Coronary Heart Disease: Summary

Transcription

1 Coronary Heart Disease: Summary The recently launched National Cardiovascular Disease Strategy advises that all the cardiovascular diseases (CVD) should be managed as a family and when a physician diagnoses one type of CVD such as CHD s/he should look for the others and that service should be aimed at managing all the disease manifestations in a combined service. Overall mortality from coronary heart disease (CHD) is declining in all age groups Premature mortality (deaths before the age of 75 years) from CHD has decreased by 44% since 2007 in men, but increased by 6.5% in women The prevalence of CHD is increasing as more people survive an acute event and as the population gets older, but the incidence appears to be decreasing. Up to 52% of people with CHD are missing from the General Practitioner long term conditions register CVD is responsible for 54% of total years of life lost due to causes considered preventable, with CHD alone contributing 40% of total years of life lost Raised cholesterol is a key risk factor for CHD; 56% of global ischaemic heart disease is thought to be due to high cholesterol Obesity is another key risk factor with 63% of heart attacks thought to be due to increased abdominal obesity Greenwich rates of obesity and smoking are higher than the average London rates Primary care has a key role in addressing risk factors including smoking, maintaining healthy weight and identifying and treating high blood pressure and high cholesterol as well as maximising opportunities for secondary prevention Estimates suggest only 48% of patients with CHD are recorded on General Practice registers; this could be due to patients not being diagnosed with CHD, disease coding errors or practices not keeping registers up to date The management of Acute Coronary Syndrome depends on whether the patient presents with ST elevation myocardial infarction (STEMI), non- ST-elevation myocardial infarction (nstemi), or unstable angina Nearly all STEMI is managed at Kings or GSTT. Primary percutaneous intervention (PCI) rates are high at both these hospitals, with 99% of patients receiving PCI. More patients need to receive their intervention in less than 150 minutes of calling for help as per best practice guidelines All nstemi and unstable angina is managed at the QEH. More of these patients need to be managed on a cardiac ward, as this is known to reduce mortality at 30 days Stable ischaemic heart disease should be managed with combined medical therapy and when this is not sufficient PCI or a coronary artery bypass grafting (CABG) should be considered There is strong evidence that cardiac rehabilitation for people with ischaemic heart disease is effective, reducing mortality by 26% 1

2 What do we know? Coronary heart disease is one of a number of cardiovascular diseases. This section provides background information on coronary heart disease and outlines the main treatment interventions and national strategies in place. 1. Introduction 1.1 Cardiovascular diseases Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include: coronary (ischaemic) heart disease disease of the blood vessels supplying the heart muscle; cerebrovascular disease - disease of the blood vessels supplying the brain; peripheral arterial disease disease of blood vessels supplying the arms and legs; rheumatic heart disease damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; congenital heart disease - malformations of heart structure existing at birth; deep vein thrombosis and pulmonary embolism blood clots in the leg veins, which can dislodge and move to the heart and lungs CVD is the UK s biggest killer. In 2010, almost 180,000 people died from CVD, one in three deaths and around 80,000 of these deaths were from coronary heart disease (ONS 2010). This situation has been socially generated by smoking, diets high in saturated fats and salt and a sedentary lifestyle (Pearson 2007). The Incidence of CVD peaked in the 1970s and 1980s, but death rates have halved since then. Despite this reduction CVD remains a leading cause of death, in particular of premature death, an increasing cause of morbidity and a major cause of disability and ill-health. In addition increase rates of obesity and diabetes threaten to reverse these achievements. These disorders are often discussed together as they share common risk factors. We have decided in this JSNA to describe the different elements of CVD in separate chapters as there are some differences in the risk factors for each of these types of CVD and there are significant differences in the clinical and social management of people who have had a stroke or heart attack. This chapter will focus on coronary heart disease. Please see the JSNA chapters on stroke and high blood pressure that will focus on other components of CVD. 2

