best practice in mi care 2009 -...

Best practice in MI care 2009Radisson Edwardian HotelManchester

Chairmen: Professor Martin Cowie and Dr Simon Williams

Delegate Booklet21 October 2009

One-day meeting for health care professionals

Supported by Pfizer Ltd

Accredited by Royal College of Physicians (5 hours) and Royal College of Nursing (6 hours)

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SURVIVAL AFTER MYOCARDIALinfarction (MI) has improved markedly inrecent years, largely due to faster reperfu-sion treatment and better prescribing of evi-dence-based secondary prevention treat-ment.

However, many challenges remainregarding the optimum care of all patientswith MI. The purpose of today's conferenceis to provide an update on the achievementsto date and to highlight where serviceimprovement is still needed and how thismight be achieved.

We have a distinguished panel of speak-ers whose presentations will cover treat-ment of acute MI pre-hospital and in-hospi-tal and the appropriate continuing care afterdischarge.

In terms of emergency treatment of MI,the conference is timely given theDepartment of Health's recent recommen-dation of primary PCI as the main treatmentfor ST-elevation MI in England, with pre-

hospital thrombolysis encouraged whereprimary PCI is not possible.1 We will hearabout the opportunities and logistic chal-lenges of primary PCI services and UKguidelines on MI care.

Another key issue to be discussed isheart failure, which often develops in thecontext of MI. Left ventricular dysfunctionmust be identified promptly so that earlytreatment can be initiated, as this has beenshown to influence outcome. Specialistnurses have an important role in helping toscreen MI patients for heart failure, particu-larly when patients are not being treated ona cardiology ward.

We will also hear how the recentchanges in acute MI care – as well as pres-sures to limit length of hospital stay –impact on work in district general hospitalsand what systems can be put in place tooptimise patient care in response to thesechanges.

Cardiac rehabilitation is a key compo-

nent of best practice after MI and a furtherpresentation will discuss how uptake mightbe improved.

One major point that is likely to beemphasised by today's speakers is theimportance of collaborative multidiscipli-nary working between primary and second-ary care as a key component of best practicein MI care.

The conference is accredited forContinuing Professional Development bythe Royal College of Physicians and theRoyal College of Nursing. It is intended tobe an interactive meeting and there will beplenty opportunity for questions. Please donot hold back from contributing to the dis-cussion sessions.

Reference

1. Treatment of heart attack national guid-ance: final report of the National InfarctAngioplasty Project (NIAP). Departmentof Health, 2008.

Chairmen’s introduction

Professor Martin R. CowieProfessor of Cardiology, Imperial College London and Honorary Consultant Cardiologist, Royal Brompton Hospital,London

Dr Simon WilliamsConsultant Cardiologist, Wythenshawe Hospital, SouthManchester and Honorary Senior Lecturer, University ofManchester

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2 | Best practice in MI care 2009

FacultyDr Huon GrayDeputy National Director for Heart Disease andStroke, Department of Health (England), andConsultant Cardiologist, Southampton UniversityHospital

E-mail: [email protected]

Dr Clive WestonReader in Clinical Medicine, Swansea University, and Honorary Consultant Cardiologist, ABM University Trust


Dr Simon WilliamsConsultant Cardiologist, Wythenshawe Hospital, South Manchester and Honorary Senior Lecturer,University of Manchester


Dr Richard LevyConsultant Cardiologist, University Hospital SouthManchester NHS Foundation Trust


Professor Martin R. CowieProfessor of Cardiology, Imperial College London and Honorary ConsultantCardiologist, Royal Brompton Hospital, London


Dr Nigel RowellGeneral Practitioner, Middlesbrough


Professor Patrick DohertyProfessor of Rehabilitation, York St John University


Michael CullenSpecialist Nurse in Cardiology, University HospitalSouth Manchester NHS Foundation Trust


Dr Tim GrayConsultant Cardiologist, Pennine Acute Hospitals NHS Trust


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Programme9.30 Welcome and introduction

