ton
1571%
280
1
The
Alex
andr
a H
ospi
tal,
Red
ditc
h87%
3852%
4896%
2674%
31
The
Gre
at W
este
rn H
ospi
tal,
Swin
don
1886%
433
6
The
Ipsw
ich
Hos
pita
l, Ip
swic
h18
72%
320
1
Torb
ay H
ospi
tal,
Torq
uay
59%
2258%
3116
58%
24
Uni
vers
ity C
olle
ge H
ospi
tal,
Lond
on0
01
1
Uni
vers
ity H
ospi
tal A
intr
ee, L
iver
pool
76
52
Uni
vers
ity H
ospi
tal C
oven
try,
Cov
entr
y0
24
3
Uni
vers
ity H
ospi
tal o
f Har
tlepo
ol, H
artle
pool
11
11
Uni
vers
ity H
ospi
tal o
f Nor
th S
taffo
rdsh
ire,
Sto
ke-o
n-Tr
ent
11
01
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
33
16/0
8/20
11
14:1
3
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Thro
mbo
lytic
trea
tmen
t with
in
30 m
ins
of
hosp
ital a
rriv
al
Thro
mbo
lytic
trea
tmen
t with
in
60 m
ins
of
calli
ng fo
r he
lp
Year
2009
/10
2010
/11
%n
%n
%
n%
n
34 MINAP
Uni
vers
ity H
ospi
tal o
f Nor
th T
ees,
Sto
ckto
n on
Tee
s0
01
1
Uni
vers
ity H
ospi
tal Q
ueen
s M
edic
al, N
ottin
gham
68%
5644%
7374%
2748%
33
Vict
oria
Hos
pita
l, B
lack
pool
55
63
War
ring
ton
Dis
tric
t Gen
eral
Hos
pita
l, W
arri
ngto
n83%
3583%
294
4
Wes
t Cor
nwal
l Hos
pita
l, P
enza
nce
74
50
Wes
t Cum
berl
and
Hos
pita
l, W
hite
have
n72%
2561%
3181%
3678%
41
Wex
ham
Par
k H
ospi
tal,
Slou
gh74%
3578%
402
1
Whi
ston
Hos
pita
l, P
resc
ott
33
21
Will
iam
Har
vey
Hos
pita
l, As
hfor
d90%
4286%
355
4
Wor
cest
ersh
ire
Roy
al H
ospi
tal,
Wor
cest
er81%
5753%
6483%
2959%
39
Wor
thin
g H
ospi
tal,
Wor
thin
g61%
2369%
2613
13
Wyc
ombe
Gen
eral
Hos
pita
l, H
igh
Wyc
ombe
76%
4935%
4611
10
Wyt
hens
haw
e H
ospi
tal,
Man
ches
ter
10
33
Yeov
il D
istr
ict H
ospi
tal,
Yeov
il9
82%
222
2
York
Dis
tric
t Hos
pita
l, Yo
rk10
112
1
35
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
34
16/0
8/20
11
14:1
3
“MIN
AP
dat
a is
a s
igni
fican
t too
l sup
port
ing
serv
ice
deve
lopm
ent,
iden
tifyi
ng a
reas
for
curr
ent a
nd fu
ture
wor
k.”
Jan
Kee
nan
Con
sult
ant N
urse
and
Dr
Rob
in C
houd
hury
,
Seni
or R
esea
rch
Fell
ow a
t Oxf
ord
Hea
rt C
entr
e
35MINAP
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
35
16/0
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11
14:1
3
37MINAP
Thro
mbo
lytic
trea
tmen
t w
ithin
30
min
s of
ho
spita
l arr
ival
Thro
mbo
lytic
trea
tmen
t w
ithin
60
min
s of
ca
lling
for
help
Thro
mbo
lytic
trea
tmen
t w
ithin
30
min
s of
ho
spita
l arr
ival
Thro
mbo
lytic
trea
tmen
t w
ithin
60
min
s of
ca
lling
for
help
Year
2009
/10
2010
/11
%n
%n
%n
%n
table
3 th
romb
olyt
ic t
reat
ment
in
hosp
ital
s in wales and belfast
36 MINAP
Wal
es n
atio
nal a
vera
ge67%
356
55%
484
62%
298
53%
402
Bro
ngla
is G
ener
al H
ospi
tal,
Aber
ystw
yth
65
1313
Gla
n C
lwyd
DG
H T
rust
, Bod
elw
ydda
n84%
3258%
5097%
3059%
49
Llan
doug
h H
ospi
tal,
Llan
doug
h8
53
2
Llan
dudn
o G
ener
al H
ospi
tal,
Llan
dudn
o8
134
3
Mae
lor
Hos
pita
l, W
rexh
am71%
4946%
4866%
4456%
48
Mor
rist
on H
ospi
tal,
Swan
sea
00
11
Nea
th P
ort T
albo
t Hos
pita
l, N
eath
43
32
Nev
ill H
all H
ospi
tal,
Aber
gave
nny
59%
2949%
3966%
2946%
28
Pri
nce
Cha
rles
Hos
pita
l, M
erth
yr T
ydfil
1771%
3559%
2256%
32
Pri
nce
Phi
lip H
ospi
tal,
Llan
elli
148
106
Pri
nces
s of
Wal
es H
ospi
tal,
Bri
dgen
d13
67%
2414
60%
25
Roy
al G
lam
orga
n, L
lant
risa
nt74%
2751%
354
7
Roy
al G
wen
t Hos
pita
l, N
ewpo
rt57%
4656%
7060%
4052%
62
Sing
leto
n H
ospi
tal,
Swan
sea
20
00
Uni
vers
ity H
ospi
tal o
f Wal
es, C
ardi
ff55%
2969%
515
88%
32
Wes
t Wal
es G
ener
al, C
amar
then
74%
2342%
2672%
2946%
26
With
ybus
h G
ener
al H
ospi
tal,
Hav
erfo
rdw
est
82%
2259%
2711
18
Ysby
ty G
wyn
edd
, Ban
gor
56%
2744%
4544%
3642%
48
Bel
fast
ave
rage
46%
2648%
310
0
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
36
16/0
8/20
11
14:1
3
table
4 am
bula
nce
serv
ices
in
engl
and
and
wales
Pat
ient
s ha
ving
thro
mbo
lytic
tr
eatm
ent w
ithin
60
min
s of
ca
lling
for
help
Pat
ient
s ha
ving
thro
mbo
lytic
tr
eatm
ent w
ithin
60
min
s of
ca
lling
for
help
Pat
ient
s ha
ving
pr
e-ho
spita
l th
rom
boly
sis
Pat
ient
s ha
ving
pr
e-ho
spita
l th
rom
boly
sis
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp fo
r pa
tient
s w
ith d
irec
t adm
issi
on
to in
terv
entio
nal c
entr
e
Pri
mar
y an
giop
last
y w
ithin
15
0 m
ins
of c
allin
g fo
r he
lp
for
patie
nts
tran
sfer
red
to
inte
rven
tiona
l cen
tre
Year
20
09/1
020
10/1
120
09/1
020
10/1
120
10/1
1
%
n%
nn
n%
n%
n
Engl
and
nati
onal
ave
rage
70%
3473
69%
1732
1633
824
88%
9995
50%
1543
Isle
of W
ight
74%
3885%
2619
172
1
Lond
on10
81
288%
1375
51%
256
Gre
at W
este
rn71%
156
52%
2989
1484%
547
58%
79
Nor
th E
ast
68
11
97%
886
61%
192
Nor
th W
est
70%
837
74%
576
165
146
92%
865
47%
297
York
shir
e60%
198
37%
4189
1284%
1007
19%
104
East
Mid
land
s72%
820
72%
513
487
309
89%
675
22%
27
Wes
t Mid
land
s59%
212
66%
125
9965
88%
1189
46%
125
East
of E
ngla
nd79%
206
71%
48192
7690%
1300
52%
282
Sout
h Ea
st C
oast
81%
394
72%
103
215
4580%
823
74%
88
Sout
h C
entr
al50%
219
38%
5238
492%
861
29%
58
Sout
h W
este
rn70%
377
68%
203
238
133
89%
465
97%
34
Wel
sh55%
489
53%
406
250
219
75%
221
7
37MINAP
MIN
AP P
ublic
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ort L
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16/0
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table
5 se
cond
ary
prev
enti
on m
edic
atio
n in
england
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
38 MINAP
39MINAP
Engl
and
nati
onal
ave
rage
99%
52189
96%
47008
97%
52723
94%
48856
95%
49755
Adde
nbro
oke'
s H
ospi
tal,
Cam
brid
ge99%
170
99%
151
99%
179
99%
136
99%
142
Aire
dale
Gen
eral
Hos
pita
l, St
eeto
n98%
192
99%
169
99%
198
99%
179
89%
209
Arro
we
Par
k H
ospi
tal,
Wir
ral
100%
252
93%
201
90%
277
71%
241
89%
222
Bar
net G
ener
al H
ospi
tal,
Bar
net
100%
42100%
3998%
4397%
3997%
39
Bar
nsle
y D
istr
ict G
ener
al H
ospi
tal,
Bar
nsle
y96%
159
93%
151
97%
162
93%
146
96%
147
Bar
ts &
the
Lond
on, L
ondo
n99%
985
95%
950
99%
988
96%
962
96%
989
Bas
ildon
Hos
pita
l, B
asild
on99%
679
99%
655
99%
682
98%
658
96%
661
Bas
ings
toke
& N
orth
Ham
pshi
re H
ospi
tal,
Bas
ings
toke
100%
201
95%
188
100%
202
99%
197
99%
199
Bas
setl
aw D
istr
ict G
ener
al H
ospi
tal,
Not
tingh
am100%
230
100%
219
100%
251
100%
246
100%
213
Bed
ford
Hos
pita
l, B
edfo
rd96%
7797%
7897%
7996%
8092%
79
Bir
min
gham
Hea
rtla
nds
Hos
pita
l, B
irm
ingh
am100%
595
95%
529
100%
591
95%
573
99%
599
Bra
dfor
d R
oyal
Infir
mar
y, B
radf
ord
100%
547
98%
486
97%
553
97%
532
98%
537
Thes
e an
alys
es a
re b
ased
on
all p
atie
nts
disc
harg
ed fr
om h
ospi
tal w
ith
a di
agno
sis
of m
yoca
rdia
l inf
arct
ion.
Pat
ient
s ar
e ex
clud
ed if
the
y ar
e tr
ansf
erre
d fr
om t
he a
dmit
ting
hos
pita
l to
anot
her
hosp
ital
for f
urth
er t
reat
men
t. P
atie
nts
are
also
exc
lude
d fr
om a
naly
sis
if t
here
is a
con
trai
ndic
atio
n to
a d
rug,
if t
hey
refu
se t
reat
men
t, o
r hav
e se
vere
non
car
diac
co-
mor
bidi
ty t
hat
limit
s pr
ogno
sis.