3 1.2 Coronary heart disease Coronary heart disease (CHD), which includes heart attacks and other heart problems such as abnormal rhythms or heart failure, results from blockage of the main arteries supplying the heart muscle caused by atherosclerosis (the thickening and hardening of arteries as a result of fatty deposits within the blood vessel lining). The atherosclerosis can be slowly progressive, giving rise to angina (usually presenting as pain in the chest on exertion) or can be sudden, resulting in a complete blockage of one or more arteries supplying the heart. The acute blockage can lead to death of the heart muscle supplied by that artery (a myocardial infarction/ heart attack) because of a lack of oxygen if action is not taken promptly. Patients can develop heart failure or fatal arrhythmias as a result of damage to the heart muscle. The two main causes of CHD mortality are acute myocardial infarctions (AMI) and chronic ischaemic heart disease (CIHD), otherwise known as stable angina. Although the term heart attack is used colloquially, the abrupt reduction in blood supply to the heart muscle is now referred to as an Acute Coronary Syndrome (ACS) and the death of the heart muscle as a Myocardial Infarction (MI). ACS is suggested by characteristic symptoms (eg. central chest discomfort, sweating, breathlessness) and abrupt changes in blood pressure, heart rate and heart rhythm, in some cases leading to collapse or sudden death. ACS can often be detected as electrical alterations on the electrocardiogram (ECG). Patients with the characteristic symptoms are categorised into those with, and those without, ST segment elevation as indicated by the ECG (the ST segment is one part of an ECG tracing). Patients are by this distinction diagnosed as one of two categories; those with ST elevation myocardial infarction (STEMI) and those with non- ST-elevation myocardial infarction (nstemi). The distinction between STEMI and nstemi is important for management. Emergency reperfusion treatment is required for STEMI patients to restore blood flow through the blocked coronary artery responsible for the heart attack, and two forms of treatment are available. The great majority of patients now receive primary percutaneous coronary intervention (PCI), where the artery is re-opened mechanically using a balloon catheter inserted into the blocked artery and a stent is deployed within the artery. Alternatively thrombolytic treatment, where the clot is dissolved by a drug given by ambulance or hospital staff, is also available. Delay in providing either treatment is associated with poorer outcomes. Patients with nstemi do not require emergency reperfusion treatment. However those assessed as having a more than moderate risk of death (>3% mortality at 6 months) require coronary angiography to examine the coronary arteries within 2-4 days of admission and may require subsequent coronary interventions (NICE 2009). 1.3 National strategies The National Service Framework (NSF) targets launched in 2000 aimed to reduce mortality from heart disease, stroke and related circulatory diseases in people under 75 by at least 40% by In 2004 a further target was added to address inequalities: To reduce the inequalities gap in death rates from CHD, stroke and related diseases between the fifth of areas with the worst health and deprivation indicators and the population as a whole in people under 75 years by 3

4 40% by The target to reduce mortality was achieved in 2009 and although there has not been a subsequent target set, CVD remains a high priority. A new cardiovascular disease strategy was launched by the government in March 2013 in line with the NHS, Public Health and Adult and Social Care Outcomes Frameworks. The Public Health Outcomes Framework and the NHS Outcomes Framework both have mortality from CVD as a key indicator, along with other major causes of mortality. The two indicators for CVD are: Age standardised rate of mortality from all cardiovascular diseases (heart disease and stroke) in persons less than 75 years of age per 100,000 population Age standardised rate of mortality that is considered preventable for all cardiovascular diseases in persons less than 75 years of age per 100,000 population Standardised mortality rates for CVD at the local authority level are published by the Health and Social Care Information Centre ( Since the success of achieving the NSF targets which focused on treatment interventions, there has been an increasing emphasis on the prevention of cardiovascular disease, and the National Institute for Health and Care Excellence (NICE) has published guidelines specifically relating to CVD prevention in individuals and at the population level (NICE 2010). The NHS Quality Outcomes Framework (QOF) which measures General Practice performance also includes indicators related to reducing several CVD risk factors. These different mechanisms will all continue to drive improvements in the prevention and treatment of cardiovascular disease. 2. Facts and Figures: The Burden of Disease; trends and health inequalities This section outlines trends and health inequalities related to Coronary Heart Disease and Heart failure is in Greenwich, and how this compares to the National Average and other boroughs. 2.1 Mortality from Coronary Heart Disease Burden of disease Ischaemic heart disease is one the conditions considered to be amenable to treatment and therefore preventable. 4

5 Years lost per 100,000 of the population registered with Greenwich GP practices Figure 1: Scarf plot showing the relative contribution to the total male and female years of life lost to potentially preventable causes in Greenwich 2007/8 2011/ Rate of years of life lost due to amenable mortality per Greenwich registered patients in Nutitional, Endocrine and Metabolic Injuries Neurological disorders Genitourinary disorders Maternal & infant Respiratory disease Infections Digestive disorders Neoplasms CVD Males Females Notes: Including only practices in existence throughout Source of data: Public Health Mortality Files The potential years of life lost indicator measures the years of life lost from people dying early as a result of not receiving treatment for conditions for which there is good evidence that early identification and treatment are effective. Cardiovascular disease contributes to 54% of the total years of life lost to amenable causes in Greenwich (Figure 1) and most of the cardiovascular deaths are from coronary heart disease. Coronary heart disease alone contributes to 40% of the years of life lost. The JSNA section considering mortality from preventable causes can be read here Mortality by Gender In 2011,185 Greenwich residents died from CHD (International Classification of Diseases (ICD) 10 codes I20 I25); 104 males and 81 females. Eighty five deaths were specifically from a myocardial infarction (MI). Deaths in men are still significantly higher and at a younger age than women, with 45.6% of deaths having occurred before the age of 75 years in men versus only 22.6% in women (Figures 2 and 3). Death rates from CHD have been falling since the early 1970s and this decline is also demonstrated in Greenwich (Figure 3). 5