Professor Martin R. Cowie and Dr Simon Williams

The big picture9.45 MI care: National progress and challenges Page 4

Dr Huon Gray

10.15 MINAP: Painting the picture Dr Clive Weston

10.45 Post-MI secondary prevention: NICE guidance Page 6Dr Simon Williams

11.15 Panel Discussion

11.30 Coffee

Key areas12.00 Access to revascularisation Page 7

Dr Richard Levy

12.20 Heart failure detection and treatment in acute MI Page 8Professor Martin R. Cowie

12.40 Hand-over to primary care: Don’t drop the ball Page 9Dr Nigel Rowell

1.00 Panel discussion

1.30 Lunch

Time for action2.30 Cardiac rehabilitation: new opportunities and new challenges Page 10

Professor Patrick Doherty

2.50 Joining up care: Evolving role of the nurse in MI care Page 11Michael Cullen

3.10 How to make it happen in real life Page 12Dr Tim Gray

3.30 Panel discussion

4.15 Summary and close


THE MANAGEMENT OF patients withmyocardial infarction, both ST elevation(STEMI) and non-ST elevation (NSTEMI),has been transformed over the last 25 years,from conditions often associated with an in-hospital mortality of over 20% in the early1980s to a current day average mortalityapproaching 5%. These acute coronary syn-dromes are all part of a single spectrum andthe factors associated with the dramaticimprovement in outcome owe much to thesuccess of intervening at different patho-physiological points in their development.These interventions include the use of phar-macotherapy (such as antithrombins andantiplatelet agents), the uptake of earliercoronary angiography and appropriate coro-nary revascularisation, greatly increaseduse of secondary prevention intervention,and thrombolytic agents and primary PCIfor the management of patients withSTEMI.

The mortality from cardiovascular dis-eases has been falling for many years butthere is a risk of complacency unless weremind ourselves that cardiovascular dis-eases are still the number one cause of deathworldwide and carry with them an associat-ed high morbidity. With the alarming rate ofincrease in obesity and diabetes there is arisk of these positive trends being reversed.

This talk will present an overview ofthese developments, the importance of datacollection and analysis, some of theDepartment of Health policy initiatives thathave encouraged change,1-4 and a brief sum-mary of the challenges still to be overcome.

References

1. National Service Framework for CoronaryHeart Disease. Department of Health,2000.http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservice

circulars/DH_40048132. The Coronary Heart Disease National

Service Framework: Building on excel-lence, maintaining progress. ProgressReport for 2008. Department of Health,2009.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_096555

3. Treatment of heart attack national guid-ance: final report of the National InfarctAngioplasty Project (NIAP). Departmentof Health, 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_089455

4. High quality care for all: NHS Next StageReview final report. Department ofHealth; 2008.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825

MI care: National progress and challenges

Dr Huon Gray

DR HUON GRAY trained in cardiology at theBrompton and St George’s Hospitals, London,and was appointed Consultant Cardiologist atSouthampton University Hospital in 1989. He hasbeen Honorary Secretary of the BritishCardiovascular Intervention Society, President ofthe British Cardiovascular Society, and co-chaired the UK National Infarct AngioplastyProject (NIAP).

Dr Gray is currently clinical adviser to NICEon acute coronary syndromes and DeputyNational Director for Heart Disease and Stroke atthe Department of Health (England). He chairsthe International Council of the American Collegeof Cardiology.

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THE MYOCARDIAL ISCHAEMIANational Audit Project (MINAP) collects datafrom all English and Welsh hospitals withresponsibility for the management of patientswith acute coronary syndromes. Although thedata are not exhaustive, and the emphasis,until recently, has been the care of those pre-senting with ST-segment elevation, analysisof the dataset allows important audit of hospi-

tal (and pre-hospital) management against alimited number of agreed standards of care.This forms part of the public assurance of thequality of care provided by the health serviceas well as being a useful tool for healthcareworkers and health service commissioners.

Additionally, analysis gives an insightinto the types of patient presenting with heartattack, improvements in particular aspects of

care within individual hospitals and changesin patterns of care across regions and nation-ally. Observational studies using the datasetgenerate interesting hypotheses for later test-ing.

In my talk I will introduce the concept ofnational registries and national audit andpresent a mix of data as examples of the util-ity of MINAP.