MIN
AP P
ublic
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ort L
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39MINAP
Bri
stol
Roy
al In
firm
ary,
Bri
stol
98%
791
90%
790
96%
790
90%
789
92%
791
Bro
omfie
ld H
ospi
tal,
Che
lmsf
ord
94%
310
89%
256
91%
312
88%
250
88%
273
Cal
derd
ale
Roy
al H
ospi
tal,
Hal
ifax
99%
292
98%
245
97%
299
99%
256
99%
281
Cas
tle H
ill H
ospi
tal,
Hul
l95%
835
90%
844
94%
847
88%
846
92%
848
Cen
tral
Mid
dles
ex H
ospi
tal,
Lond
on98%
108
88%
9695%
110
92%
106
94%
107
Cha
ring
Cro
ss H
ospi
tal,
Lond
on95%
4192%
3893%
4194%
36100%
40
Cha
se F
arm
Hos
pita
l, En
field
97%
105
99%
97100%
108
100%
935%
106
Che
lsea
& W
estm
inis
ter
Hos
pita
l, Lo
ndon
100%
2217
100%
2295%
20100%
21
Che
ltenh
am G
ener
al H
ospi
tal,
Che
ltenh
am100%
178
100%
157
99%
172
100%
172
99%
174
Che
ster
field
Roy
al, C
hest
erfie
ld99%
274
99%
234
99%
279
97%
259
99%
265
Cho
rley
Hos
pita
l, C
horl
ey99%
8588%
9199%
9389%
9287%
94
City
Hos
pita
l, B
irm
ingh
am100%
216
100%
174
100%
219
100%
192
100%
216
Col
ches
ter
Gen
eral
Hos
pita
l, C
olch
este
r100%
354
98%
304
98%
361
99%
335
99%
346
Con
ques
t Hos
pita
l, St
Leo
nard
s on
Sea
100%
270
98%
229
99%
282
97%
261
100%
264
Cou
ntes
s of
Che
ster
Hos
pita
l, C
hest
er99%
211
99%
206
97%
236
99%
187
99%
179
Cou
nty
Hos
pita
l Her
efor
d, H
eref
ord
95%
2095%
2095%
2019
100%
20
Cum
berl
and
Infir
mar
y, C
arlis
le97%
191
97%
150
80%
199
78%
180
89%
196
Dar
ent V
alle
y H
ospi
tal,
Dar
tfor
d96%
206
93%
188
94%
208
90%
192
91%
197
Dar
lingt
on M
emor
ial H
ospi
tal,
Dar
lingt
on99%
125
98%
126
92%
133
90%
125
96%
125
Der
rifo
rd H
ospi
tal,
Ply
mou
th100%
2611
84%
2561%
2395%
42
Dew
sbur
y D
istr
ict H
ospi
tal,
Dew
sbur
y98%
286
96%
253
97%
298
94%
278
95%
270
Dia
na, P
rinc
ess
of W
ales
Hos
pita
l, G
rim
sby
99%
167
94%
159
98%
180
84%
166
95%
176
Don
cast
er R
oyal
Infir
mar
y, D
onca
ster
100%
296
100%
281
99%
315
100%
292
92%
309
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
39
16/0
8/20
11
14:1
3
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
40 MINAP
41MINAP
Dor
set C
ount
y H
ospi
tal,
Dor
ches
ter
100%
236
97%
215
96%
235
94%
225
98%
234
Ealin
g H
ospi
tal,
Sout
hall
94%
6291%
6496%
6897%
6082%
60
East
Sur
rey
Hos
pita
l, R
edhi
ll99%
413
95%
360
94%
425
93%
383
95%
399
East
bour
ne D
GH
, Eas
tbou
rne
100%
226
100%
179
100%
231
99%
194
100%
187
Epso
m H
ospi
tal,
Epso
m100%
5998%
58100%
59100%
60100%
60
Fair
field
Gen
eral
Hos
pita
l, B
ury
100%
190
100%
178
100%
197
100%
185
99%
191
Free
man
Hos
pita
l, N
ewca
stle
100%
1505
100%
1414
100%
1504
100%
1454
100%
1506
Fren
chay
Hos
pita
l, B
rist
ol100%
256
92%
250
91%
264
86%
244
92%
251
Fria
rage
Hos
pita
l, N
orth
alle
rton
100%
22100%
20100%
22100%
2011
Frim
ley
Par
k H
ospi
tal,
Frim
ley
100%
402
97%
322
98%
397
95%
366
99%
398
Furn
ess
Gen
eral
, Bar
row
-in-
Furn
ess
96%
2581%
2192%
2687%
2392%
26
Geo
rge
Ellio
t Hos
pita
l, N
unea
ton
100%
134
98%
128
98%
139
93%
127
99%
120
Gle
nfiel
d H
ospi
tal,
Leic
este
r100%
573
100%
548
100%
573
100%
554
96%
584
Glo
uces
ters
hire
Roy
al H
ospi
tal,
Glo
uces
ter
100%
98100%
82100%
96100%
86100%
96
Goo
d H
ope
Gen
eral
Hos
pita
l, Su
tton
Col
dfiel
d100%
173
100%
148
99%
183
99%
173
99%
179
Gra
ntha
m &
Dis
tric
t Gen
eral
, Gra
ntha
m96%
7292%
6490%
8290%
6790%
70
Ham
mer
smith
Hos
pita
l, Lo
ndon
97%
374
89%
334
95%
371
89%
359
96%
373
Har
efiel
d H
ospi
tal
96%
838
87%
826
92%
835
83%
834
73%
829
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
40
16/0
8/20
11
14:1
3
41MINAP
Har
roga
te D
istr
ict H
ospi
tal,
Har
roga
te100%
280
99%
232
98%
283
99%
256
100%
260
Hex
ham
Gen
eral
Hos
pita
l, H
exha
m98%
4184%
3893%
4197%
3891%
35
Hill
ingd
on H
ospi
tal,
Uxb
ridg
e100%
222
100%
150
99%
205
100%
186
100%
170
Hin
chin
gbro
oke
Hos
pita
l, H
untin
gdon
108
99
11
Hom
erto
n H
ospi
tal,
Lond
on95%
2095%
2095%
2195%
2086%
21
Hop
e H
ospi
tal,
Man
ches
ter
99%
308
98%
287
97%
313
96%
294
94%
299
Hor
ton
Gen
eral
Hos
pita
l, B
anbu
ry100%
74100%
59100%
71100%
54100%
66
Hud
ders
field
Roy
al In
firm
ary,
Hud
ders
field
100%
245
99%
209
98%
248
96%
225
100%
237
Hul
l Roy
al In
firm
ary,
Hul
l85%
3453%
3859%
3753%
3865%
37
Jam
es C
ook
Uni
vers
ity H
ospi
tal,
Mid
dles
boro
ugh
100%
756
99%
712
99%
760
99%
736
99%
730
Jam
es P
aget
Hos
pita
l, G
reat
Yar
mou
th87%
3885%
3987%
3985%
3987%
38
John
Rad
cliff
e H
ospi
tal,
Oxf
ord
100%
764
100%
670
100%
729
100%
717
100%
730
Ken
t & C
ante
rbur
y H
ospi
tal,
Can
terb
ury
99%
184
94%
154
91%
195
98%
151
95%
178
Ken
t & S
usse
x H
ospi
tal,
Tunb
ridg
e W
ells
98%
8397%
6699%
8190%
7396%
81
Ket
teri
ng G
ener
al H
ospi
tal,
Ket
teri
ng100%
378
97%
329
99%
377
97%
340
99%
375
Kin
g G
eorg
e H
ospi
tal,
Goo
dmay
es100%
115
100%
100
99%
122
98%
105
100%
99
Kin
g's
Col
lege
Hos
pita
l, Lo
ndon
99%
629
95%
626
98%
628
96%
615
84%
627
Kin
gs M
ill H
ospi
tal,
Not
tingh
am97%
279
95%
252
95%
277
90%
262
97%
279
Kin
gsto
n H
ospi
tal,
Kin
gsto
n-up
on-T
ham
es100%
2217
96%
2791%
2219
Leed
s G
ener
al In
firm
ary,
Lee
ds100%
861
97%
777
99%
848
96%
788
97%
67
Leic
este
r R
oyal
Infir
mar
y, L
eice
ster
100%
40100%
4698%
41100%
3968%
41
Leig
hton
Hos
pita
l, C
rew
e98%
281
97%
245
97%
313
95%
286
97%
277
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
41
16/0
8/20
11
14:1
3
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
42 MINAP
43MINAP
Linc
oln
Cou
nty
Hos
pita
l, Li
ncol
n96%
351
85%
341
95%
354
86%
346
90%
346
List
er H
ospi
tal,
Stev
enag
e98%
271
98%
262
100%
271
97%
266
98%
265
Live
rpoo
l Hea
rt &
Che
st H
ospi
tal,
Live
rpoo
l100%
741
100%
719
100%
743
100%
735
99%
743
Luto
n &
Dun
stab
le H
ospi
tal,
Luto
n100%
189
99%
146
100%
206
99%
166
100%
187
Mac
cles
field
Dis
tric
t Gen
eral
, Mac
cles
field
96%
198
88%
171
92%
197
85%
185
82%
194
Mai
dsto
ne G
ener
al H
ospi
tal,
Mai
dsto
ne97%
124
88%
106
96%
116
84%
111
97%
124
Man
ches
ter
Roy
al In
firm
ary,
Man
ches
ter
98%
226
92%
215
97%
233
83%
222
94%
225
Man
or H
ospi
tal,
Wal
sall
96%
8284%
7696%
8486%
7884%
80
May
day
Uni
vers
ity H
ospi
tal,
Cro
ydon
86%
7682%
6789%
7979%
7283%
71
Med
way
Mar
itim
e H
ospi
tal,
Gill
ingh
am100%
312
100%
301
99%
323
100%
303
100%
316
Milt
on K
eyne
s G
ener
al H
ospi
tal,
Milt
on
Key
nes
98%
4286%
42100%
4188%
4086%
35
Mon
tagu
Hos
pita
l, M
exbo
roug
h19
1590%
2014
19
New
Cro
ss H
ospi
tal,
Wol
verh
ampt
on100%
827
99%
714
99%
832
93%
745
98%
803
New
ark
Hos
pita
l, N
ewar
k97%
3589%
3692%
3997%
3694%
36
New
ham
Gen
eral
Hos
pita
l, Lo
ndon
100%
133
100%
102
100%
133
100%
84100%
119
Nor
folk
& N
orw
ich
Uni
vers
ity H
ospi
tal,
Nor
wic
h98%
1115
100%
957
100%
1085
100%
1023
96%
1120
Nor
th D
evon
Dis
tric
t Hos
pita
l, B
arns
tabl
e100%
179
100%
119
100%
170
100%
142
100%
146
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
42
16/0
8/20
11
14:1
3
43MINAP
Nor
th M
anch
este
r G
ener
al H
ospi
tal,
Man
ches
ter
99%
192
99%
169
99%
190
97%
186
98%
185
Nor
th M
iddl
esex
Hos
pita
l, Lo
ndon
94%
121
86%
110
92%
123
87%
120
81%
116
Nor
th T
ynes
ide
Gen
eral
Hos
pita
l, N
orth
Sh
ield
s100%
168
100%
149
100%
174
98%
129
99%
158
Nor
tham
pton
Gen
eral
Hos
pita
l, N
orth
ampt
on100%
440
100%
380
100%
425
100%
367
100%
410
Nor
ther
n G
ener
al H
ospi
tal,
Shef
field
99%
909
99%
741
99%
875
98%
736
99%
644
Nor
thw
ick
Par
k H
ospi
tal,
Har
row
99%
292
89%
261
97%
303
89%
289
92%
293
Not
tingh
am C
ity H
ospi
tal,
Not
tingh
am99%
353
93%
325
98%
352
94%
344
95%
353
Pap
wor
th H
ospi
tal,
Cam
brid
ge99%
541
95%
524
99%
541
96%
531
77%
539
Pet
erbo
roug
h C
ity H
ospi
tal,
Pet
erbo
roug
h100%
260
100%
191
100%
264
100%
224
100%
255
Pilg
rim
Hos
pita
l, B
osto
n90%
198
79%
201
83%
208
81%
205
82%
204
Pin
derfi
elds
Gen
eral
Hos
pita
l, W
akefi
eld
100%
295
99%
286
99%
308
96%
285
99%
289
Pon
tefr
act G
ener
al In
firm
ary,
Pon
tefr
act
100%
206
99%
196
99%
215
94%
204
97%
203
Poo
le H
ospi
tal,
Poo
le17
1216
1512
Pri
nces
s Al
exan
dra
Hos
pita
l, H
arlo
w88%
199
76%
200
91%
203
85%
202
91%
203
Pri
nces
s R
oyal
Hos
pita
l, H
ayw
ards
Hea
th99%
142
98%
121
93%
137
90%
120
92%
121
Pri
nces
s R
oyal
Hos
pita
l, Te
lford
100%
8199%
6995%
8486%
7796%
72
Pri
nces
s R
oyal
Uni
vers
ity H
ospi
tal,
Orp
ingt
on86%
218
81%
218
83%
218
81%
218
68%
218
Que
en A
lexa
ndra
Hos
pita
l, P
orts
mou
th98%
550
96%
541
97%
543
88%
504
92%
547
Que
en E
lizab
eth
Hos
pita
l, B
irm
ingh
am100%
442
99%
367
100%
439
100%
400
100%
428
Que
en E
lizab
eth
Hos
pita
l, G
ates
head
96%
241
95%
198
94%
247
86%
197
90%
233
Que
en E
lizab
eth
Hos
pita
l, K
ing'
s Ly
nn93%
274
85%
245
86%
274
80%
254
83%
261
Que
en E
lizab
eth
Hos
pita
l, W
oolw
ich
100%
104
99%
90100%
103
94%
9099%
98
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
43
16/0
8/20
11
14:1
3
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
44 MINAP
45MINAP
Que
en E
lizab
eth
II H
ospi
tal,
Wel
wyn
Gar
den
City
99%
6993%
7297%
7095%
6490%
62
Que
en E
lizab
eth
the
Que
en M
othe
r, M
arga
te98%
146
90%
126
86%
157
83%
117
84%
135
Que
en M
ary'
s H
ospi
tal,
Sidc
up12
1213
1312
Que
en's
Hos
pita
l, R
omfo
rd100%
182
100%
162
100%
195
99%
185
99%
142
Que
en's
Hos
pita
l, B
urto
n-up
on-T
rent
100%
108
100%
88100%
106
98%
8699%
100
Roc
hdal
e In
firm
ary,
Roc
hdal
e100%
192
97%
158
100%
195
100%
184
99%
170
Rot
herh
am G
ener
al H
ospi
tal,
Rot
herh
am100%
321
100%
244
99%
323
100%
280
99%
309
Roy
al A
lber
t Edw
ard
Infir
mar
y, W
igan
100%
379
100%
356
100%
388
100%
368
100%
367
Roy
al B
erks
hire
Hos
pita
l, R
eadi
ng100%
412
99%
392
99%
412
95%
380
98%
401
Roy
al B
lack
burn
Hos
pita
l, B
lack
burn
99%
538
96%
500
96%
560
94%
523
97%
535
Roy
al B
olto
n H
ospi
tal,
Bol
ton
99%
442
94%
397
98%
441
89%
403
86%
420
Roy
al B
ourn
emou
th G
ener
al H
ospi
tal,
Bou
rnem
outh
100%
199
95%
181
98%
200
96%
197
96%
203
Roy
al C
ornw
all H
ospi
tal,
Trur
o100%
651
100%
483
100%
595
100%
478
98%
622
Roy
al D
erby
Hos
pita
l, D
erby
100%
483
100%
409
100%
463
100%
390
100%
449
Roy
al D
evon
& E
xete
r H
ospi
tal,
Exet
er100%
411
99%
376
97%
423
96%
400
96%
417
Roy
al F
ree
Hos
pita
l, Lo
ndon
97%
306
97%
306
97%
306
97%
304
97%
305
Roy
al H
amps
hire
Cou
nty
Hos
pita
l, W
inch
este
r100%
112
100%
7099%
99100%
94100%
91
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
44
16/0
8/20
11
14:1
3
45MINAP
Roy
al L
anca
ster
Infir
mar
y, L
anca
ster
99%
99100%
9199%
100
98%
9997%
99
Roy
al L
iver
pool
Uni
vers
ity H
ospi
tal,
Live
rpoo
l99%
138
100%
141
100%
150
100%
8699%
137
Roy
al L
ondo
n H
ospi
tal,
Lond
on4
24
100%
2017
Roy
al O
ldha
m H
ospi
tal,
Old
ham
99%
281
98%
252
99%
290
95%
273
96%
281
Roy
al P
rest
on H
ospi
tal,
Pre
ston
95%
105
90%
102
92%
105
90%
107
88%
107
Roy
al S
hrew
sbur
y H
ospi
tal,
Shre
wsb
ury
99%
100
98%
8697%
9785%
7193%
89
Roy
al S
urre
y C
ount
y H
ospi
tal,
Gui
ldfo
rd19
1618
96%
2588%
26
Roy
al S
usse
x C
ount
y H
ospi
tal,
Bri
ghto
n100%
311
97%
280
98%
308
95%
291
97%
302
Roy
al U
nite
d H
ospi
tal B
ath,
Bat
h100%
260
97%
231
99%
252
96%
220
99%
232
Roy
al V
icto
ria
Infir
mar
y, N
ewca
stle
100%
103
100%
85100%
108
100%
97100%
97
Rus
sells
Hal
l Hos
pita
l, D
udle
y99%
183
93%
167
93%
185
92%
180
92%
170
Salis
bury
Dis
tric
t Hos
pita
l, Sa
lisbu
ry100%
205
98%
185
99%
204
98%
197
96%
194
Sand
wel
l Dis
tric
t Hos
pita
l, W
est B
rom
wic
h100%
236
99%
187
100%
245
100%
218
100%
233
Scar
boro
ugh
Gen
eral
Hos
pita
l, Sc
arbo
roug
h98%
138
92%
121
97%
142
93%
137
92%
146
Scun
thor
pe G
ener
al H
ospi
tal,
Scun
thor
pe95%
278
89%
263
95%
295
89%
266
96%
295
Selly
Oak
Hos
pita
l, B
irm
ingh
am1
11
11
Solih
ull G
ener
al H
ospi
tal,
Bir
min
gham
96%
5294%
4996%
5294%
49100%
51
Sout
h Ty
nesi
de D
istr
ict H
ospi
tal,
Sout
h Sh
ield
s100%
141
100%
107
99%
136
100%
122
100%
116
Sout
ham
pton
Gen
eral
Hos
pita
l, So
utha
mpt
on99%
700
98%
663
99%
703
94%
689
95%
643
Sout
hend
Hos
pita
l, W
estc
liffe
on
Sea
100%
370
100%
340
100%
385
100%
324
100%
350
Sout
hmea
d H
ospi
tal,
Bri
stol
94%
252
94%
224
91%
253
83%
186
85%
233
Sout
hpor
t & F
orm
by D
istr
ict G
ener
al,
Sout
hpor
t100%
114
98%
8798%
119
92%
112
100%
117
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
45
16/0
8/20
11
14:1
3
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
46 MINAP
47MINAP
St G
eorg
e's
Hos
pita
l, Lo
ndon
99%
444
94%
435
98%
445
93%
442
99%
444
St H
elie
r H
ospi
tal,
Car
shal
ton
100%
7097%
6799%
6997%
72100%
72
St M
ary'
s H
ospi
tal,
New
port
100%
6798%
51100%
59100%
5298%
56
St M
ary'
s H
ospi
tal,
Lond
on91%
138
74%
138
85%
138
69%
138
77%
138
St P
eter
's H
ospi
tal,
Che
rtse
y100%
215
100%
207
100%
215
100%
199