6 Figure 2: Absolute number of deaths from CHD (ICD 10 codes: I20 - I25) from 2007 to 2012 in men and women in Greenwich Source of the data: The NHS Information Centre for health and social care and Public Health Mortality files, (ICD 10 codes: I20 - I25) Men start dying from CHD in their thirties and early forties, with more than double the mortality compared to women until their mid-seventies when the difference starts to decrease. The lifetime risk of developing CHD at age 40 years is 50% in men and 33% in women (Lloyd Jones 1999). The reason for a higher mortality in men at a younger age was thought to be due to a protective effect in women of oestrogen; however this has not been substantiated. Further studies suggest that the difference is due to the effects of LDL and HDL types of cholesterol, but more research is required (Barrett - Connor 1997). When comparing rates of death in Greenwich with elsewhere, a directly standardised rate (DSR) is used in order to take into account differences in the age structure of the Greenwich population compared the population of England as a whole. Over the last two decades male mortality from CHD in Greenwich has halved, but this reduction has not always been as consistent as that seen nationally. A dramatic drop since 2008 has brought the Greenwich male CHD mortality rate almost to the England average (Figure 3). The fall in female mortality from CHD in Greenwich has reduced at a similar rate to the national average, but since 2004 has slightly diverged from this trend, with only a drop back towards the national average in the last year. 6

7 Figure 3: Coronary Heart Disease mortality in the Royal Borough of Greenwich and England for Men and Women from All ages. 3 year average rates Source: The NHS Information Centre for Health and Social Care & Public health mortality file data for 2011 A 2004 study to explain the decline in CHD mortality concluded that more than half (58%) of the decline in England and Wales during the 1980s and 1990s was attributable to reductions in major risk factors, principally smoking. Treatment interventions, including secondary prevention, explained the remaining two-fifths (42%) of the mortality decline (Unal B 2004) Causes of coronary heart disease mortality Coronary heart disease deaths are made up of six ICD 10 codes, but the two main contributors to CHD mortality are acute myocardial infarctions (AMI) and chronic ischaemic heart disease (CIHD), which represent 45% and 54% of the deaths respectively. The trend in mortality from AMI and CIHD has been compared to England in Figures 4 and 5. Figure 4 shows that mortality from acute and chronic ischaemic heart disease has been declining in Greenwich in line with the National average. 7

8 Figure 4: The trend in mortality rate for Chronic Ischaemic Heart Disease (ICD I23-35) for men and women all ages from 2006 to 2011 Source: ONS Vital Statistics, ONS Mid-Year Population Estimates Figure 5 shows that the mortality rate in Greenwich from acute myocardial infarction has been substantially higher than the national average in the last few years, and how this reduced to just above England from The above average trend in mortality from acute myocardial infarction in Greenwich appears to be the reason for the high CHD mortality and its subsequent decline. Figure 5: The trend in mortality rates for Acute Myocardial Infarction for men and women all ages from 2003 to 2011 Source: ONS Vital Statistics, ONS Mid-Year Population Estimates 8

9 2.1.4 Mortality by Ward Figure 6 illustrates how the CHD age standardised mortality rate in Greenwich varies between wards. The rate varies from 135 deaths per 100,000 population in Woolwich Riverside, to 54 deaths per 100,000 in Blackheath. The confidence intervals, represented by the vertical bars, show the range in which could be the actual mortality rate for each ward. The bars are wide, as the number of deaths per ward is relatively small even when aggregating five years of data, and nearly all overlap, showing that there may in fact be no actual difference between them. Figure 6 does show however, that there is a significant difference between the wards with the most deaths and the wards with the least. Woolwich Riverside and Charlton have significantly higher burden of mortality, 2.5 times higher than the ward with the lowest burden of mortality (Blackheath Westcombe). As there is a well-established relationship between increased mortality and deprivation (Gregory 2009), one would expect to find a higher CHD mortality rate in the more deprived boroughs. As 42.9% of Greenwich residents are in the most deprived national quintile, and with only 1% from the least deprived, there is not a distinct difference between some wards (SEPHO CVD profile 2012). Figure 6: Age standardised CHD mortality rates by ward from 2007 to 2011 in Greenwich Source of data: ONS Public Health mortality files using GLA population projections Premature mortality Premature mortality refers to deaths before the age of 75 years, and three year average rates for Greenwich have been compared with England in Figure 7. This shows that for the last ten years, the trend in premature CHD mortality in Greenwich for men and women has been consistently higher than the national average. The divergence from the national average has been greatest in men where the gap appears to be diminishing, with a decline of 44% since Figure 7 also shows however, that since 2007 the female premature mortality rate has actually increased by 6.5%, and does not appear to be declining in line with the England average. In the population as a whole, all age CHD mortality is falling (Figure 3), but it is 9