MINAP: Painting the picture

Dr Clive Weston

DR CLIVE WESTON is Reader in ClinicalMedicine at the School of Medicine, SwanseaUniversity, and Honorary Consultant Cardiologistat ABM University Trust. He is also Chair of theSteering Group of the Myocardial IschaemiaNational Audit Project (MINAP) within theNational Institute for Clinical OutcomesResearch, University College London.

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THE NATIONAL INSTITUTE for Healthand Clinical Excellence (NICE) publishedupdated guidance for post myocardial infarc-tion (MI) secondary prevention in May2007.1 Unlike many other NICE guidelines,these were generally met with universalacceptance by healthcare professionals inthis most important of areas. The guidelineaddresses key areas for implementation.These include: Confirmation of diagnosisand future assessment and management after

leaving hospital; advice on lifestyle factors,such as adoption of regular exercise and ahealthy (Mediterranean-style) diet; equalaccessibility of rehabilitation and smokingcessation advice; and recommendations forpharmacological treatment.

Pharmacological secondary preventionfollowing an MI is heavily evidence basedand theoretically patients may be prescribedas many as seven medications when leavinghospital. This, of course, may be difficult to

achieve in real life. This discussion will out-line key recommendations made by NICEand look at the evidence base in the second-ary prevention pharmacological treatment ofpatients following an MI.

Reference

1. NICE. Secondary prevention in primaryand secondary care for patients followinga myocardial infarction. Clinical guideline48; 2007.

Post-MI secondary prevention: NICE guidance

Dr Simon Williams

DR SIMON WILLIAMS is a ConsultantCardiologist at Wythenshawe Hospital, SouthManchester, where he is the clinical lead forheart failure. He specialises in cardiac transplantassessment and complex device therapy. DrWilliams is also an honorary senior lecturer atthe University of Manchester where his researchgroup is currently studying the immune system inheart failure and following cardiac transplanta-tion.

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THE NATIONAL INFARCT AngioplastyProject (NIAP) has demonstrated the effica-cy of primary angioplasty. There is substan-tial variation in the access to cardiac careacross the UK. These issues will beaddressed together with lessons learnt fromthe inter-hospital transfer of patients withacute coronary syndromes.

Access to revascularisation

Dr Richard Levy

DR RICHARD LEVY is a Consultant Cardiologistat University Hospital South Manchester NHSFoundation Trust. He qualified at StBartholomew's Hospital, London in 1978.

He is a Fellow of the Royal College ofPhysicians, American College of Cardiology andEuropean Society of Cardiology.

Dr Levy has been Lead Clinician for theGreater Manchester and Cheshire CardiacNetwork, responsible for service improvementand the 18-week programme. He was NationalClinical Lead for the Heart ImprovementProgramme with specific responsibility forredesign of the management of angina, percuta-neous intervention and inter-hospital transfers.The redesign and audit of inter-hospital transferswas the largest study of its kind undertaken with-in the NHS, resulting in a major improvement forpatients.

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MUCH OF THE improvement in standardsof care for heart failure in the UK has arisenfrom professional guidelines for chronicheart failure (such as from NICE, SIGN andthe European Society of Cardiology) cou-pled with a workforce targeted on imple-menting good practice for such patients.

There has been little focus, however, onacute heart failure such as that occurring inthe context of acute myocardial infarction(MI). Despite improvements in the treat-ment of ST elevation MI, with more rapidthrombolysis or access to primary percuta-neous intervention, up to 20% of patientsstill suffer from significant left ventriculardamage and/or heart failure peri-infarction.Even transient signs of heart failure are

associated with a worse prognosis, and heartfailure is now the leading cause of death inboth the short and medium term after MI.

Detection of significant left ventriculardamage post-infarction should not be diffi-cult, with a key role for echocardiography inaddition to good clinical examination.Neglected groups include the elderly, thosewith diabetes, and those with non-ST eleva-tion infarction. “MI detectives” have beenused to good effect at some hospitals – theseare heart failure nurse specialists who sys-tematically screen new patients admitted tohospital with a troponin rise to identifythose with left ventricular damage or heartfailure.