100%
201
St R
icha
rd's
Hos
pita
l, C
hich
este
r97%
114
90%
112
89%
123
85%
110
88%
97
St T
hom
as H
ospi
tal,
Lond
on100%
262
100%
244
100%
264
100%
248
100%
256
Staf
ford
shir
e G
ener
al H
ospi
tal,
Staf
ford
97%
152
91%
139
95%
161
90%
141
89%
132
Step
ping
Hill
Hos
pita
l, St
ockp
ort
96%
437
94%
435
95%
490
92%
443
81%
493
Stok
e M
ande
ville
Hos
pita
l, Ay
lesb
ury
100%
7198%
5198%
6597%
6497%
66
Sund
erla
nd R
oyal
Hos
pita
l, Su
nder
land
99%
170
95%
165
97%
172
95%
164
98%
166
Tam
esid
e G
ener
al H
ospi
tal,
Asht
on U
nder
Ly
me
99%
292
98%
258
95%
317
97%
280
89%
300
Taun
ton
& S
omer
set H
ospi
tal,
Taun
ton
99%
399
89%
376
94%
413
87%
386
95%
390
The
Alex
andr
a H
ospi
tal,
Red
ditc
h96%
164
86%
158
93%
164
87%
163
92%
164
The
Gre
at W
este
rn H
ospi
tal,
Swin
don
99%
368
96%
291
96%
365
93%
321
98%
337
The
Ipsw
ich
Hos
pita
l, Ip
swic
h92%
329
71%
319
78%
365
63%
350
77%
327
Torb
ay H
ospi
tal,
Torq
uay
99%
368
80%
316
96%
366
86%
339
95%
354
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
46
16/0
8/20
11
14:1
3
47MINAP
Traf
ford
Gen
eral
Hos
pita
l, M
anch
este
r19
1919
1918
Uni
vers
ity C
olle
ge H
ospi
tal G
ower
Str
eet,
Lond
on95%
5693%
5498%
5794%
5370%
57
Uni
vers
ity C
olle
ge H
ospi
tal,
Lond
on100%
173
98%
157
99%
179
99%
174
96%
175
Uni
vers
ity H
ospi
tal A
intr
ee, L
iver
pool
100%
287
99%
225
96%
324
94%
213
98%
231
Uni
vers
ity H
ospi
tal C
oven
try,
Cov
entr
y100%
436
96%
413
98%
439
96%
435
97%
436
Uni
vers
ity H
ospi
tal L
ewis
ham
, Lon
don
95%
6193%
5995%
6287%
6285%
61
Uni
vers
ity H
ospi
tal o
f Har
tlepo
ol, H
artle
pool
100%
102
100%
75100%
94100%
82100%
95
Uni
vers
ity H
ospi
tal o
f Nor
th D
urha
m, D
urha
m97%
9590%
9193%
9489%
8577%
102
Uni
vers
ity H
ospi
tal o
f Nor
th S
taffo
rdsh
ire,
St
oke-
on-T
rent
96%
1050
88%
921
95%
1052
83%
1051
90%
1053
Uni
vers
ity H
ospi
tal o
f Nor
th T
ees,
Sto
ckto
n on
Tee
s100%
88100%
7796%
8396%
6997%
72
Uni
vers
ity H
ospi
tal Q
ueen
s M
edic
al,
Not
tingh
am100%
5180%
4693%
5484%
4992%
52
Vict
oria
Hos
pita
l, B
lack
pool
100%
648
100%
606
98%
653
98%
591
98%
596
Wan
sbec
k G
ener
al H
ospi
tal,
Ashi
ngto
n100%
141
100%
121
100%
151
99%
134
100%
131
War
ring
ton
Dis
tric
t Gen
eral
Hos
pita
l, W
arri
ngto
n100%
270
100%
215
98%
285
98%
244
100%
250
War
wic
k H
ospi
tal,
War
wic
k100%
3282%
2897%
3294%
32100%
32
Wat
ford
Gen
eral
Hos
pita
l, W
atfo
rd99%
330
99%
301
97%
334
100%
309
98%
325
Wes
t Cor
nwal
l Hos
pita
l, P
enza
nce
23
20
3
Wes
t Cum
berl
and
Hos
pita
l, W
hite
have
n92%
9293%
8190%
9780%
8681%
95
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l, Is
lew
orth
100%
48100%
46100%
4794%
4893%
44
Wes
t Suf
folk
Hos
pita
l, B
ury
St E
dmun
ds97%
152
94%
135
94%
161
92%
142
95%
149
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
47
16/0
8/20
11
14:1
3
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
48 MINAP
49
Wes
ton
Gen
eral
Hos
pita
l, W
esto
n-Su
perm
are
100%
127
98%
9098%
127
98%
114
99%
119
Wex
ham
Par
k H
ospi
tal,
Slou
gh96%
172
83%
169
88%
172
87%
170
93%
170
Whi
pps
Cro
ss H
ospi
tal,
Lond
on100%
205
97%
148
98%
206
97%
174
97%
174
Whi
ston
Hos
pita
l, P
resc
ott
100%
301
100%
255
99%
302
99%
278
99%
277
Whi
ttin
gton
Hos
pita
l, Lo
ndon
100%
59100%
58100%
59100%
59100%
58
Will
iam
Har
vey
Hos
pita
l, As
hfor
d99%
662
94%
602
98%
680
94%
619
96%
660
Wor
cest
ersh
ire
Roy
al H
ospi
tal,
Wor
cest
er99%
178
99%
157
100%
179
100%
172
100%
174
Wor
thin
g H
ospi
tal,
Wor
thin
g100%
228
96%
192
94%
218
98%
204
98%
210
Wyc
ombe
Gen
eral
Hos
pita
l, H
igh
Wyc
ombe
99%
175
99%
164
98%
179
99%
176
93%
178
Wyt
hens
haw
e H
ospi
tal,
Man
ches
ter
100%
307
99%
288
98%
308
96%
306
98%
304
Yeov
il D
istr
ict H
ospi
tal,
Yeov
il100%
8495%
5985%
8087%
6996%
77
York
Dis
tric
t Hos
pita
l, Yo
rk100%
422
99%
329
99%
411
99%
359
100%
410
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
48
16/0
8/20
11
14:1
3
49MINAP
“The
cha
nces
of s
urvi
val a
fter
hea
rt a
ttac
k
have
impr
oved
yea
r on
yea
r de
spite
an
agei
ng
popu
latio
n so
that
the
outc
omes
in th
is c
ount
ry
mat
ch th
e be
st in
the
wor
ld.”
Pro
fess
or S
ir R
oger
Boy
le C
BE
Nat
iona
l Dir
ecto
r fo
r H
eart
Dis
ease
and
Str
oke
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
49
16/0
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11
14:1
3
table
6 se
cond
ary
prev
enti
on i
n wa
les
and
belfast
Pat
ient
s di
scha
rged
on
seco
ndar
y pr
even
tion
med
icat
ion
Asp
irin
Bet
a bl
ocke
rSt
atin
sAC
E in
hibi
tor
Clo
pido
grel
/Th
ieno
pyri
dine
inhi
bito
r
Year
20
10/1
1
%n
%n
%n
%n
%n
50 MINAP
51MINAP
Wal
es n
atio
nal a
vera
ge98%
1279
95%
1179
95%
1319
91%
1220
92%
1213
Bro
ngla
is G
ener
al H
ospi
tal,
Aber
ystw
yth
97%
3290%
3189%
3783%
3591%
33
Gla
n C
lwyd
DG
H T
rust
, Bod
elw
ydda
n96%
309
87%
308
89%
317
75%
299
82%
310
Llan
doug
h H
ospi
tal,
Llan
doug
h1
11
11
Llan
dudn
o G
ener
al H
ospi
tal,
Llan
dudn
o9
99
89
Mae
lor
Hos
pita
l, W
rexh
am100%
135
100%
123
99%
152
99%
118
99%
92
Mor
rist
on H
ospi
tal,
Swan
sea
100%
193
99%
181
100%
199
99%
192
99%
194
Nea
th P
ort T
albo
t Hos
pita
l, N
eath
96%
26100%
2396%
25100%
2396%
24
Nev
ill H
all H
ospi
tal,
Aber
gave
nny
97%
7597%
6493%
7596%
7596%
70
Pri
nce
Cha
rles
Hos
pita
l, M
erth
yr T
ydfil
100%
22100%
2296%
2396%
2487%
23
Pri
nce
Phi
lip H
ospi
tal,
Llan
elli
100%
3394%
3291%
3485%
3392%
36
Pri
nces
s of
Wal
es H
ospi
tal,
Bri
dgen
d100%
27100%
21100%
27100%
24100%
24
Roy
al G
lam
orga
n, L
lant
risa
nt3
34
33
Roy
al G
wen
t Hos
pita
l, N
ewpo
rt99%
127
100%
101
95%
130
98%
124
95%
119
Sing
leto
n H
ospi
tal,
Swan
sea
96%
2386%
22100%
2419
86%
21
Uni
vers
ity H
ospi
tal o
f Wal
es, C
ardi
ff100%
163
99%
149
98%
162
97%
150
96%
164
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
50
16/0
8/20
11
14:1
3
51MINAP
Wes
t Wal
es G
ener
al, C
amar
then
1112
1211
10
With
ybus
h G
ener
al H
ospi
tal,
Hav
erfo
rdw
est
100%
5996%
4793%
5796%
5194%
49
Ysby
ty G
wyn
edd
, Ban
gor
100%
3197%
3097%
3193%
30100%
31
Bel
fast
ave
rage
99%
483
99%
459
99%
480
97%
408
98%
459
Bel
fast
City
Hos
pita
l99%
149
99%
141
98%
151
91%
121
98%
141
Mat
er In
firm
orum
Hos
pita
l100%
9998%
95100%
9998%
91100%
97
Roy
al V
icto
ria
Hos
pita
l99%
235
100%
223
100%
230
100%
196
97%
221
MIN
AP P
ublic
Rep
ort L
ands
cape
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als
Blue
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51
16/0
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11
14:1
3
table
7 ca
rdia
c ne
twor
ks i
n en
glan
d an
d wa
les
52 MINAP
53MINAP
Thro
mbo
lytic
tr
eatm
ent w
ithin
60
min
s of
ca
lling
for
help
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
Pat
ient
s ha
ving
pr
e-ho
spita
l ly
sis
Pat
ient
s ha
ving
in
-hos
pita
l lys
isP
atie
nts
havi
ng p
rim
ary
angi
opla
sty
Pat
ient
s ha
ving
no
rep
erfu
sion
tr
eatm
ent
Thro
mbo
lytic
tr
eatm
ent w
ithin
60
min
s of
ca
lling
for
help
Pri
mar
y an
giop
last
y w
ithin
150
min
s of
cal
ling
for
help
Pat
ient
s ha
ving
pr
e-ho
spita
l ly
sis
Pat
ient
s ha
ving
in
-hos
pita
l lys
isP
atie
nts
havi
ng p
rim
ary
angi
opla
sty
Pat
ient
s ha
ving
no
rep
erfu
sion
tr
eatm
ent
Year
20
09/1
020
10/1
1
%n
%n
%n
%n
%n
%n
%n
%n
%n
%n
%n
%n
Engl
and
nati
onal
ave
rage
69%
3458
1001280%
1646
6%5183
20%
1250549%
6374
25%
68%
1723
1286881%
848
3%2450
10%
1581762%
6217
25%
Angl
ia C
ardi
ac N
etw
ork
69%
84725
80%
100
7%76
6%814
61%
348
26%
80%
20802
81%
463%
171%
897
67%
379
28%
Avon
, Glo
uces
ters
hire
, Wilt
shir
e &
So
mer
set C
ardi
ac &
Str
oke
Net
wor
k70%
222
452
77%
137
11%
280
22%
507
40%
329
26%
53%
38832
81%
181%
615%
917
69%
334
25%
Bed
ford
shir
e &
Her
tfor
dshi
re C
ardi
ac
Net
wor
k10
130
91%
319
152
56%
9736%
1111
91%
04
135
61%
8137%
Bir
min
gham
, San
dwel
l & S
olih
ull
Car
diac
Net
wor
k4
484
77%
118
638
80%
139
17%
4486
84%
17
680
81%
155
18%
Bla
ck C
ount
ry C
ardi
ac N
etw
ork
3369
80%
102
476
77%
131
21%
2386
81%
73
537
83%
100
15%
Car
diac
& S
trok
e N
etw
orks
in C
umbr
ia
& L
anca
shir
e70%
264
144
88%
7810%
338
42%
195
24%
186
23%
73%
206
140
95%
568%
274
41%
173
26%
164
25%
Che
shir
e &
Mer
seys
ide
Car
diac
N
etw
ork
76%
190
387
84%
262%
412
31%
413
31%
499
37%
82%
55601
82%
1989
8%715
62%
326
28%
Cov
entr
y &
War
wic
kshi
re C
ardi
ac
Net
wor
k2
274
90%
21
368
92%
307%
4304
85%
07
370
93%
205%
Dor
set C
ardi
ac &
Str
oke
Net
wor
k70%
113
9795%
4413%
163
47%
120
34%
226%
70%
7793
91%
4315%
102
37%
106
38%
2810%
East
Mid
land
s C
ardi
ac N
etw
ork
68%
613
348
75%
343
20%
628
36%
426
24%
345
20%
70%
429
595
87%
245
13%
462
24%
728
38%
468
25%
Esse
x C
ardi
ac N
etw
ork
87%
126
347
85%
110
13%
153
18%
382
44%
226
26%
72%
29589
84%
435%
71%
588
64%
278
30%
Gre
ater
Man
ches
ter
& C
hesh
ire
Car
diac
Net
wor
k70%
328
399
77%
322%
600
34%
628
36%
492
28%
74%
245
492
74%
262%
395
24%
679
41%
540
33%
Her
efor
dshi
re &
Wor
cest
ersh
ire
Car
diac
Net
wor
k57%
141
067
18%
210
56%
21%
9425%
72%
115
1164
21%
183
60%
145%
4515%
Ken
t Car
diac
Net
wor
k82%
200
1106
14%
458
59%
51%
209
27%
13441
75%
20%
537%
555
69%
196
24%
Nor
th &
Eas
t Yor
kshi
re &
Nor
ther
n Li
ncol
nshi
re C
ardi
ac N
etw
ork
59%
105
125
75%
9513%
157
22%
155
22%
308
43%
57%
21300
89%
436%
548%
370
52%
249
35%
Nor
th C
entr
al L
ondo
n C
HD
Net
wor
k1
272
76%
15
357
83%
6515%
2310
81%
24
360
81%
7717%
Nor
th E
ast L
ondo
n C
ardi
ac N
etw
ork
1500
56%
04
554
86%
8513%
2418
80%
05
557
89%
6711%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
52
16/0
8/20
11
14:1
3
53MINAP
Nor
th o
f Eng
land
Car
diov
ascu
lar
Net
wor
k52%
841253
85%
271%
141
6%1410
64%
620
28%
71%
991150
89%
402%
137
7%1349
69%
437
22%
Nor
th T
rent
Net
wor
k of
Car
diac
Car
e82%
170
274
70%
105
10%
211
20%
371
35%
383
36%
14581
75%
101%
253%
570
60%
342
36%
Nor
th W
est L
ondo
n C
HD
Net
wor
k3
709
81%
09
829
84%
145
15%
2666
80%
09
950
78%
265
22%
Pen
insu
la C
ardi
ac M
anag
ed C
linic
al
Net
wor
k69%
205
294
84%
141
13%
216
20%
455
42%
260
24%
66%
121
380
82%
798%
124
13%
498
52%
264
27%
Shro
pshi
re &
Sta
fford
shir
e C
ardi
ac
Net
wor
k66%
87240
84%
365%
153
23%
353
53%
129
19%
8282
73%
122%
397%
410
71%
115
20%
Sout
h C
entr
al V
ascu
lar
Net
wor
k54%
252
658
85%
604%
352
22%
835
52%
365
23%
55%
76956
85%
342%
106
6%1189
72%
323
20%
Sout
h Ea
st L
ondo
n C
ardi
ac N
etw
ork
3339
60%
18
414
82%
8216%
0%26
359
70%
24
491
86%
7413%
Sout
h W
est L
ondo
n C
ardi
ac N
etw
ork
1278
87%
04
319
80%
7719%
0306
90%
11
346
89%
4211%
Surr
ey H
eart
& S
trok
e N
etw
ork
80%
8294
88%
469%
234
44%
134
25%
119
22%
83%
42203
85%
194%
124
23%
255
48%
135
25%
Suss
ex H
eart
Net
wor
k79%
120
158
77%
639%
242
36%
194
29%
181
27%
69%
49281
83%
264%
110
16%
346
50%
211
30%
Wes
t Yor
kshi
re C
ardi
ac N
etw
ork
25%
44661
80%
1289
6%999
66%
408
27%
13%
23793
64%
1044
3%1032
65%
502
32%
Wal
es n
atio
nal a
vera
ge55%
484
180
76%
239
18%
608
45%
232
17%
276
20%
53%
402
225
75%
212
17%
476
38%
301
24%
274
22%
Nor
th W
ales
Car
diac
Net
wor
k51%
156
271
20%
192
53%
493
26%
52%
148
372
21%
170
50%
689
26%
Sout
h W
ales
Car
diac
Net
wor
k57%
328
178
77%
168
17%
416
42%
228
23%
183
18%
54%
254
222
76%
140
15%
306
33%
295
32%
185
20%
Bel
fast
ave
rage
48%
3147
77%
137%
4123%
7845%
4325%
0124
90%
00%
10%
173
70%
7430%
99%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
53
16/0
8/20
11
14:1
3
table
8 ca
re o
f pa
tien
ts w
ith
non
st e
leva
tion infarction(nSTEMI) in england
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
54 MINAP
55MINAP
Engl
and
nati
onal
ave
rage
21843
47%
41269
89%
23286
50%
42555
91%
Adde
nbro
oke'
s H
ospi
tal,
Cam
brid
ge150
53%
282
100%
179
68%
263
100%
Aire
dale
Gen
eral
Hos
pita
l, St
eeto
n75
50%
122
81%
8453%
155
98%
Arro
we
Par
k H
ospi
tal,
Wir
ral
263
65%
352
87%
269
66%
341
83%
Bar
net G
ener
al H
ospi
tal,
Bar
net
3141%
7296%
2346%
50100%
Bar
nsle
y D
istr
ict G
ener
al H
ospi
tal,
Bar
nsle
y187
89%
190
90%
127
73%
153
88%
Bar
ts &
the
Lond
on, L
ondo
n85
99%
86100%
433
98%
440
100%
Bas
ildon
Hos
pita
l, B
asild
on229
93%
240
98%
356
97%
364
99%
Bas
ings
toke
& N
orth
Ham
pshi
re H
ospi
tal,
Bas
ings
toke
6064%
3537%
4542%
107
99%
Bas
setl
aw D
istr
ict G
ener
al H
ospi
tal,
Not
tingh
am168
79%
180
85%
181
72%
212
84%
Bed
ford
Hos
pita
l, B
edfo
rd50
47%
102
95%
5355%
9599%
Bir
min
gham
Hea
rtla
nds
Hos
pita
l, B
irm
ingh
am156
67%
233
100%
189
61%
308
99%
Bra
dfor
d R
oyal
Infir
mar
y, B
radf
ord
119
32%
369
99%
178
46%
381
99%
Bri
stol
Roy
al In
firm
ary,
Bri
stol
112
55%
203
100%
101
51%
193
97%
Bro
omfie
ld H
ospi
tal,
Che
lmsf
ord
7923%
281
81%
7319%
338
88%
It is
reco
gnis
ed t
hat
not
all n
STEM
I are
ent
ered
into
MIN
AP.