10 evident that in Greenwich, women less than 75 years of age are the only group for whom mortality is not clearly declining, creating a significant inequality gap. Figure 7: CHD mortality in men and women <75 years in Greenwich & England from 1993 to 2011 (3 year average rates) Source: The NHS Information Centre for Health and Social Care, supplemented by local data from mortality files A review of stroke premature mortality revealed that mortality in Greenwich was higher than the national average in both men and women. As stroke has similar risk factors to CHD, this suggests that the decline in CHD premature mortality in men is not due to an improvement in mens risk factor profile, as if this was the case there would have been a drop in premature male stroke mortality, but an improvement in their survival after an event. In addition, the fact that the female premature mortality trend is opposite to the trend in male premature mortality suggests that the reasons for this lack in decline is specific to women. The reasons for this lack of decline could be due to a different risk profile in young women, a lack of awareness of risk or poor access to health care interventions. A Swedish study suggested that women could not access lifesaving treatments as easily as men. They reviewed patients admitted with STEMI during 1995 and 2006 found that women were 17% less likely to receive reperfusion therapies and were at 1.2 times greater risk of dying in hospital than men (Lawsson 2012). Other evidence in the literature indicates that the problem could also be a lack of awareness from both the patient and clinicians on the degree of severity of the ischaemic heart disease in women. A study by Lutfey in 2009 revealed that physicians were less certain about their diagnosis of CHD in a woman, especially a younger woman (47.5% certain of diagnosis in a woman compared with 67.3% certain in a man). 10

11 To understand why efforts to reduce CHD mortality are reaching men under 75 years of age better than women more work could be done to describe the risk profile of men and women, their perception of their risks and the perception of their clinicians, their access to health care interventions including prevention, and their prognosis at different ages Mortality due to heart failure and arrhythmia Heart failure is a complex clinical syndrome characterised by the reduced ability of the heart to pump blood around the body, and approximately 70% of all heart failure cases are caused by CHD (National Heart failure Audit). Mortality for heart failure and arrhythmia is classified under ICD 10 codes I26 I52. These codes are reported together and in any case as numbers are small separate analysis would not be feasible. Survival rates for heart failure are poor, with 40% of newly diagnosed patients dying within one year (Cowie 2000). Figure 8 below shows that deaths from heart failure and arrhythmias have been less than the national average since Figure 8: Mortality due to I26 I52 for Greenwich and England from 2002 to 2011 (3 year average rates) Source: The NHS Information Centre for health and social care, supplemented by local Greenwich data from the mortality files The number of deaths each year is small and could be affected by the accuracy of certification of cause of death but the data suggests that the local approach to managing heart failure and arrhythmia is working effectively. 2.2 Morbidity from Coronary Heart Disease Recorded and Estimated Prevalence of CHD Statistics indicate that approximately 1 million men and nearly ½ million women in the UK have had a myocardial infarction, and in total there are around 2.3 million people in the UK living with CHD (CHD Statistics 2012). Some estimates suggest the prevalence (ie. the number of people living with CHD), is actually increasing as more people are surviving CHD events, and because 11

12 CHD prevalence increases with age and overall life expectancy is increasing. The 2011 Health Survey for England reports that in both men and women there was an increase in prevalence of CHD between 1994 and 1998, but levels have generally fallen since then to 5.7% in men and 3.5% in women in By contrast, the incidence, or number of new CVD cases each year, is stable, rather than declining (Pearson 2007) and therefore there is a need to continue to focus on preventing CVD and decreasing risk in the population. General Practices are encouraged to keep a CHD register of patients who have ever suffered from angina or who have had a previous myocardial infarction, providing an observed estimate of the prevalence of CHD in an area. In Greenwich, 2.2% of the population is on a CHD disease register in contrast to 3.4% of the population in England. Greenwich has a smaller elderly population compared with the England, and this would explain the lower percentage on the Greenwich CHD register. The number of patients on the CHD register is generally considered an under-estimate of the actual prevalence, as it does not account for undiagnosed people and those that have failed to register with a GP. Also the percentage is a crude figure that does not take account of variations in population structure. Predictive modelling of the disease burden estimates that there are 8,839 people living with CHD in Greenwich in This equates to a prevalence of 3% in the Greenwich practice population and indicates that 69% of people with CHD in Greenwich are on a register. South East Public Health Observatory (SEPHO) estimates the prevalence of CHD in Greenwich to be higher, at 4.6%; this estimate is population structure adjusted and considers the over 16 years of age population. The SEPHO estimated prevalence of 4.6% would equate to only 48% of patients with CHD being recorded on the register, with the remaining 52% of those with CHD in the borough missing from registers. This discrepancy could be accounted for as patients are not diagnosed with CHD, or because in some Practices the register is not kept up to date or diagnoses are not properly coded and consequently do not appear on the register Incidence of coronary heart disease According to one study into the determinants of the decline in acute myocardial infarction mortality in the UK, the MI incidence rate in England decreased by around a third between 2002 and 2010 (Smolina 2012). However, the incidence of CVD (which includes arrhythmias, heart failure, stroke and peripheral vascular disease) appears to be no longer declining (Pearson 2007). In 2010/11 there were 263,538 inpatient episodes for CHD for men in English NHS hospitals, and another 141,558 for women (Total 405,096). This represents around 3% of all male and 1% of all female hospital inpatient episodes in England (SUS data reported in the British Heart Foundation Statistics 2012). In Greenwich residents there are on average 822 inpatient episodes for CHD each year, which comprises 2.75% of all hospital in-patient episodes (CHD in these statistics includes angina pectoris, acute or subsequent MI, acute ischaemic heart disease and chronic ischaemic heart disease, but do not include heart failure and heart arrhythmias). The absolute number of in-patient episodes has not significantly changed over the last 4 years, but the percentage that CHD episodes represent out of all episodes has decreased from 3.14% in 2009/10 to 2.43% in 2012/13 (representing a decrease of 0.71%). 12