What is more difficult is to ensure that

such patients are considered for appropriatedrug therapy and monitoring over the daysand weeks after their infarction. Thisrequires good communication between dif-ferent services in hospital and in the com-munity, and a sense of ownership of theprocess by a local champion. Rehabilitationservices, chronic heart failure services, thecoronary care unit, and primary care all havea role to play. Too many patients still do notgain the full benefits of modern therapy withappropriate doses of renin-angiotensin sys-tem blockers, beta-blockers and eplerenone,titrated upwards in the early period afterinfarction when the ventricle is likely to beremodelling and the risk of arrhythmia andprogressive heart failure is at its highest.

Heart failure – detection and treatment

Professor Martin R. Cowie

PROFESSOR MARTIN R. COWIE is Professor ofCardiology, Imperial College London andHonorary Consultant Cardiologist, RoyalBrompton Hospital, London.

Professor Cowie has a longstanding clinicaland research interest in heart failure diagnosisand management. He was Chair of the BritishSociety for Heart Failure from 2007 to 2009, andacted as the clinical expert for the NICE guide-line on chronic heart failure, published in 2003.He advised the Healthcare Commission on itsrecent national audit of heart failure. Since 2007,Professor Cowie has chaired the EducationCommittee of the Heart Failure Association of theEuropean Society of Cardiology, and sits on itsBoard.

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SINCE THE PUBLICATION of the NICEsecondary prevention document1 the medicalmanagement of patients post-MI is relativelystraightforward. But very important issuesremain for the patient recovering from aheart attack. Will I have another? How do Istop smoking? When can I drive? When canI fly? Should my children have checks?When should I return to work?

For the GP there can remain uncertainty:Is the patient's breathlessness the advent ofheart failure? When should I re-refer withangina? Will the patient stay on their tablets

and how do I know if they don't?I shall discuss these frequently asked

questions that appear in the GP consultation,as well as some interesting infrequentqueries.

The 2004 GP contract brought incen-tivised systematic care for a number ofchronic diseases. Communication from sec-ondary care is crucial in initiating thatprocess. I shall outline the Quality andOutcomes Framework (QOF) as it pertains toMI care and how to maximise benefit forpatient and GP alike.

As holistic practitioners who hold thelifelong record of patients' health, GPs knowthat an MI is only one of many events in apatient's life. It is our job to demonstratethrough cardiac rehabilitation in its widestsense that this is the end of the beginning andnot the beginning of the end.

References

1. NICE. Secondary prevention in primaryand secondary care for patients followinga myocardial infarction. Clinical guideline48; 2007.

Hand-over to primary care: Don’t drop the ball

Dr Nigel Rowell

DR NIGEL ROWELL has been a GP Partner at theEndeavour Practice in Middlesbrough for 20 years.He has also worked at the James Cook UniversityHospital since 1998, initially performing an outpa-tient echocardiography clinic. Latterly he “brought”BNP testing to Teesside and established the HeartFailure Service with Dr Adrian Davies. They nowrun a community screening clinic based on araised BNP. This is a one-stop echocardiographyservice with clinical opinion, leaving the hospitalclinic free to see complex cases.

Dr Rowell's interest in heart failure isenhanced by his association with the BritishSociety for Heart Failure and the GPSI Forum ofthe Primary Care Cardiovascular Society.

He has been involved in commissioning andservice development on Teesside for 14 years andis currently Middlesbrough's Practice-BasedCommissioning Chair.

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THE SESSION WILL highlight recent suc-cess in cardiac rehabilitation (CR) and ourwork with external stakeholders and policydevelopment. With almost 300 CR pro-grammes in England and an annual datatrawl of 50,000 patients we will explore what

CR looks like on the ground and how thiscompares to national minimum standards.The session will consider how to translateevidence into best practice and the role ofcommissioning in achieving this. Factorsthat are presently influencing CR, or are like-

ly to impact on the future shape of CR, suchas tariffs, world class commissioning, serv-ice specification and procurement and theprevention agenda will be explored. The ses-sion will finish with examples of innovationin CR from NHS Improvement (Heart).

Cardiac rehabilitation: new opportunities and new challenges

Professor Patrick Doherty

PROFESSOR PATRICK DOHERTY is Professorof Rehabilitation at York St John University. He isa physiotherapist and has a PhD inRehabilitation from the University of Manchester.He continues to work as a clinical specialist withhigh-risk cardiac patients at York Hospitals NHSFoundation Trust.