A nu
mbe
r of h
ospi
tals
repo
rt a
lack
of r
esou
rces
to
colle
ct d
ata
on n
STEM
I, an
d m
ore
gene
rally
tho
se p
atie
nts
not
adm
itte
d to
a c
ardi
ac
unit
are
less
like
ly t
o be
ent
ered
. Thu
s th
e pe
rcen
tage
s re
port
ed b
elow
do
not
take
into
acc
ount
eve
ry p
atie
nt a
dmit
ted
to h
ospi
tal w
ith
nSTE
MI.
In a
ddit
ion
som
e ho
spit
als
in t
he L
ondo
n ar
ea t
hat
have
no
nSTE
MI a
re p
arti
cipa
ting
in a
pro
ject
for d
irec
t ad
mis
sion
of t
hese
pat
ient
s to
a h
eart
att
ack
cent
re in
a m
anne
r sim
ilar t
o th
at fo
r pri
mar
y an
giop
last
y fo
r STE
MI.
MIN
AP P
ublic
Rep
ort L
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als
Blue
.indd
54
16/0
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11
14:1
3
55MINAP
Cal
derd
ale
Roy
al H
ospi
tal,
Hal
ifax
126
43%
254
86%
134
39%
291
85%
Cas
tle H
ill H
ospi
tal,
Hul
l317
94%
333
99%
383
90%
420
98%
Cen
tral
Mid
dles
ex H
ospi
tal,
Lond
on4
117
97%
5111
98%
Cha
ring
Cro
ss H
ospi
tal,
Lond
on8
43100%
540
100%
Cha
se F
arm
Hos
pita
l, En
field
118
99%
119
100%
155
100%
155
100%
Che
lsea
& W
estm
inis
ter
Hos
pita
l, Lo
ndon
2328%
82100%
982
100%
Che
ltenh
am G
ener
al H
ospi
tal,
Che
ltenh
am45
38%
109
93%
4031%
113
88%
Che
ster
field
Roy
al, C
hest
erfie
ld155
48%
295
91%
110
48%
216
95%
Cho
rley
Hos
pita
l, C
horl
ey7
221
25%
6781%
City
Hos
pita
l, B
irm
ingh
am39
20%
192
100%
3924%
163
100%
Col
ches
ter
Gen
eral
Hos
pita
l, C
olch
este
r300
57%
430
82%
220
56%
342
87%
Con
ques
t Hos
pita
l, St
Leo
nard
s on
Sea
177
86%
204
100%
163
72%
201
89%
Cou
ntes
s of
Che
ster
Hos
pita
l, C
hest
er167
41%
382
94%
126
29%
386
89%
Cou
nty
Hos
pita
l Her
efor
d, H
eref
ord
4637%
8366%
4029%
103
74%
Cou
nty
Hos
pita
l Lou
th, L
outh
2292%
170
0
Cum
berl
and
Infir
mar
y, C
arlis
le86
27%
283
89%
7630%
225
89%
Dar
ent V
alle
y H
ospi
tal,
Dar
tfor
d170
82%
203
98%
253
80%
311
98%
Dar
lingt
on M
emor
ial H
ospi
tal,
Dar
lingt
on64
27%
211
89%
5224%
193
91%
Der
rifo
rd H
ospi
tal,
Ply
mou
th3
311
3359%
Dew
sbur
y D
istr
ict H
ospi
tal,
Dew
sbur
y117
49%
165
69%
102
38%
217
82%
Dia
na, P
rinc
ess
of W
ales
Hos
pita
l, G
rim
sby
151
58%
250
96%
161
65%
229
93%
Don
cast
er R
oyal
Infir
mar
y, D
onca
ster
6927%
224
87%
9031%
268
92%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
55
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11
14:1
3
56 MINAP
57MINAP
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
Dor
set C
ount
y H
ospi
tal,
Dor
ches
ter
9649%
186
94%
9751%
177
94%
Ealin
g H
ospi
tal,
Sout
hall
4291%
46100%
7091%
7699%
East
Sur
rey
Hos
pita
l, R
edhi
ll136
49%
9434%
177
46%
315
83%
East
bour
ne D
GH
, Eas
tbou
rne
157
72%
178
81%
170
81%
193
92%
Epso
m H
ospi
tal,
Epso
m165
84%
197
100%
121
85%
143
100%
Fair
field
Gen
eral
Hos
pita
l, B
ury
3625%
138
97%
3623%
151
97%
Free
man
Hos
pita
l, N
ewca
stle
707
95%
741
100%
776
99%
786
100%
Fren
chay
Hos
pita
l, B
rist
ol68
51%
118
88%
137
41%
263
78%
Fria
rage
Hos
pita
l, N
orth
alle
rton
8182%
99100%
6564%
101
100%
Frim
ley
Par
k H
ospi
tal,
Frim
ley
146
42%
332
95%
122
40%
290
95%
Furn
ess
Gen
eral
, Bar
row
-in-
Furn
ess
2740%
2537%
2850%
2138%
Geo
rge
Ellio
t Hos
pita
l, N
unea
ton
6449%
125
96%
7746%
162
96%
Gle
nfiel
d H
ospi
tal,
Leic
este
r148
75%
198
100%
144
77%
185
98%
Glo
uces
ters
hire
Roy
al H
ospi
tal,
Glo
uces
ter
7069%
9796%
8872%
115
94%
Goo
d H
ope
Gen
eral
Hos
pita
l, Su
tton
Col
dfiel
d84
30%
278
98%
5424%
229
100%
Gra
ntha
m &
Dis
tric
t Gen
eral
, Gra
ntha
m100
34%
284
98%
8243%
191
100%
Ham
mer
smith
Hos
pita
l, Lo
ndon
9664%
148
99%
101
62%
148
91%
Har
efiel
d H
ospi
tal
206
98%
207
99%
136
93%
119
82%
Har
roga
te D
istr
ict H
ospi
tal,
Har
roga
te291
86%
294
87%
288
91%
278
88%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
56
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14:1
3
57MINAP
Hex
ham
Gen
eral
Hos
pita
l, H
exha
m17
927
24%
12
Hill
ingd
on H
ospi
tal,
Uxb
ridg
e263
80%
292
89%
359
84%
368
86%
Hin
chin
gbro
oke
Hos
pita
l, H
untin
gdon
3853%
6996%
2460%
40100%
Hom
erto
n H
ospi
tal,
Lond
on1
1520
80%
25100%
Hop
e H
ospi
tal,
Man
ches
ter
9027%
282
83%
7826%
278
92%
Hor
ton
Gen
eral
Hos
pita
l, B
anbu
ry17
8569%
958
48%
Hud
ders
field
Roy
al In
firm
ary,
Hud
ders
field
129
36%
313
86%
102
39%
237
91%
Hul
l Roy
al In
firm
ary,
Hul
l7
6118%
135
55%
Jam
es C
ook
Uni
vers
ity H
ospi
tal,
Mid
dles
boro
ugh
190
95%
201
100%
163
89%
183
100%
Jam
es P
aget
Hos
pita
l, G
reat
Yar
mou
th132
61%
203
94%
153
89%
172
100%
John
Rad
cliff
e H
ospi
tal,
Oxf
ord
110
25%
340
78%
172
36%
421
89%
Ken
t & C
ante
rbur
y H
ospi
tal,
Can
terb
ury
112
47%
153
65%
129
55%
162
69%
Ken
t & S
usse
x H
ospi
tal,
Tunb
ridg
e W
ells
2841%
6697%
3136%
8599%
Ket
teri
ng G
ener
al H
ospi
tal,
Ket
teri
ng120
48%
232
92%
149
63%
224
95%
Kin
g G
eorg
e H
ospi
tal,
Goo
dmay
es89
32%
265
94%
125
71%
156
88%
Kin
g's
Col
lege
Hos
pita
l, Lo
ndon
7339%
160
86%
162
45%
197
55%
Kin
gs M
ill H
ospi
tal,
Not
tingh
am85
21%
385
97%
6218%
336
100%
Kin
gsto
n H
ospi
tal,
Kin
gsto
n-up
on-T
ham
es9
113
97%
229
52%
Leed
s G
ener
al In
firm
ary,
Lee
ds475
80%
583
98%
508
84%
597
99%
Leic
este
r R
oyal
Infir
mar
y, L
eice
ster
6348%
129
98%
3449%
6797%
Leig
hton
Hos
pita
l, C
rew
e161
44%
344
95%
132
33%
374
94%
Linc
oln
Cou
nty
Hos
pita
l, Li
ncol
n91
30%
286
93%
7429%
236
93%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
57
16/0
8/20
11
14:1
3
58 MINAP
59MINAP
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
List
er H
ospi
tal,
Stev
enag
e122
46%
233
89%
143
58%
223
91%
Live
rpoo
l Hea
rt &
Che
st H
ospi
tal,
Live
rpoo
l6
95
5
Luto
n &
Dun
stab
le H
ospi
tal,
Luto
n84
19%
437
98%
7216%
443
98%
Mac
cles
field
Dis
tric
t Gen
eral
, Mac
cles
field
7123%
272
89%
5626%
196
92%
Mai
dsto
ne G
ener
al H
ospi
tal,
Mai
dsto
ne61
54%
109
97%
9057%
157
99%
Man
ches
ter
Roy
al In
firm
ary,
Man
ches
ter
2714%
181
93%
19139
99%
Man
or H
ospi
tal,
Wal
sall
108
48%
1128
59%
176
81%
May
day
Uni
vers
ity H
ospi
tal,
Cro
ydon
107
86%
117
94%
7299%
6488%
Med
way
Mar
itim
e H
ospi
tal,
Gill
ingh
am123
33%
340
92%
161
49%
293
90%
Milt
on K
eyne
s G
ener
al H
ospi
tal,
Milt
on K
eyne
s46
84%
4989%
3978%
4896%
Mon
tagu
Hos
pita
l, M
exbo
roug
h0
140
14
New
Cro
ss H
ospi
tal,
Wol
verh
ampt
on39
17%
225
100%
5019%
270
100%
New
ark
Hos
pita
l, N
ewar
k0
5268%
029
63%
New
ham
Gen
eral
Hos
pita
l, Lo
ndon
237
99%
227
95%
187
99%
188
99%
Nor
folk
& N
orw
ich
Uni
vers
ity H
ospi
tal,
Nor
wic
h490
61%
809
100%
387
55%
704
100%
Nor
th D
evon
Dis
tric
t Hos
pita
l, B
arns
tabl
e56
17%
286
89%
5517%
283
87%
Nor
th M
anch
este
r G
ener
al H
ospi
tal,
Man
ches
ter
3120%
155
99%
3821%
183
99%
Nor
th M
iddl
esex
Hos
pita
l, Lo
ndon
6050%
116
96%
101
62%
159
98%
Nor
th T
ynes
ide
Gen
eral
Hos
pita
l, N
orth
Shi
elds
124
35%
278
79%
110
34%
277
85%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
58
16/0
8/20
11
14:1
3
59MINAP
Nor
tham
pton
Gen
eral
Hos
pita
l, N
orth
ampt
on319
81%
381
97%
336
75%
434
97%
Nor
ther
n G
ener
al H
ospi
tal,
Shef
field
341
45%
592
78%
366
48%
686
90%
Nor
thw
ick
Par
k H
ospi
tal,
Har
row
11463
98%
2369
99%
Not
tingh
am C
ity H
ospi
tal,
Not
tingh
am1
144
51%
8599%
Pap
wor
th H
ospi
tal,
Cam
brid
ge10
816
15
Pet
erbo
roug
h C
ity H
ospi
tal,
Pet
erbo
roug
h107
38%
244
87%
175
49%
316
89%
Pilg
rim
Hos
pita
l, B
osto
n128
32%
346
85%
121
32%
323
86%
Pin
derfi
elds
Gen
eral
Hos
pita
l, W
akefi
eld
6020%
221
75%
6420%
266
84%
Pon
tefr
act G
ener
al In
firm
ary,
Pon
tefr
act
4717%
222
80%
3015%
175
86%
Poo
le H
ospi
tal,
Poo
le10
108
11
Pri
nces
s Al
exan
dra
Hos
pita
l, H
arlo
w137
67%
186
92%
144
59%
230
93%
Pri
nces
s R
oyal
Hos
pita
l, H
ayw
ards
Hea
th105
80%
100
76%
100
82%
9981%
Pri
nces
s R
oyal
Hos
pita
l, Te
lford
17188
88%
17116
92%
Pri
nces
s R
oyal
Uni
vers
ity H
ospi
tal,
Orp
ingt
on66
22%
258
87%
9735%
262
94%
Que
en A
lexa
ndra
Hos
pita
l, P
orts
mou
th147
38%
388
100%
5016%
310
100%
Que
en E
lizab
eth
Hos
pita
l, B
irm
ingh
am15
7229
99%
231
100%
Que
en E
lizab
eth
Hos
pita
l, G
ates
head
228
57%
351
88%
252
66%
338
89%
Que
en E
lizab
eth
Hos
pita
l, K
ing'
s Ly
nn13
190
80%
246%
305
73%
Que
en E
lizab
eth
Hos
pita
l, W
oolw
ich
100
43%
217
94%
2722%
119
97%
Que
en E
lizab
eth
II H
ospi
tal,
Wel
wyn
Gar
den
City
109
53%
187
91%
108
56%
169
88%
Que
en E
lizab
eth
the
Que
en M
othe
r, M
arga
te76
40%
118
62%
8037%
135
63%
Que
en M
ary'
s H
ospi
tal,
Sidc
up33
77%
4195%
3497%
35100%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
59
16/0
8/20
11
14:1
3
60 MINAP
61MINAP
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
Que
en's
Hos
pita
l, R
omfo
rd103
25%
386
93%
212
57%
282
75%
Que
en's
Hos
pita