13 Emergency admissions for MI and other forms of ischaemic heart disease are used as a proxy for measuring the incidence of coronary heart disease. Figure 8 shows that the admission rate for Greenwich residents is per 100,000 (comprising of 431 admissions), which is lower than England (198.3 per 100,000) and London (205.5 per 100,000) (SEPHO 2012). This suggests that the CHD incidence rate in Greenwich is lower than that for both London and England. Figure 8: CHD emergency admission rates for all ages, comparing Greenwich, London and England, 2011/12 Source: South East Public Health Intelligence Observatory 2012 Figure 9 shows that this fall to below the National and London admission rates may be a recent phenomenon. There was a sharp decline in emergency admissions before 2006, but since then a more gradual decline in the rate over the last five years, and Greenwich now has a similar rate to London and England. Overall the emergency admission rate for CHD in Greenwich has decreased by 52.4% between 2004/05 and 2011/12. 13

14 Figure 9: Trend in coronary heart disease emergency admission rates, 2004/05 to 2011/12 Source: SEPHO, (HES, Health and Social Care Information Centre, ONS) As detailed in above, Greenwich has a lower SEPHO age population adjusted CHD modelled prevalence (4.6%) than England (5.8%). Figure 9 shows that the rate of CHD admissions varies significantly between wards, with the highest rates of admission in Charlton (544 admissions per 100,000), Plumstead and Kidbrooke with Hornfair, and the lowest rate of admissions in Blackhealth Westcombe (169 admissions per 100,000 population). Figure 9: Admissions or hospital spells for CHD in by Ward in Greenwich Source of Data: Secondary Uses Services data provided by NHS SE London 14

15 The confidence intervals in Figure 9, represented by the vertical bars, are the range in which the actual admission rate for that ward could lie. The bars are wide because the numbers per ward are small and many of them overlap. However there is significant difference in burden of disease with Charlton having a 3.2 times higher admission rate than Blackheath Incidence of heart failure In 2011/12 the emergency admission rate for heart failure in Greenwich residents of all age groups was 64.5 per 100,000 (177 admissions). Figure 10 shows that the Greenwich emergency admission rate for heart failure is higher than England, but significantly lower than London. As would be expected, male heart failure emergency admission rates are higher than female admission rates, and the most deprived areas have a 2.1 times greater admission rate than the least deprived areas (SEPHO 2012). The emergency admission rates for heart failure in Greenwich have been declining slowly over the last decade. Figure 10: The heart failure emergency admission rates (DSRs), for all ages, 2011/12 Source: SEPHO, Hospital Episode Statistics, Health and Social Care Information Centre Health inequalities Mortality from coronary heart disease is known to be socially patterned with the highest deaths in people from lower socioeconomic groups. Analysis by South East Public Health Observatory (SEPHO) in 2011/12 showed that the standardised emergency admission rate in the most deprived areas of Greenwich was per 100,000 population compared with per 100,000 in the least deprived areas, which is 1.9 times higher. 15

16 Figure 12: CHD mortality in Greenwich by deprivation quintiles 2006 to 2011 Source: The NHS Information Centre for Health and Social Care Figure 12 illustrates direct age standardised CHD mortality across five quintiles, with quintile 1 being the most deprived and quintile 5 the least deprived, over a five year period. There were significantly more deaths in quintile 2 than 3-5, but an unusually low number of deaths in quintile 1. Quintile 1 has a very high number of ethnic minorities, with only 55% White British (JSNA 2012). This does not explain why there are fewer deaths in quintile 1 as some ethnic minorities, such as South Asians and Black African women are known to have a higher incidence of cardiovascular disease (Lip 2007). In Greenwich the CHD mortality rate is higher in Black Africans and Indians, but as numbers are small, it is not possible to demonstrate a significant higher mortality rate in these ethnic groups in locally (Figure 13). The health inequalities related to socio-economic status and ethnicity are well established but it has not proved possible to illustrate this in respect of either of these factors with local data due to the relatively small numbers. 16

17 Figure 13: Coronary heart disease mortality in different ethnic groups in Greenwich 2007 to 2011 all ages Source: ONS PH Mortality files, GLA Ethnic Group Population Projections (Ethnicity estimated from place of birth of the deceased (i.e. India - Indian)) Prevalence of behavioural risk factors Population attributable fractions attempt to measure the contribution each risk factor makes to cardiovascular disease. Adjusted population attributable fractions for cardiovascular disease mortality in the USA in 2012 for each of the different risk factors have been estimated in Table 1 as follows: Table 1: Adjusted population attributable fractions for cardiovascular disease mortality Risk factor Population attributable Possible range at 95% Confidence Interval fraction high blood pressure 40.6% smoking 13.7% poor diet 13.2% insufficient physical 11.9% activity abnormal glucose levels 8.8% Source: Alan 2013 The rise in prevalence of obesity and diabetes have the potential to reverse the decline in mortality achieved by medical interventions and the decrease in smoking. The prevalence (proportion of the population affected ) of these behavioural risk factors in Greenwich based on estimates from the Health Survey for England compared with London and England are outlined in Table 2 below. 17