Professor Doherty was part of theDepartment of Health writing group for chaptereight of the NSF for Coronary Heart Disease. Heis National Clinical Lead for CR within NHSImprovement (Heart) and President of the BritishAssociation of Cardiac Rehabilitation. He chairedthe BACR Standards and Core Components writ-ing group and contributed to the NICE CR serv-ice commissioning guide. Professor Doherty is anucleus member of the European Association forCardiovascular Prevention and Rehabilitation.

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FOR A PATIENT who has had a myocar-dial infarction (MI), admission to the coro-nary care unit should ensure a standardisedapproach to care. Specialist nurses work-ing within these areas ensure ongoingassessment, investigation and optimisationof treatment. They have a positive impacton a patient's care by improving compli-ance and ensuring that decision-making isevidence based. They are often the focalpoint for stimulating multiprofessionalcare.

However, many patients suffering anMI are admitted to other areas of the hos-

pital where they are often managed by non-cardiologists. This can result in differenttreatment strategies being adopted and adelay in referral and review by cardiologyservices. The patient's journey followingan MI can be complex: primary angioplas-ty, day-case angiography and "treat andreturn" have resulted in shorter hospitalstays, with patients being more likely totransfer between different hospitals on thesame admission. Within the same hospital,patients can undergo multiple ward movesand this can complicate continuity of care.

The cardiology co-ordinator is able to

identify and track patients, influence pre-scribing decisions, organise investigations,follow up results and refer on to appropri-ate colleagues, eg, cardiac rehabilitation.As a key player in the cardiology team theco-ordinator ensures equity of access, bestpractice and continuity of care no matterwhere the patient is placed.

In my talk I hope to give a flavour ofthe role of the cardiology co-ordinator atSouth Manchester University HospitalsFoundation Trust, emphasising the needfor flexibility in addition to clinical andcommunication skills.

Joining up care: Evolving role of the nurse in MI care

Michael Cullen

MICHAEL CULLEN is a Specialist Nurse inCardiology at University Hospital SouthManchester NHS Foundation Trust. His currentpost as Cardiology Co-ordinator involves ensur-ing equity of access to cardiology services for allpatients.

He is lead nurse for the expanding primaryPCI service and has developed robust systemsfor rapid investigation, diagnosis and treatmentof patients presenting with chest pain andarrhythmia.

Following a mathematics degree atNewcastle University and nurse training inSunderland, Mr Cullen worked for a number ofyears in coronary care and then as researchnurse at the University of Manchester on projectsrelated to hypertension and cardiovascular dis-ease.

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CARING FOR PATIENTS with myocar-dial infarction (MI) remains challenging inreal world practice. Although the numberof ST elevation MIs appears to be falling,the evolution to primary angioplastymeans that many of these patients presentto their local hospital having already hadan angioplasty at their regional “heart

attack centre.” With an emphasis on get-ting these patients home more quickly, dis-trict general cardiologists often find them-selves trying to initiate and titrate vitalmedications, arrange important investiga-tions like echocardiography, and start theprocess of cardiac rehabilitation in ever-reducing time frames. Add to this the enor-

mous rise in patients who are now beingdiagnosed with non-ST elevation MI sincethe introduction of troponin testing, andthere are increasing pressures on our coro-nary care units.

This talk will describe the processes inplace to tackle these issues, as well as howwe monitor our performance.

How to make it happen in real life

Dr Tim Gray

DR TIM GRAY graduated from St John’s College,Cambridge University and completed his basicmedical training in Southampton. He then spenttwo years in Papworth Hospital performingresearch into chronic angina before moving tothe North West of England to complete his cardi-ology training. He was appointed ConsultantCardiologist for the Pennine Acute HospitalsNHS Trust, based at The Royal Oldham Hospital,in May 2007.

Dr Gray is trained in all aspects of interven-tional cardiology which he carries out atRochdale Infirmary and Manchester RoyalInfirmary. He looks after patients with all aspectsof general cardiology in both inpatient and outpa-tient settings, but his interests lie particularly inpatients with acute coronary syndrome and themedical and interventional treatments of this.

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