l, B
urto
n-up
on-T
rent
212
82%
216
84%
190
79%
216
89%
Roc
hdal
e In
firm
ary,
Roc
hdal
e41
28%
142
97%
6646%
141
97%
Rot
herh
am G
ener
al H
ospi
tal,
Rot
herh
am41
16%
175
67%
104
33%
252
81%
Roy
al A
lber
t Edw
ard
Infir
mar
y, W
igan
172
70%
238
98%
203
65%
309
99%
Roy
al B
erks
hire
Hos
pita
l, R
eadi
ng178
76%
235
100%
210
77%
261
96%
Roy
al B
lack
burn
Hos
pita
l, B
lack
burn
237
40%
548
93%
245
45%
496
91%
Roy
al B
olto
n H
ospi
tal,
Bol
ton
118
35%
337
99%
135
41%
321
98%
Roy
al B
ourn
emou
th G
ener
al H
ospi
tal,
Bou
rnem
outh
30100%
30100%
5589%
6097%
Roy
al C
ornw
all H
ospi
tal,
Trur
o223
39%
389
69%
254
41%
419
68%
Roy
al D
erby
Hos
pita
l, D
erby
278
60%
458
99%
237
75%
316
100%
Roy
al D
evon
& E
xete
r H
ospi
tal,
Exet
er117
37%
293
92%
115
45%
240
94%
Roy
al F
ree
Hos
pita
l, Lo
ndon
6475%
8296%
8998%
91100%
Roy
al H
amps
hire
Cou
nty
Hos
pita
l, W
inch
este
r55
16%
315
94%
4316%
249
94%
Roy
al L
anca
ster
Infir
mar
y, L
anca
ster
7174%
9498%
6577%
8399%
Roy
al L
iver
pool
Uni
vers
ity H
ospi
tal,
Live
rpoo
l132
53%
232
92%
154
64%
231
95%
Roy
al L
ondo
n H
ospi
tal,
Lond
on0
012
0
Roy
al O
ldha
m H
ospi
tal,
Old
ham
3715%
234
96%
2811%
233
94%
Roy
al P
rest
on H
ospi
tal,
Pre
ston
1035
100%
652
87%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
60
16/0
8/20
11
14:1
3
61MINAP
Roy
al S
hrew
sbur
y H
ospi
tal,
Shre
wsb
ury
6651%
116
89%
3429%
108
92%
Roy
al S
urre
y C
ount
y H
ospi
tal,
Gui
ldfo
rd14
37100%
627
96%
Roy
al S
usse
x C
ount
y H
ospi
tal,
Bri
ghto
n73
95%
77100%
7574%
102
100%
Roy
al U
nite
d H
ospi
tal B
ath,
Bat
h75
54%
128
93%
111
49%
185
82%
Roy
al V
icto
ria
Infir
mar
y, N
ewca
stle
16347
100%
8277
99%
Rus
sells
Hal
l Hos
pita
l, D
udle
y155
87%
178
100%
314
100%
315
100%
Salis
bury
Dis
tric
t Hos
pita
l, Sa
lisbu
ry79
42%
186
99%
9134%
268
100%
Sand
wel
l Dis
tric
t Hos
pita
l, W
est B
rom
wic
h50
27%
182
100%
4529%
155
99%
Scar
boro
ugh
Gen
eral
Hos
pita
l, Sc
arbo
roug
h95
88%
9386%
159
82%
191
98%
Scun
thor
pe G
ener
al H
ospi
tal,
Scun
thor
pe51
14%
246
68%
4113%
252
82%
Selly
Oak
Hos
pita
l, B
irm
ingh
am98
82%
119
99%
55
Solih
ull G
ener
al H
ospi
tal,
Bir
min
gham
6176%
80100%
4345%
9599%
Sout
h Ty
nesi
de D
istr
ict H
ospi
tal,
Sout
h Sh
ield
s65
24%
244
91%
5426%
196
94%
Sout
ham
pton
Gen
eral
Hos
pita
l, So
utha
mpt
on300
81%
367
99%
342
79%
428
98%
Sout
hend
Hos
pita
l, W
estc
liffe
on
Sea
251
77%
310
95%
301
79%
363
96%
Sout
hmea
d H
ospi
tal,
Bri
stol
115
55%
183
88%
136
41%
280
85%
Sout
hpor
t & F
orm
by D
istr
ict G
ener
al, S
outh
port
6241%
149
98%
6129%
207
100%
St G
eorg
e's
Hos
pita
l, Lo
ndon
8171%
110
96%
9175%
120
99%
St H
elie
r H
ospi
tal,
Car
shal
ton
129
75%
172
99%
9474%
127
100%
St M
ary'
s H
ospi
tal,
Lond
on147
80%
166
91%
114
85%
134
100%
St M
ary'
s H
ospi
tal,
New
port
127
77%
166
100%
112
82%
135
99%
St P
eter
's H
ospi
tal,
Che
rtse
y160
99%
159
98%
156
96%
161
99%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
61
16/0
8/20
11
14:1
3
62 MINAP
63MINAP
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
St R
icha
rd's
Hos
pita
l, C
hich
este
r31
15%
201
97%
3820%
189
97%
St T
hom
as H
ospi
tal,
Lond
on48
48%
9798%
7568%
111
100%
Staf
ford
shir
e G
ener
al H
ospi
tal,
Staf
ford
8645%
178
93%
7437%
190
96%
Step
ping
Hill
Hos
pita
l, St
ockp
ort
303
44%
546
80%
217
39%
441
80%
Stok
e M
ande
ville
Hos
pita
l, Ay
lesb
ury
3227%
9580%
2320%
6456%
Sund
erla
nd R
oyal
Hos
pita
l, Su
nder
land
101
90%
108
96%
150
87%
171
99%
Tam
esid
e G
ener
al H
ospi
tal,
Asht
on U
nder
Lym
e13
326
98%
215%
375
97%
Taun
ton
& S
omer
set H
ospi
tal,
Taun
ton
7545%
164
99%
5523%
229
96%
The
Alex
andr
a H
ospi
tal,
Red
ditc
h22
19%
116
98%
3320%
163
96%
The
Gre
at W
este
rn H
ospi
tal,
Swin
don
116
26%
403
89%
8318%
402
86%
The
Ipsw
ich
Hos
pita
l, Ip
swic
h442
67%
537
81%
369
52%
479
67%
Torb
ay H
ospi
tal,
Torq
uay
190
68%
254
91%
188
70%
251
94%
Traf
ford
Gen
eral
Hos
pita
l, M
anch
este
r3
156
18
Uni
vers
ity C
olle
ge H
ospi
tal G
ower
Str
eet,
Lond
on2
6498%
857
93%
Uni
vers
ity C
olle
ge H
ospi
tal,
Lond
on17
2095%
2281%
2696%
Uni
vers
ity H
ospi
tal A
intr
ee, L
iver
pool
292
59%
417
85%
256
44%
516
89%
Uni
vers
ity H
ospi
tal C
oven
try,
Cov
entr
y49
100%
49100%
8287%
94100%
Uni
vers
ity H
ospi
tal L
ewis
ham
, Lon
don
1939
87%
3253%
5693%
Uni
vers
ity H
ospi
tal o
f Har
tlepo
ol, H
artle
pool
148
60%
152
62%
164
59%
205
74%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
62
16/0
8/20
11
14:1
3
63MINAP
Uni
vers
ity H
ospi
tal o
f Nor
th D
urha
m, D
urha
m180
62%
284
98%
160
63%
250
99%
Uni
vers
ity H
ospi
tal o
f Nor
th S
taffo
rdsh
ire,
Sto
ke-o
n-Tr
ent
483
93%
447
86%
498
94%
466
88%
Uni
vers
ity H
ospi
tal o
f Nor
th T
ees,
Sto
ckto
n on
Tee
s95
41%
203
88%
104
40%
235
90%
Uni
vers
ity H
ospi
tal Q
ueen
s M
edic
al, N
ottin
gham
34
8060%
103
77%
Vict
oria
Hos
pita
l, B
lack
pool
123
30%
338
83%
126
27%
375
81%
Wan
sbec
k G
ener
al H
ospi
tal,
Ashi
ngto
n219
47%
337
72%
191
52%
331
91%
War
ring
ton
Dis
tric
t Gen
eral
Hos
pita
l, W
arri
ngto
n114
23%
481
98%
129
31%
414
98%
War
wic
k H
ospi
tal,
War
wic
k16
42100%
1237
100%
Wat
ford
Gen
eral
Hos
pita
l, W
atfo
rd60
17%
335
96%
258%
294
99%
Wes
t Cor
nwal
l Hos
pita
l, P
enza
nce
00
00
Wes
t Cum
berl
and
Hos
pita
l, W
hite
have
n96
64%
139
92%
125
60%
181
87%
Wes
t Mid
dles
ex U
nive
rsity
Hos
pita
l, Is
lew
orth
5543%
103
81%
2149%
3888%
Wes
t Suf
folk
Hos
pita
l, B
ury
St E
dmun
ds73
28%
236
91%
6122%
254
93%
Wes
ton
Gen
eral
Hos
pita
l, W
esto
n-Su
perm
are
176
71%
189
77%
104
61%
142
83%
Wex
ham
Par
k H
ospi
tal,
Slou
gh47
30%
155
98%
111
100%
107
96%
Whi
pps
Cro
ss H
ospi
tal,
Lond
on27
11%
206
85%
3713%
262
90%
Whi
ston
Hos
pita
l, P
resc
ott
167
29%
531
93%
239
40%
551
92%
Whi
ttin
gton
Hos
pita
l, Lo
ndon
6689%
7095%
6689%
7399%
Will
iam
Har
vey
Hos
pita
l, As
hfor
d43
21%
178
85%
154
68%
195
86%
Wor
cest
ersh
ire
Roy
al H
ospi
tal,
Wor
cest
er73
44%
159
95%
2922%
128
99%
Wor
thin
g H
ospi
tal,
Wor
thin
g76
65%
113
97%
141
71%
194
98%
Wyc
ombe
Gen
eral
Hos
pita
l, H
igh
Wyc
ombe
152
92%
159
96%
162
92%
154
87%
MIN
AP P
ublic
Rep
ort L
ands
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als
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.indd
63
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8/20
11
14:1
3
64 MINAP
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
Wyt
hens
haw
e H
ospi
tal,
Man
ches
ter
7130%
216
91%
4528%
155
98%
Yeov
il D
istr
ict H
ospi
tal,
Yeov
il63
37%
164
96%
4334%
125
98%
York
Dis
tric
t Hos
pita
l, Yo
rk117
26%
397
88%
103
23%
390
86%
65
MIN
AP P
ublic
Rep
ort L
ands
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als
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.indd
64
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11
14:1
3
“ D
urin
g th
e pa
st d
ecad
e, M
INA
P h
as
docu
men
ted
maj
or c
hang
es in
the
care
pro
vide
d
to p
eopl
e w
ho s
uffe
r he
art a
ttac
k. W
hat h
as
not c
hang
ed is
the
com
mitm
ent o
f ind
ivid
ual
clin
icia
ns, m
anag
ers
and
adm
inis
trat
ors
who
,
thro
ugh
thei
r pa
rtic
ipat
ion
in M
INA
P, c
ontin
ue to
prom
ote
the
valu
es o
f nat
iona
l clin
ical
aud
it.”
Dr
Cliv
e W
esto
n
Clin
ical
Dir
ecto
r of
MIN
AP
65MINAP
MIN
AP P
ublic
Rep
ort L
ands
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als
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.indd
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3
table
9 ca
re o
f pa
tien
ts w
ith
non
st e
leva
tion (nSTEMI) in wales and belfast
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
nSTE
MI p
atie
nts
adm
itted
to
card
iac
unit
or w
ard
nSTE
MI p
atie
nts
seen
by
a ca
rdio
logi
st o
r m
embe
r of
team
Year
2009
/10
2010
/11
n%
n%
n %
n %
66 MINAP
67MINAP
Wal
es n
atio
nal a
vera
ge890
55%
1215
74%
948
59%
1354
84%
Bro
ngla
is G
ener
al H
ospi
tal,
Aber
ystw
yth
12
6385%
6791%
Gla
n C
lwyd
DG
H T
rust
, Bod
elw
ydda
n31
16%
159
84%
5725%
202
89%
Llan
doug
h H
ospi
tal,
Llan
doug
h1
10
0
Llan
dudn
o G
ener
al H
ospi
tal,
Llan
dudn
o35
64%
4887%
45
Mae
lor
Hos
pita
l, W
rexh
am240
68%
215
61%
221
79%
228
82%
Mor
rist
on H
ospi
tal,
Swan
sea
11
44
Nea
th P
ort T
albo
t Hos
pita
l, N
eath
2024%
3340%
1946
65%
Nev
ill H
all H
ospi
tal,
Aber
gave
nny
129
81%
156
98%
147
76%
190
98%
Pri
nce
Cha
rles
Hos
pita
l, M
erth
yr T
ydfil
2382%
28100%
4276%
55100%
Pri
nce
Phi
lip H
ospi
tal,
Llan
elli
3243%
6283%
1448
86%
Pri
nces
s of
Wal
es H
ospi
tal,
Bri
dgen
d69
79%
87100%
6286%
72100%
Roy
al G
lam
orga
n, L
lant
risa
nt49
78%
5283%
00
Roy
al G
wen
t Hos
pita
l, N
ewpo
rt50
21%
233
99%
108
38%
284
99%
It is
reco
gnis
ed t
hat
not
all n
STEM
I are
ent
ered
into
MIN
AP.