18 Table 2: Prevalence of lifestyle behaviours from RBG London England Obesity (BMI > 29) 22.6% 20.7% 24.2% Smoking 24.2% 19.8% 20.7% Smoking combined with a long term condition 21% 17.3% 17.4% Source: SEPHO Cardiovascular Profile 2013 Coronary Heart Disease: The Modifiable Risk Factors 3. What Works? 3.1 Prevention Certain behaviours and medical conditions increase the risk of CHD. Often these risk factors are inter-related, for example a poor diet and lack of physical activity can lead to obesity which in turn can result in diabetes. Therefore interventions to reduce one will have benefit on another. Interventions can be directed at the individual and others can be implemented on a population level Behavioural risk factors Smoking: Smoking increases the risk of CHD. The long-term risk of smoking to individuals has been demonstrated by a 50-year cohort study of British doctors. This study found that death from coronary heart disease was around 60% higher in smokers (and 80% higher in heavy smokers) compared to non-smokers (Doll 2004). Poor diet: High saturated fat raises cholesterol levels, high salt intake can raise blood pressure, and low intakes of fibre, fruit and vegetables can lead to a greater susceptibility to CVD. The strongest evidence for this comes from surveys undertaken over 35 years in Finland before and after the start of a comprehensive community based intervention programme to prevent CVD. The biggest health behaviour change the community made was to their diet, both in the reduction of saturated fats and the increased intake of fruit and vegetables. The community demonstrated lower cholesterol levels, reduced blood pressure and an 80% reduction in mortality from CHD over this period (Vartiainen 2010). Evidence from the 1950s identified the Mediterranean diet as protective against cardiovascular disease and other diseases of ageing (Sofi 2010). This includes eating more bread, fruit, vegetables and fish and less meat and replacing butter and cheese with plant and vegetable oils. However studies have also shown that most deprived communities find this diet the hardest to adopt as dietary habits are strongly influenced by socioeconomic factors, in particular by 18

19 income which appears to play an important role in determining people's food choices (Darmon 2002). DASH (dietary approach to stop hypertension), a diet rich in fruits, vegetables and whole grains, moderately high in protein and low in dairy fats and total saturated fat consumption, has been shown to reduce both blood pressure and cholesterol. A combined DASH diet for two months and low salt intake lowered blood pressure by 9mmHg (Sacks 2001). Physical inactivity: People who are physically active are at lower risk of CHD (Berlin 1990). The more one exercises the lower the risk, with those who exercise moderate amounts having a 20-25% reduced risk of CHD. To produce the maximum benefit, exercise needs to be regular and aerobic. The new CMOs guidelines on physical activity were published in July These guidelines recommended 30 minutes of physical activity to a point of slight breathlessness on at least five days a week for adults (CMO report 2011). Increasing physical activity in the community involves maintaining facilities for walking and cycling and increasing access to public spaces and the countryside as well as more individualised programmes. Excessive alcohol consumption: While moderate alcohol consumption (one or two drinks a day) does not increase the risk of CVD, at high levels of intake particularly in binges the risk of death from a circulatory disease is 4 times higher, particularly cardiomyopathy (Leon 2010). The most recent Government advice is that regular consumption of between three and four units a day for men, and between two and three units a day for women will not lead to significant health risk (DoH 1995). Consuming over these levels is not advised. The benchmark for heavy drinking is set at more than eight units in one day for a man and more than six units in one day for a woman Behavioural advice post-myocardial infarction Following a myocardial infarction patients should be given advice on reducing their risk of experiencing further cardiac events. NICE guidelines state that people who have suffered a myocardial infarction should be offered cardiac rehabilitation and the following lifestyle advice: Stop smoking Weight management Eat a Mediterranean diet Eat Omega 3 fatty acids (contained in fish oils or flaxseed oil) Reduce alcohol consumption Increase physical activity Stress management Medical Risk factors Blood Pressure: Risk of CHD is directly related to higher levels of both systolic and diastolic blood pressure. A meta-analysis of prospective data on over one million adults has shown that for adults aged 40 to 69 years, each 20mmHg increase in usual systolic blood pressure, or 10mmHg increase in usual diastolic blood pressure, doubles the risk of death from CHD (Prospective Studies Collaboration (2002)). Both drug treatment and lifestyle changes particularly weight loss, increase in physical activity, and a reduction in salt and alcohol intake 19