A nu
mbe
r of h
ospi
tals
repo
rt a
lack
of r
esou
rces
to
colle
ct d
ata
on n
STEM
I, an
d m
ore
gene
rally
tho
se p
atie
nts
not
adm
itte
d to
a c
ardi
ac
unit
are
less
like
ly t
o be
ent
ered
. Thu
s th
e pe
rcen
tage
s re
port
ed b
elow
do
not
take
into
acc
ount
eve
ry p
atie
nt a
dmit
ted
to h
ospi
tal w
ith
nSTE
MI.
MIN
AP P
ublic
Rep
ort L
ands
cape
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als
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.indd
66
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3
67MINAP
Sing
leto
n H
ospi
tal,
Swan
sea
5185%
4677%
4279%
5094%
Uni
vers
ity H
ospi
tal o
f Wal
es, C
ardi
ff0
00
0
Wes
t Wal
es G
ener
al, C
amar
then
2471%
2985%
3280%
3998%
With
ybus
h G
ener
al H
ospi
tal,
Hav
erfo
rdw
est
134
65%
6331%
133
68%
6433%
Ysby
ty G
wyn
edd
, Ban
gor
00
00
Bel
fast
ave
rage
282
82%
345
100%
305
81%
373
99%
Bel
fast
City
Hos
pita
l84
64%
131
99%
8062%
127
98%
Mat
er In
firm
orum
Hos
pita
l106
90%
118
100%
116
94%
123
100%
Roy
al V
icto
ria
Hos
pita
l92
96%
96100%
109
88%
123
99%
MIN
AP P
ublic
Rep
ort L
ands
cape
Visu
als
Blue
.indd
67
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8/20
11
14:1
3
68 MINAP How the NHS cares for patients with heart attack
12. Difference in performance in England and Wales
In the last three reports we have commented on differences in performance between Wales and England. These differences have been felt to reflect the largely rural nature of Wales, and the effect this has had on the configuration of cardiac services – with an emphasis on the delivery of pre-hospital thrombolytic treatment. The move from thrombolytic therapy to primary angioplasty has occurred more slowly in Wales than in most (but not all) of the English regions. So, it is still the case that in Wales the majority (70%) of patients receiving reperfusion therapy for STEMI receive thrombolytic therapy rather than primary angioplasty – 53% within 60 minutes of calling for help. In keeping with best practice, most (81%) of those who receive thrombolytic treatment for STEMI, or have no reperfusion treatment at all, subsequently undergo coronary angiography.
Two cardiac centres (in Swansea and Cardiff) are now able to offer primary angioplasty to their local populations, with continuous availability, and there has been a 29% increase in the number of patients so treated. 75% of these patients were treated within 150 minutes of calling for help. The Welsh cardiac networks are working closely with the Welsh Ambulance Service and local hospitals to develop management strategies that promote the use of primary angioplasty. This will include an increase the number of centres providing continuously available primary angioplasty and the number of patients transported directly to these centres. These strategies will be put in place over the next 12 months.
Importantly, a review of 30-day mortality rate after STEMI and nSTEMI for both England and Wales is presented in Fig 20 and Fig 21. It should be noted that these data are unadjusted for known predictors of outcome, such as age and co-morbidity and so formal statistical analysis has not been performed. Reassuringly the figures show falling mortality rates in both countries and the mean 30 day mortality for STEMI is now virtually identical for England and Wales.
It is of continuing concern that, as shown within the relevant tables, some of the Welsh hospitals are not submitting data on the management they provide to patients with nSTEMI (the most common type of acute coronary syndrome). This weakens the capacity of the National Audit to assure good quality care is being provided in these hospitals. Fig 21 shows 30 day mortality following nSTEMI, though obviously this only reflects those patients managed in hospitals that enter data. For that group mortality rates have continued to fall and are similar to results from England.
The use of secondary preventive medication remains good and equivalent to English hospitals.
Fig 19.
14
15
16
17
18
13
12
11
10
9
8
7
6
%
Financial year
2004-52003-4
Wales
2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
England
Fig 19.
15
5
%
Financial year
6
7
8
9
14
13
12
11
10
2004-52003-4
Wales
2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
England
Fig 20. 30 day mortality for STEMI (mean and 95% confidence intervals) for England and Wales.
All age groups, and all treatment modalities
Fig 21. 30 day mortality for nSTEMI (mean and 95% confidence intervals) for England and Wales.
The wider confidence limits for Wales reflect the smaller numbers recorded
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69MINAP Tenth Public Report 2011
Implementing a primary PCI service in Oxford
Oxford Heart Centre
Jan Keenan, Consultant Nurse Dr Robin Choudhury, Senior Research Fellow
The Oxford Heart Centre began developing a PPCI service in late 2006. Like other areas of the UK we began by introducing a daytime service, rolling out to develop a 24/7 service from the summer of 2007. With the opening of the new Heart Centre in October 2009 direct access to the angiography suite became possible, and further developments came in 2009/10 with the roll-out of a regional service to Buckinghamshire and parts of Northants and Wiltshire. Chart one shows the increase in activity over the three years to date, and it is interesting to reflect on the continuing achievements for people in our care.
To introduce a new service and roll this out to a 24/7 service places demands on the clinical teams to develop new ways of working across the patient pathway, and to give up conventional professional boundaries and to use and develop skills that best serve patient needs, at the point of presentation, often in an unfamiliar environment. We have seen our ambulance crews and CCU nursing team supporting patients and medical colleagues in the lab, focusing on more active management of the acute care team. Importantly we were able to use MINAP data to see developments over time as we focused our energies on improving team working and availability to see a significant reduction over time in door to balloon time (see chart two).
Alongside a rollout of PPCI across the region however, come longer transit times and to an extent this is understandable. However significant variation in call to door times for people arriving from the same areas, again seen within MINAP data, offers further opportunities for development in terms of transit time to hospital and, using the data, we are able to work closely with our ambulance service colleagues to expedite the patient pathway. Importantly however as also shown in chart two, we are also able to continue to progress important developments in the in-hospital pathway that allow us to continue to reduce the call to balloon time overall, particularly by making significant reductions in door to balloon time. In terms of national drivers in addition to this, we are able to examine trends in length of hospital stay (see chart three).
MINAP data is a significant tool supporting service development, identifying areas for current and future work. Achieving national standards offers no room for complacency in an era in which we know that the impact of early treatment means better survival, and whilst MINAP data demonstrates the achievement of national standards, for those interested in improving the lot of our patients it shows us where to focus our efforts.
Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital in E&W.
0
50
100
150
200
250
300
350
400
2008-9 2009-10 2010-11
0
20
40
60
80
100
120
2008-9 2009-10 2010-11
Call-to-door time
Door-to-balloon time
Call-to-balloon time
Mins
part three: case studies
How hospitals, ambulance services and cardiac networks have used MINAP data to improve patient care.
Chart one: Increase in total number of PPCI cases since 2008
Chart two: Increase in call-to-door time with increasing geo-graphical spread with concurrent decrease in door to balloon time with pathway development
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70 MINAP How the NHS cares for patients with heart attack
MINAP, promoting prevention.
The Heart Hospital, University College London Hospitals Foundation Trust
Dr Costas O’Mahoney, Cardiology
Dr Clare Dollery, Clinical Director.
The Heart Hospital (University College Hospitals NHS trust) is a heart attack centre with an established 24 hour primary PCI service. Monthly multidisciplinary MINAP meetings, with the participation of cardiologists, nurses, physiologists, London Ambulance Service representatives, Accident and Emergency department staff and other support personnel scrutinise challenging cases in a constructive and transparent manner. Feedback is given to the primary PCI team and other stakeholders to maintain and improve the quality of the service. Analysis of data provided by MINAP have led to a number of interventions over the years which helped reduce the time to reperfusion (MINAP public report 2009).
Even though shortening the time to reperfusion remains a central aim of our service, review of routinely collected MINAP data has also been used in the local implementation of NICE guidelines on secondary prevention interventions in post MI patients. We use our monthly MINAP meetings to review
referrals to cardiac rehabilitation services, and the use of anti-platelet agents, statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers in patients post primary PCI. The interventional cardiology integrated care pathway was modified to include a checklist of secondary prevention interventions for the physicians responsible for discharging the patients (see figure below). A weekly feedback project also included discussion of these metrics in a multidisciplinary coronary care unit hand over. We also continue this surveillance after discharge via a quality scorecard owned by our heart failure team.
MINAP has thus helped shape the long term as well as the short term management of patients undergoing primary PCI at our unit.
0
1
2
3
4
5
6
2008-9 2009-10 2010-11
Mean length of stay
Median length of stay
Chart three: Whilst median hospital stay has remained relatively constant, there is a downward trend in mean length of stay
% o
f pat
ient
s
Year
Cardiac Rehab ACEi beta-blocker
Statin Aspirin Clopidogrel
2003
60
80
100
40
20
02004 2005 2006 2007 2008 2009 2010
Patients discharged on secondary prevention medication
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71MINAP Tenth Public Report 2011
Establishing a primary angioplasty service in Lincolnshire
United Lincolnshire Hospitals NHS Trust
Dr David O’Brien, Interventional Cardiologist,
Alun Roebuck, Consultant Nurse Critical and Acute Care
A review by the East Midlands Strategic Health Authority considered the clinical case for change in primary reperfusion practice and established that a 24/7 primary angioplasty service must be provided within Lincolnshire; with the provision of a new heart attack centre based at Lincoln County Hospital. Without such service, Lincolnshire would remain the only region within England without a primary angioplasty service for its population. The decision and justifications to base such a service in Lincolnshire were largely based on assessment of the number of patients presenting with both
ST elevation and non-ST elevation myocardial infarction as recorded in MINAP.
The Lincolnshire Heart Attack Centre started a primary angioplasty service in December 2010. This new service is currently limited to a restricted geography on an 8 a.m. until 6 p.m. basis, five days a week. In order to realise our aspiration to provide the service 24/7 and county-wide, plans are currently underway to build a second cardiac catheter laboratory, a cardiac short stay unit and a larger recovery ward. These plans aim to deliver the service to all eligible patients within Lincolnshire in 2012.
This huge change in how cardiac care is delivered has only been achievable by team work between United Lincolnshire Hospitals NHS Trust, Lincolnshire Primary Care Trust, East Midlands Ambulance Service and the East Midlands Heart and Stoke Network. Initial feedback from patients and relatives needing to access this service has been overwhelmingly positive and we all look forward to rolling out the service fully next year.
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72 MINAP How the NHS cares for patients with heart attack
Improvement in call-balloon times at the London Chest Hospital, Barts and the London NHS Trust
London Chest Hospital, Barts and the London NHS Trust
Eileen Ferguson, Heart attack centre coordinator
Ajay Jain, HAC lead clinician
Andrew Wragg, Clinical Effectiveness Lead
Anthony Mathur, Cardiology lead clinician
Charles Knight, CAU director
Andrew Archbold, North East London Cardiac Network lead
London Ambulance Service NHS Trust
Mark Whitbread, Clinical Practice Manager/ Cardiac Lead
Joanne Smith, Clinical Advisor to the Medical Director
The London Chest Hospital is the heart attack centre for North East London cardiac network and serves a large population spread over a large geographical area and receives referrals from 6 district general hospitals. This referral base posed significant logistical problems to get patients with STEMI treated in a timely manner. The MINAP and BCIS audits demonstrated that we had to evolve our service to achieve the important call-to-balloon standard (CTB) and improve the outcome of our patients with STEMI.
In 2010/11 Barts and the London NHS Trust was successful in achieving the national standard for call-to-balloon times and this was based on using MINAP/ BCIS data to drive a quality improvement program.
We initially invested in improving the quality and reporting of our audit data. The trust and local cardiac network invested significant manpower resources. This included a Heart Attack Centre (HAC) coordinator to manage the whole HAC pathway, a dedicated HAC team and investment in data analysis. This resulted in high quality audit data that could be analysed in real time and support a process of formal weekly reporting. Once this audit process was established we could then focus on improving the clinical pathway.
The first challenge was to increase the direct transfer rate as patients who came via the network A&Es rarely achieved the call-to-balloon national standard. Armed with accurate audit data of performance, the HAC team set about working in collaboration with the London Ambulance Service (LAS) and A&E departments. This was based around sharing audit data, education using case by case feedback and formal study days. A weekly HAC meeting was established with LAS where audit data was studied in great detail.
Simultaneously we worked on our internal pathway to improve our door-to-balloon times. Producing weekly reports from MINAP helped focus organisational and individual attention on performance. These weekly reports demonstrated the immediate benefit from locally implemented changes and the team members were encouraged by seeing the real time audit result. Changes that had positive effects included a policy of going direct to lab 24 hours a day (instead of going to CCU out of hours), employing a dedicated nurse to meet all heart attack patients and setting an internal door-to-balloon national standard of 60 minutes (the national standard being 90 minutes). To focus the team on the clock- every individual breach was investigated.
These improvements led to a marked transformation in our call-to-balloon performance for 2010-2011. 80% of STEMI patients now receive reperfusion within 150 minutes from call for help, a great achievement in view of the geographical challenges of North East Thames. This improvement has been associated with a reduction of mortality of our heart attack patients according to data from Dr Foster Intelligence.
MINAP and BCIS proved great tools to drive these changes but it was recognition by our Trust and local Network that service improvements of this kind do require significant investment to be successful, coupled with a lot of hard work by the entire HAC team.
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73MINAP Tenth Public Report 2011
Using data from MINAP to model a PPCI service in the Cheshire and Merseyside network area
Cheshire and Merseyside Cardiac and Stroke Network
Ruth Grainger, Clinical Information Analyst
Cheshire and Merseyside is now one of the largest Cardiac and Stroke Networks in England and covers a geographical area with a population of approximately 2.3 million. MINAP has been used in our network area for many years to audit and improve reperfusion times and numbers of those receiving the appropriate medication.
We have recently improved our services for patients who have a heart attack known as a ST elevation Myocardial Infarction (STEMI) by introducing a primary percutaneous coronary intervention (PPCI ) service. PPCI is the preferred treatment if it can be provided promptly, providing faster perfusion and better outcomes for patients. Whilst thrombolysis treatment offers benefits to patients suffering from a STEMI, PPCI is a far more effective and safer option, with the added benefits of shorter recovery times and reduced morbidity.