20 can effectively lower blood pressure. The 2011 National Institute of Health and Clinical Excellence (NICE) guidelines recommended persistent high blood pressure of 150/95 mmhg (or 135/85 mmhg with higher CVD risk) as the threshold for offering drug treatments, and that optimal blood pressure treatment targets are 140/90 mmhg (NICE 2011). The prevention paradox is that more acute coronary syndromes occur in people with a normal blood pressure because there are more people with a normal blood pressure than a high blood pressure. This does not mean that it is not important to focus on reducing individual s blood pressure, but that it is also important for everyone to try to reduce their blood pressure and shift the mean blood pressure for the population. Blood Cholesterol: Risk of CHD is directly related to blood cholesterol levels. Blood cholesterol levels can be reduced by drugs, physical activity and by dietary changes, in particular a reduction in the consumption of saturated fat. The INTERHEART case-control study estimated that 45% of heart attacks in Western Europe are due to abnormal blood lipids (>3.8 mmol/l), and that those with abnormal lipids are at over three times the risk of a heart attack compared to those with normal lipids (Yusuf 2004). Lowering cholesterol is of particular importance in preventing CHD. A systematic review looking at cholesterol and cardiovascular risk demonstrated that the lowering of cholesterol was of significant benefit to CHD risk, with less evidence for stroke and other diseases that harden the arteries. This suggests that although the risk profiles for CHD and stroke are similar, cholesterol is a more significant risk factor for CHD than stroke (Chirovsky 2009). According to the World Health Report 2002, 56% of global ischaemic heart disease is due to high cholesterol. The 2008 NICE guidance states that statins should be initiated in adults with clinical evidence of CVD or adults considered to have a greater than 20% risk of death in the next ten years. A recent study in the Lancet showed that moderate physical activity alone could reduce cholesterol and as a result the risk of death by 26% (Kokkinos 2013). Obesity: Overweight and obesity increase the risk of CHD. As well as being an independent risk factor, obesity is also a major risk factor for high blood pressure, raised blood cholesterol, diabetes and impaired glucose tolerance (WHO 2002). The adverse effects of excess weight are more pronounced when fat is concentrated in the abdomen (Zhang 2008). This is known as central or abdominal obesity and is assessed using the waist to hip ratio or waist circumference. The INTERHEART case-control study estimated that 63% of heart attacks in Western Europe were due to abdominal obesity (a high waist to hip ratio), and those with abdominal obesity were at over twice the risk of a heart attack compared to those without (NICE 2006). Overweight and obesity has been increasing rapidly. In England, the percentage of men aged 16 and over who are obese rose from 14% in 1994 to 26% in 2010, and for women who are obese, from 17% in 1994 to 26% in 2010 (Health survey for England 2010). Clinical management of obese patients is limited to behaviour modification and psychological support and now increasingly bariatric surgery is an option, as drug treatments have been of only partial success. These are interventions at the level of the individual and the evidence for each of them is limited, as individuals are hard to engage and long term benefit difficult to maintain. A recent randomized control trial demonstrated that commercially led weight reduction programmes were more successful than primary care NHS led programmes, but even in this 20

21 trial setting uptake of this service was only 11.5% among those who were offered the service for free (Jolly 2011). The obesity epidemic threatens to reverse the CHD mortality achievements made over the last two decades and needs to be addressed at both an individual and population level. Some approaches are outlined in the 2007 Foresight report Tackling Obesity, but would require a huge shift in the way society currently lives. Diabetes: Diabetes substantially increases the risk of CHD. Men with non-insulin dependent (Type 2) diabetes have a two to fourfold greater annual risk of CHD and women have a three to fivefold greater annual risk of CHD (Garcia 1974). Patients with diabetes are advised to take the following steps to help prevent CVD: Don t smoke, but if you do, ask your GP if you need help to give up Eat a healthy, balanced diet Be more physically active. If you are overweight, try to get down to a healthy weight (any weight loss will be of benefit). Take medication as prescribed. Have blood glucose levels, blood pressure and blood cholesterol checked at least once a year and aim to keep to the targets agreed with your healthcare team. If you have any chest pain, intermittent pain when walking, impotence or signs of a stroke, such as facial or arm weakness or slurred speech, contact your doctor as soon as possible. Source: Diabetes UK Click here to read the JSNA chapter on diabetes. 3.2 Treatment Acute Coronary Syndrome Management of acute ischaemic heart disease varies depending on how the patient presents. Table 3 summarises the interventions included in the NICE guidelines for management of acute coronary syndrome. Management of the syndrome differs for STEMI and unstable angina or NSTEMI 21