In 2008, working with management consultants, Cap Gemini, we used MINAP data to demonstrate how a new PPCI service would look. One of the main aims when setting up the service was to quantify the impact on current services. It was necessary to know how many patients would be accessing this service and by what method. In order to do this an extract of data was downloaded from MINAP to establish firstly, how many STEMIs would be expected at the tertiary centre, Liverpool Heart and Chest Hospital (LHCH), secondly, were there any trends in day/time of presentation and thirdly, what impact would the new service have on the North West Ambulance Service (NWAS). The intended outcome was to understand the balance of risks and benefits of service change.
Comparing with previous years’ data it was concluded that the numbers, channels and locations of STEMI presentations would continue to be similar in future years and that there would be no expected differences in ambulance handover and turnaround times. All data sources and assumptions used in the model were agreed during a series of meetings between LHCH, NWAS and the network.
Using both MINAP data and modelled ambulance journey times it was possible to establish an average extra journey time for each patient. This was then used to gauge both worst case and best case scenarios, and combined with financial information provided by NWAS, to establish how many extra ambulance shifts NWAS would need, how much this would cost, and using postcode information where to locate the extra ambulances.
Funds were secured and it was agreed that PPCI should be rolled out in two phases. Phase one would cover the three hospitals nearest to LHCH (Aintree, Whiston and Royal Liverpool) and was implemented on 26th January 2009. Phase two was then rolled out to the rest of the Cheshire and Merseyside area (Southport, Warrington, Wirral and Countess of Chester) on 1st June 2010.
MINAP data is still used to audit and improve services for STEMI patients. Staff from local district general hospitals, NWAS, LHCH and the network meet regularly as part of the PPCI monitoring group to discuss any local issues and suggest areas for improvement.
Since the full roll-out we have seen patient outcomes improve greatly, national standards are consistently being met and the service is running smoothly. After 1st June 2011 we will have one full year’s worth of complete Cheshire and Merseyside PPCI data and are looking forward to validating the model used to implement our PPCI service.
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Use of MINAP data to analyse and improve the PPCI service
Papworth Hospital NHS Foundation Trust
Dr Sarah Clarke, Clinical Director for Cardiac Services
Hayley Dimmock, Cardiac Information Analyst
Papworth Hospital NHS Foundation Trust opened a Primary Percutaneous Coronary Intervention (PPCI) service in September 2008. Since then there have been over 1500 activations of the service and for the year 2010-11 Papworth averaged 60 PPCI patient activations per month. MINAP is used within Papworth hospital to accurately record data on each patient who arrives at the heart attack centre following a PPCI activation. We believe data accuracy is extremely important and ensure that each individual PPCI patient’s MINAP entry is validated and checked alongside their hospital notes post discharge to ensure excellent data completeness. MINAP is used as an analysis tool as much as for data collection in order to produce figures for activity, outcomes and especially to monitor Papworth hospital’s performance in achieving national standards.
In 2010-11 there were 702 activations of the PPCI service with two thirds of patients continuing to have an intervention and the remaining third either not going into the lab or not proceeding to PCI post angiogram for various reasons. The national standard of door to balloon time (90 minutes) was achieved in 98% of all cases with an average time of 37 minutes.
The use of MINAP was instrumental in improving communication with our colleagues from the East of England Ambulance Service NHS Trust (EEAST) and has been particularly helpful in increasing the accuracy of timings. This has helped facilitate information flow concerning the patients’ journey including any delays or complications encountered which could affect their overall outcome. Papworth hospital use the data collected in MINAP to look in detail at every patient who breaches either the national or local standards. These reports are discussed in multi-disciplinary team meetings on a bi-weekly basis and the information used to highlight ways of improving patient flow and patient’s clinical care.
74 MINAP How the NHS cares for patients with heart attack
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75MINAP Tenth Public Report 2011
1. MINAP Academic Group – five year overview
Professor Adam Timmis, Chairman, MINAP Academic Group
1.1 Background
We recognise the value of the MINAP data certainly in improving patient care but also in its secondary use for research. The MINAP Academic Group (MAG) was established in 2005 to maximise the research potential of MINAP database and to establish processes for the safe distribution and return of sub-sets of MINAP data to research groups. The MAG is responsible for ensuring that data are only accessed by researchers with bona fide projects of high scientific probity who respect the conditions of confidentiality and security. The MAG was delegated the responsibility for releasing MINAP data by the Health Quality Improvement Partnership (HQIP) through which MINAP is funded.
All datasets issued to research groups are sourced from the dataset that is collected from CCAD annually and cleaned in a way that it is not significantly changed by this process. Although NICOR (UCL) was granted Section 251 exemption of the NHS Act 2006 for all the cardiac audits, including MINAP to hold patient identifiable data without consent, this approval is not extended to release of patient identifiable data. We are however in a position to release data for research in anonymised, or pseudo-anonymised for and the linkage with other dataset(s) can be performed by the trusted 3rd party.
1.2 Current position
The last year has seen major developments driven by the MINAP Academic Group. We now have a truly nationwide programme incorporating many of the top cardiological and epidemiological research groups in the UK. In the last 12 months alone approvals have been given for data-sharing with researchers in London, Birmingham, Belfast, Leeds, Leicester, Surrey and Edinburgh Previous applications have already led to seven publications in major cardiovascular and general journals in 2010, more than ever before, with a further four publications by May 2011.
Particularly significant has been the establishment of international collaborations with the SWEDEHEART investigators in Upsalla (Sweden) to complement the international collaborative analysis of pre-hospital thrombolysis previously undertaken in Europe and North America.
The development that will underpin research activity through the next decade and beyond has been the successful bid by the NICOR executive to become responsible for the management of MINAP and five other national cardiovascular registries. Leaders within MINAP and MAG played a key role in securing the bid which will now allow direct involvement of the management and linkage of this unique data resource. Only in the UK are national registry data on this scale available providing opportunities for cardiovascular researchers that cannot be found elsewhere.
1.3 How to apply
For more information on how to make an application for MINAP data please email Lucia Gavalova, MINAP Project Co-ordinator at [email protected].
2. Use of MINAP data to evaluate the impact of acute coronary syndrome care by patient age: resolving inequities in care?
Dr Chris Gale, University of Leeds
Dr Robert West, University of Leeds
Professor Keith Fox, University of Edinburgh
Evidence suggests that primary percutaneous coronary intervention (pPCI) results in better outcomes than thrombolysis for the treatment of STEMI provided it is delivered promptly. Due to initial perceived risk of complications in pPCI in very elderly (80 years of age or older), pPCI was not considered to be a preferred treatment option in this age group. Recently Shelton28 and colleagues compared outcomes in patients aged ≥80 years presenting with STEMI who were treated pPCI with patients who received thrombolytic treatment. Their work suggested that primary PCI can be effectively delivered to very elderly patients resulting in a substantial reduction in mortality compared to patients treated by thrombolytic treatment. So is there inequality in care in patients presenting with ACS in England and Wales?
Current data suggest that elderly patients who are hospitalised with an ACS are less likely to receive the preferred treatment (PCI) and that they have higher mortality rates than their younger counterparts. We studied 616,011 ACS events at 255 hospitals in England and Wales recorded in MINAP between 2003 and 2010 to establish whether age-dependent inequalities in care existed and to measure effects on in-hospital mortality over time for ACS in different age groups.
This revealed that almost 40% admissions with ACS in England and Wales were elderly (≥75 years). They were less likely to receive specialist care and evidence-based treatments including pPCI for STEMI. As a result, the elderly were found to have significantly longer hospital lengths of stay and higher in-hospital mortality rates.
Although progressive improvements in risk of in-hospital mortality were noted, for example, STEMI ≥85 years, in-hospital mortality reduced from 30.1% in 2003 to 19.4% in 2010 and for nSTEMI ≥85 years from 31.5% in 2003 to 20.4% in 2010, overall rates of emergency reperfusion (primary PCI and thrombolysis) for STEMI in those <55 years of age were nearly a third higher than for those aged ≥85 years.
28. Shelton RJ, Crean AM, Somers K, et al. Real-world outcome from ST eleva-tion myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service. Am Heart J. 2010 Jun; 159(6):956-63.
part four: research use of minap data
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Data also suggest that use of secondary prevention medication such as aspirin, clopidogrel, beta-blockers, ACE inhibitors, and statins are effective in secondary prevention of coronary heart disease in patients aged 65 years and over. This benefit is similar to, and often greater than that observed in younger patients. We have shown that older patients with heart attack were less likely to be discharged on aspirin, clopidogrel, beta-blockers, ACE inhibitors, and statins.
These findings support a notion of age-dependent inequality in ACS care – biases in elderly ACS care remain and the elderly do have significantly longer hospital lengths of stay and high in-hospital mortality. It therefore highlights gaps in key aspects of the management of elderly patients with ACS who benefit equally as much as their young counterparts from an early invasive strategy.
The causes for discrepancies in quality of care for elderly are multifactorial. In part, the shortfall in treatment may be due to lack of appropriate specialist care and inappropriate placement within the hospital. The elderly are more likely to present differently and less likely to have the same diagnosis on discharge from hospital as that which they were given on admission. It is also not very unlikely that that age dependent inequalities in treatments may be the legacy of a risk-adverse strategy to ACS care through lack of accurate estimate of ACS risk.
Despite this, we can report an improvements in the application of evidence-based ACS care across all age groups from 2003 to 2010, and year-on-year reductions in in-hospital mortality equally across all age groups, both sexes as well as for STEMI and nSTEMI.
3. Enriching MINAP through linkage to primary care and investigator led cohorts
Professor Harry Hemingway University College London
Internationally and nationally MINAP is a special resource. England and Wales along with Sweden are among the few countries which have a national registry of acute coronary syndromes in which all hospitals participate. Registries in the US do not have this coverage. Like SwedeHeart, MINAP has developed Information and Research Governance structures to facilitate access to and use of MINAP data for research purposes. Over the last years this has led to some success with 23 projects.
Further enhancement of the MINAP resource is made possible thought linkage to other forms of electronic health record data. One example of this has been the linkage of the general
practice research database (GPRD) with MINAP, carried out for the first time in 2010. Primary care data in the UK are in their own right a special research resource; offering a longitudinal record of diagnoses, symptoms, tests, drugs and procedures. Because nearly every adult in the UK is registered with a GP there is an opportunity for population based studies.
Linking MINAP to primary care electronic health records allows two different types of question to be addressed. First, what is the quality of care across the ‘patient journey’. In other words examining care before, during and after a MINAP event can lead to a better understanding of what needs to change.
Second, what is the aetiology and prognosis of specific forms of coronary syndrome? Most epidemiological enquiry to date has investigated broad aggregates of coronary heart disease or heart attack and there are few prospective studies which examine whether risk factors for STEMI and nSTEMI are qualitatively or quantitatively different. Because MINAP distinguishes these ‘endpoints’, there are new possibilities for analysis.
Examination of genetic, biomarker and other research based measures in relation to MINAP ‘phenotypes’ is made possible by linkages with investigator led (i.e. bespoke data collection) cohort studies (e.g. 200,000 women in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) 2011. Discussion is underway for a linkage of MINAP with UK Biobank, with over 500,000 consented participants one of the largest, best characterised cohorts in the world.
CALIBER (Cardiovascular disease research using Linked Bespoke studies and Electronic Records) is a collaborative programme of such research using linked MINAP data funded by the Wellcome Trust (under the electronic health records initiative) and an NIHR programme grant. Further details can be obtained from [email protected].
4. Management of hyperglycaemia in acute coronary syndromes
Dr Clive Weston, University of Swansea
In addition to its primary purpose, as an audit of actual care received against ideal care, the MINAP database lends itself to a variety of subsidiary uses of potential clinical value in the form of observational studies. One such area of work has been the confirmation of an association between blood glucose in ACS and outcome. Those patients who on arrival at hospital have high blood glucose concentrations – hyperglycaemia – have a greater risk of dying than those with normal concentrations (Figure 22).
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From the Figure 22 it can be seen that the association between blood glucose and mortality occurs both in diabetic patients and those without a prior diagnosis of diabetes. In fact the increase in risk is greater in the latter group. So, while at normal levels of admission glucose diabetic patients have a higher death rate than non-diabetics, this difference is reversed in the presence of hyperglycaemia (from approximately 11 mmol/L and greater).
The possible reasons for the association: the link to previously undiagnosed diabetes, to ‘stress hyperglycaemia associated with larger heart attacks, and to potential direct adverse effects of glucose during ACS, has been detailed elsewhere29.
Further observations from the database show that the use of insulin infusions to treat hyperglycaemia in non-diabetic patients with ACS is associated with a reduction in risk of death by about a third30. Despite this, the use of insulin in this high risk group is the exception rather than the rule and lags behind the use of insulin in the (relatively) lower-risk diabetic group. In 2008/9, for those arriving at hospital with blood glucose >10.0 mmol/L, infused (intravenous) insulin was given to, 14.6% of non-diabetics, 39.8% of diabetics who normally took tablet treatment and 47.4% of diabetic patients who normally took subcutaneous insulin.
So observational data analysis suggests that: high levels of blood glucose are a marker of increased risk, treatment that reduces blood glucose is associated with a reduction of risk, but only a minority of patients who are eligible for treatment actually receive it. Is this a cause for concern?
Here, such observational analysis reaches its limit, but can at least expose a gap in knowledge. Some clinicians will interpret the available data to support the use of insulin in all patients with ACS presenting with hyperglycaemia. Others will look on the evidence as circumstantial and will be unpersuaded. What is required is a large randomised trial of insulin treatment given in the early stage of ACS (particularly in the non-diabetic group) to rapidly and reliably normalise blood glucose. Only then will it become clear whether untreated patients presenting with ACS and hyperglycaemia presently are being denied an effective life-saving treatment.
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Figure 23 Survival to 180 days after admission to hospital with STEMI, in patients not known to be diabetic with an admission blood glucose >11.0 mmol/L, with respect to normal treatment or an insulin infusion
29. Anantharaman R, Heatley M, Weston CFM. Hyperglycaemia in acute coronary syndromes: risk marker or therapeutic target? Heart 2009;95:697-703.
30. Weston CFM, Walker L, Birkhead JS. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007;93:1542-6.
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Figure 22 Death rates at 30 days after admission to hospital with ACS for those with and those without prior diagnosis of diabetes, with respect to admission blood glucose (mmol/L) – patients with blood glucose <6mmol/L excluded for clarity.
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Appendix 1: MINAP Steering Group
Chairman Dr Clive Weston Clinical Director MINAP
Dr John Birkhead Previous Clinical Director MINAP
Department of Health Professor Sir Roger Boyle CBE National Director for Heart Disease and Stroke (to Aug 2011)
Ms Sue Dodd Emergency and Acute Care Manager, Vascular Programme (to July 2011)
NICOR Dr David Cunningham Senior Strategist for National Cardiac Audits
Royal College of Dr Jonathan Potter Physicians Director, Clinical Effectiveness and Evaluation Unit (to May 2011)
British Heart Foundation Professor Peter Weissberg Medical Director
Ambulance Services Dr Steven Rawstone Medical Director, Great Western Ambulance Service
Welsh Assembly Dr Phillip Thomas Government Lead Cardiac Clinician
British Cardiovascular Professor Keith Fox Society President
Royal College of Nursing Professor Tom Quinn University of Surrey
MINAP Patient/Carer Group Mr Iain Thomas South West London Cardiac and Stroke Network Patient Carer Group
MINAP Patient/Carer Group Mr David Geldard MBE Past President, Heart Care Partnership (UK)
MINAP Hospital User Ms Fiona Dudley Lead Nurse for Cardiology, Mid Yorkshire Hospitals NHS Trust
MINAP Academic Group Professor Adam Timmis Chairman
NHS Improvement Dr Mark Dancy National Clinical Chair
British Cardiovascular Dr Mark de Belder Intervention Society President
Cardiac Networks Mr Mark Walsh Network Director, Black Country Cardiovascular Network
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Appendix 2: Glossary
ACE inhibitors A class of drug with powerful dilating effects on arteries. Used – in the context of heart attack - for the treatment and prevention of heart failure. Also used widely for treatment of high blood pressure. Angiotensin receptor blockers (ARBs) have broadly similar effects.
Acute coronary syndrome This term covers all cardiac episodes that result from sudden and spontaneous blockage or near blockage of a coronary artery; often resulting in some degree of heart muscle damage. The usual underlying cause is rupture of the fine lining of a heart artery, which allows blood to come in contact with the tissues of the wall of the artery, promoting the development of a blood clot (thrombus). The degree of damage, and the type of syndrome (heart attack), that results from the blockage depends on the size of the artery, where in the course of the artery the blockage occurs, the amount of clot that develops and how long it persists within the artery. Not all acute coronary syndromes are suitable for treatment with primary angioplasty or thrombolytic drugs, and the decision is mainly guided by the appearances of the ECG when such treatments are being considered.
Angina Symptoms of chest discomfort that occur when narrowing of the coronary arteries prevent enough oxygen-containing blood reaching the heart muscle when its demands are high, such as during exercise.
Angiogram An X-ray investigation, performed under a local anaesthetic, which produces images of the flow of blood within an artery (in this case the coronary artery). Narrowings and complete blockages within the arteries can be identified during the angiogram and this allows decisions to be made regarding treatment. Often an angiogram is an immediate precursor to an angioplasty and stent implantation or to later coronary artery bypass grafting.
Anti-platelet drugs Drugs, including aspirin, clopidogrel, prasugrel and ticagrelor, which prevent blood clotting. These drugs act by reducing the ‘stickiness’ of the small blood cells (platelets) that can clump together to form a clot.
Aspirin An anti-platelet drug used to help prevent blood clots forming.
Beta-blockers Beta-blockers are drugs that block the actions of the hormone adrenaline (that makes the heart beat faster and more vigorously). They are used to help prevent attacks of angina, to lower blood pressure, to help control abnormal heart rhythms
and to reduce the risk of further heart attack in people who have already had one. They may also be used in small doses in heart failure.
Call-to-balloon (CTB) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the performance of primary angioplasty.
Call-to-needle (CTN) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the administration of thrombolytic therapy.
Cholesterol A fatty substance that plays a vital role in the functioning of every cell wall throughout the body and in the production of various hormones. However, too much cholesterol in the blood increases the risk of coronary heart disease and heart attacks.
Clopidogrel An anti-platelet drug that has been shown to produce added benefit when given with aspirin during an acute coronary syndrome.
Clot-dissolving drugs Drugs used to dissolve the clot (or thrombus) within a heart artery which is the underlying cause of heart attack, see ‘thrombolytic treatment’.
Contraindication The presence of a reason why a treatment is unsuitable in a particular patient.
Door-to-balloon (DTB) time The interval between the ambulance arriving at a hospital and the performance of primary angioplasty.
Door-to-needle (DTN) time The interval between the ambulance arriving at a hospital and the administration of thrombolytic therapy.
Electrocardiogram Also known as ‘ECG’. A test to record the rhythm and electrical activity of the heart. The ECG can often show if a person has had a heart attack, either recently or some time ago. It can also tell if reperfusion therapy is appropriate and if it has been effective.
Heart attack The term applied to the symptoms, usually, but not always, including chest pain, which develop when a clot (thrombus) develops within a heart artery as a result of spontaneous damage to the inner lining of the artery (plaque rupture). The heart muscle supplied by the blocked artery suffers permanent damage if the blood supply is not restored quickly. The damage to heart muscle carries a risk of sudden death, and heart failure in people who survive.
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Heart failure Heart failure occurs when a damaged heart becomes less efficient at pumping blood round the body. This may result from damage to the heart muscle caused by a heart attack – either at the time of the attack or many months or even years afterwards. There are typically symptoms of breathlessness during exertion and, later, swelling (oedema) of ankles.
Hyperglycaemia A high concentration of glucose (sugar) in the blood
Meta-analysis A statistical technique for combining the findings from independent studies.
Median The number falling in the middle of a ranked series of numbers.
IQR Interquartile range; the value at 25% and 75% of an ordered set of values.
Myocardial infarction A heart attack in which heart muscle damage is confirmed by blood testing.
Non ST elevation myocardial infarction (nSTEMI) A heart attack that occurs in the absence of ST segment elevation on the ECG. In these patients urgent admission to hospital is mandated but immediate reperfusion therapy is not required.
PCI Percutaneous coronary intervention (see Primary angioplasty)
Pre-hospital thrombolysis Thrombolytic treatment given before arrival in hospital, usually in the ambulance by paramedics. This saves time in providing treatment and is used where journey times to hospital are prolonged.
Primary angioplasty A technique to re-open the blocked coronary artery responsible for the heart attack. A fine catheter (tube) is passed, under local anaesthetic, from an artery in the leg or arm into the blocked heart artery. A small inflatable balloon is then passed through the catheter and across the blockage, allowing the artery to be re-opened by temporary inflation of the balloon. This technique is called angioplasty and when used as the initial treatment for heart attack it is referred to as ‘primary angioplasty’. Following opening of the artery, this is normally kept open by a small expandable metal tube (stent) which is passed into the artery with the angioplasty balloon. The umbrella term that encompasses both balloon dilatation (angioplasty) and stent insertion (stenting) is ‘percutaneous coronary intervention’ (PCI) and primary PCI is increasingly used to describe what in this report we refer to simply as primary angioplasty.
Primary PCI Primary percutaneous coronary intervention – see Primary angioplasty
Re-infarction The development of evidence of re-occlusion (further blockage) of, or development of blood clot within, the coronary artery that was responsible for the original heart attack. This would normally occur after the original blockage had been successfully treated.
Reperfusion treatment The term used to cover both techniques, thrombolytic treatment and primary angioplasty, for urgently reopening a coronary artery. These treatments are suitable only for certain types of heart attack characterised by typical electrocardiographic appearances described as ST segment elevation.
Secondary prevention treatment Medication that reduces the risk of further heart attack, or the risk of complications such as heart failure. See aspirin, beta blockers, ACE inhibitors and ARBs, clopidogrel and statins. These medications are usually initially prescribed to all patients who can tolerate them.
Statins Drugs used to reduce cholesterol levels in the blood. These have been shown to reduce the risk of further heart attacks when taken regularly after a first heart attack
ST elevation myocardial infarction A heart attack characterized by a specific abnormal appearance on the ECG (ST segment elevation) thought to be indicative of complete occlusion of a coronary artery. Reperfusion therapy with thrombolysis or angioplasty has been shown to do more good than harm in these cases.
Thienopyridine inhibitors Antiplatelet agents, of which clopidogrel and prasugrel are presently licensed for use.
Thrombolytic treatment The outcome for certain types of heart attack can be improved by using clot-dissolving (thrombolytic) drugs. Thrombolytic treatment is effective up to about 12 hours after the onset of symptoms but is most effective when given very early after the symptoms started. Thrombolytic drugs are not given unless there are typical changes on the electrocardiogram (ECG). Patients at significant risk of bleeding may not be given this treatment where the risk of bleeding is greater than any potential benefit. Where this risk exists primary angioplasty may be an effective alternative.
Thrombus A blood clot, the development of which is known a thrombosis.
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Appendix 3: MINAP publications
1999
Rickards A, Cunningham D. From quantity to quality: the central cardiac audit database project. Heart 1999;82: 1118-1122.
Birkhead JS, Norris RM, Quinn T et al. Acute myocardial infarction: a core dataset. Royal College of Physicians 1999.
2000
Birkhead JS. Responding to the requirements of the National Service Framework for coronary heart disease: a core dataset for myocardial infarction. Heart 2000; 84: 116-7.
2001
Birkhead JS, Pearson M, Norris RM et al. Measurement of Clinical Performance: Practical approaches in acute myocardial infarction. Eds Robert West and Robin Norris. Royal College of Physicians 2001.
Birkhead JS, Georgiou A, Knight L et al. (eds) A baseline survey of facilities for the management of acute myocardial infarction in England 2000. London: Royal College of Physicians 2001.
2002
Birkhead JS. The National Audit of Myocardial Infarction: A new development in the audit process. Journal of Clinical Excellence 2002; 4: 379-85.
2004
Norris RM, Lowe D, Birkhead JS. Can successful treatment of cardiac arrest be a performance indicator for hospitals? Resuscitation. 2004; 60: 263-269.
Birkhead J, Walker L. MINAP, a project in evolution. Hospital medicine 2004; 452-53.
Birkhead J, Walker L, Pearson M, at al. Improving care for patients with acute coronary syndromes; initial results from the National Audit of Myocardial Infarction (MINAP). Heart 2004; 90: 1004-9.
2005
Quinn T, Weston C, Birkhead J, et al on behalf of Steering Group. Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003- 2005. Quarterly Journal of Medicine 2005; 98 (11): 797-802.
2006
Birkhead, J, Weston, C, Lowe, D on behalf of the National Audit of Myocardial Infarction project (MINAP) Steering Group. Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study. BMJ 2006; 332:1306-1311.
Gale CP, Roberts AP, Batin PD, Hall AS. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34.
2007
Weston C, Walker L, and Birkhead J. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007; 93: 542-1546.
Birkhead J, Pearson J, Walker L on behalf of the MINAP Steering Group. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians, London 2007. ISBN 978-1-86016-314-2.
2008
Weston C. Performance indicators in acute myocardial infarction: a proposal for future assessment of good quality care. Heart 2008; 94:139-1401.
Gale CP, Manda SO, Batin PD, et al. Predictors of in-hospital mortality for patients admitted with ST-elevation myocardial infarction: a real-world study using the Myocardial Infarction National Audit Project (MINAP) database. 2008 Nov;94(11):1407-12.
Ben-Shlomo Y, Naqvi H, Baker I. Ethnic differences in healthcare-seeking behaviour and management for acute chest pain: secondary analysis of the MINAP dataset 2002–2003. Heart 2008; 94: 354 - 359.
Gale CP, Manda SO, Weston CF, et al. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database. 2009 Mar;95(3):221-7.
2009
Bhaskaran K, Hajat S, Haines A, et al. Effects of air pollution on the incidence of myocardial infarction. Heart, 2009; 95, 1746-59.
Horne S, Weston C, Quinn T, et al. The impact of pre-hospital thrombolytic treatment on re-infarction rates: analysis of the Myocardial Infarction National Audit Project (MINAP). Heart 2009; 95: 559-563.
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2009 cont.
Birkhead J, Weston C, Chen R. Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Heart 2009; 95:1593-9.
2010
Herrett E, Smeeth L, Walker L, Weston C; on behalf of the MINAP Academic Group. The Myocardial Ischaemia National Audit Project (MINAP). Heart 2010;96:1264-1267.
Bhaskaran K, Hajat S, Haines AP, et al. The short term effects of temperature on the risk of myocardial infarction in England and Wales – a multicity daily time series study using the Myocardial Ischaemia National Audit Project (MINAP) database. BMJ 2010;341: c3823.
Bhaskaran K, Hajat S, Haines AP, et al. Effects of ambient temperature on the incidence of myocardial infarction. Heart 2009, 95, 1760-9.
Gale CP, Roberts AP, Batin PD, et al. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34.
West RM, Cattle BA, Bouyssie M, et al. Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales. Eur Heart J. 2010.
McNamara RL. Cardiovascular registry research comes of age. Heart 2010; 96:908-10.
Brophy S, Cooksey R, Gravenor MB, et al. Population based absolute and relative survival to 1 year of people with diabetes following a myocardial infarction: a cohort study using hospital admissions data. BMC Public Health 2010;10:338.
Widimsky P, Wijns W, Fajadet J, et al. European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J 2010; 31:943-57.
2011
Gale CP, Cattle BA, Moore J, et al. Impact of missing data on standardised mortality ratios for acute myocardial infarction: evidence from the Myocardial Ischaemia National Audit Project (MINAP) 2004-7. Heart 2011.
Gale C, West RM, Cattle BA et al. Impact of hospital proportion and volume on primary PCI performance in England and Wales European Heart Journal (in press)
Huynh T, Birkhead J, Huber K, et al. Pre-hospital Fibrinolysis in Europe and North America. JACC: Cardiovascular Interventions (in press).
Cattle BA, Greenwood DC, Gale CP, et al. Multiple Imputation of a Large Clinical Audit Dataset. Statistics in Medicine (in press).
Appendix 4: Contacts for information on heart conditions
American Heart Association http://www.americanheart.org/hearthub/index.htm
Blood Pressure Association http://www.bpassoc.org.uk/Home
British Cardiac Patients Association http://www.bcpa.co.uk/
British Cardiovascular Society http://www.bcs.com/pages/default.asp
British Heart Foundation http://www.bhf.org.uk/
NB: The British Heart Foundation runs a heart information line that
provides information about heart conditions and their management.
It cannot respond to questions about services in individual hospitals.
Tel: 08450 70 80 70
Diabetes UK http://www.diabetes.org.uk/
Department of Health website http://www.dh.gov.uk/en/Home
HEART UK http://www.heartuk.org.uk/
NHS Evidence – cardiovascular http://www.library.nhs.uk/cardiovascular/
NHS Choices http://www.nhs.uk/Pages/HomePage.aspx
NHS Direct Tel: 0845 4647
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heart attacks recorded in minap in 2010/11This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11.
Report prepared by: Lucia Gavalova, Project co-ordinator MINAP
With assistance from:Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinatorLynne Walker, MINAP Programme managerProfessor Tom Quinn, MINAP Steering Group memberProfessor Adam Timmis, Chairman MINAP Academic GroupMrs Sirkka Thomas, MINAP Patient/carer representativeMr David Geldard, MINAP Patient representative
Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap
For further information about this report, contact:
Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes ResearchInstitute of Cardiovascular ScienceUniversity College London175 Tottenham Court RoadLondon W1T 7NU
Tel: 0203 108 3931 Email: [email protected]
University College London (media enquiries)Media Relations Manager Ruth Howells Tel: 020 3108 3845Email: [email protected]
Acknowledgements
Department of Health Enquiries to the Department should be directed to the Customer Service CentreTel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform
In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS
Welsh Assembly Government Ms Cathy WhiteHead of Adult & Children’s HealthMedical DirectorateDepartment for Health, Social Services & ChildrenWelsh GovernmentCathays Park,Cardiff CF10 3NQ
Tel: 029 20826108Email: [email protected]
Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/HomePage.aspx
The MINAP team would like to thank all the hospitals and ambulance services that have collected data.
This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.
The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.
MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk.
This report may not be published or used commercially without permission.
Designed and published by:
| www.padcreative.co.uk
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MIN
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Myocardial IschaemiaNational Audit Project
Myocardial IschaemiaNational Audit Project
myocardial ischaemia national audit project [minap]
How the NHS cares for patients with heart attack
Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group
NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH
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