22 Table 3: Evidenced treatment interventions for Acute Coronary Syndrome Aims Interventions Prompt recognition of symptoms Public education Education of professionals Provision of heart monitoring and Ambulance 999 response resuscitation Hospital Cardiac Care Units Restoration of coronary blood flow Reperfusion treatment Primary Percutaneous coronary intervention Thrombolytic therapy Nitrates Elective angioplasty/coronary Artery Bypass Surgery Prevention of further coronary Anticoagulants thrombosis Antiplatelet agents Reduction and reversal of ischaemia Reperfusion treatment Anti-anginal drugs e.g. beta blockers, nitrates Stabilisation of coronary artery Statins Optimise healing Angiotensin converting enzyme inhibitor Prevention of future myocardial Secondary prevention drugs infarction Lifestyle changes Education & support, promotion of Hospital cardiac nurse specialists healthy lifestyles Cardiac rehabilitation classes Patient support groups Public Health initiatives Source: MINAP Report 2012 A new NICE guideline for the management of STEMI was published in July2013. The guideline advocates for timely reperfusion therapies in STEMI. STEMI is caused by a complete and persistent occlusion of a coronary artery by a blood clot. The interruption of the blood supply leads to myocardial tissue damage. Nearly half of potentially salvageable myocardium affected is lost within 1 hour of the coronary artery being occluded, and two thirds is lost within 3 hours. Therefore the highest priority is to restore the coronary artery blood flow. This is now done through a mechanical process of either putting in a stent, extracting the clot with a catheter or coronary angioplasty; these mechanisms are grouped together under the overarching term primary percutaneous coronary intervention (NICE guidance CG167). In the event of a diagnosis of unstable angina or NSTEMI, aspirin or antithrombin drugs should be offered and patients should be formally assessed for their individual risk of future cardiovascular events. This is done using the GRACE (Global Registry of Acute Coronary Syndrome Events) score which predicts six month mortality. Treatment should then be administered depending on whether the patient is low, medium or high risk and the risk of adverse events. Patients with an intermediate to high risk of death should be offered an angiogram followed by a percutaneous coronary intervention within 96 hours of hospital admission. 22

23 All patients who have suffered a myocardial infarction should have a cardiology assessment of: Their left ventricular function Their need for coronary revascularisation Their need for an ICD (implantable cardioverter defibrillator) In addition patients should be given comprehensive information about their diagnosis and arrangements for follow up. They should be recommended cardiac rehabilitation and advised on lifestyle changes, such as giving up smoking, being physically active and eating a Mediterranean diet to help prevent a further event Cardiac rehabilitation is a structured set of services that enables people with coronary heart disease (CHD to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society (NICE guidance on cardiac rehabilitation 2011). A systematic review in 2010 demonstrated that exercise based cardiac rehabilitation reduced CHD mortality by 26%, hospital admissions by 31% and improved quality of life when compared to usual care (Heran 2011). The National Service Framework for Coronary Heart Disease states that more than 85% of people discharged from hospital with a primary diagnosis of acute MI or after coronary revascularisation should be offered cardiac rehabilitation Stable Ischaemic heart disease The symptoms and health risks of stable ischaemic heart disease should be treated through modification of risk factors such as smoking, high cholesterol, obesity and diabetes and through drug treatment using beta blockers, nitrates, calcium channel blockers, antiplatelet agents and statins. If these medical treatments fail or are inappropriate, then either coronary artery bypass grafting (CABG) which is major heart surgery, or percutaneous coronary intervention (PCI) employing balloon angioplasty/ stenting (NICE TA ) Heart Failure The diagnosis of heart failure is made through the measurement of serum natriuretic peptides using a blood test, and echocardiography using sound waves to build up a detailed picture of cardiac structures, cardiac walls and the velocity of blood flow at certain points in the heart (NICE guidelines for chronic heart failure 108). Management of heart failure depends on whether it is due to left ventricular dysfunction or not. If the ejection fraction (the velocity with which the heart is pumping blood) is preserved then the focus is to manage the other co-morbidities. If the ejection fraction is limited then the first line of treatment is an ACE inhibitor and a beta-blocker. If symptoms persist the aim is to offer diuretics to reduce the fluid retention combined with rehabilitation, which may be part of an existing cardiac rehabilitation programme, psychological support and education (NICE guidelines 108). Due to the complex nature of heart failure patients require detailed discharge planning. There is a high prevalence of depression in suffers of heart failure, therefore psychological status should be regularly reviewed. All the team managing a patient with heart failure should plan ample 23

24 opportunity to discuss end of life care and efforts made to manage palliative care needs as soon as possible (NICE guidance 108). 3.3 Models of Care Health care delivery models in screening and assessment of risk Health Checks began in 2009 and are a national primary prevention programme targeting all individuals aged without previously diagnosed cardiovascular disease or diabetes. The aim of the health check programme is to screen asymptomatic individuals for cardiovascular risk factors. The intention is to be able to intervene early and reduce risk, thereby preventing, delaying and in some instances reversing the onset of cardiovascular disease. CVD risk scoring systems: QRISK, JBS2 and Framingham scores are all cardiovascular risk assessment tools for Primary Care that are used to calculate a patient s risk of a CVD event in the next 10 years. The Framingham risk score is built on age, sex, systolic blood pressure, total cholesterol, high density lipoprotein (HDL), cholesterol, smoking status and the presence of left ventricular hypertrophy factors (thickening of the heart muscle), QRISK also includes socioeconomic status, obesity, recent smoking cessation and antihypertensive use or lipidlowering treatments (Bernard 2009). Generally, guidelines recommend treatment should be considered for persons with diabetes or a 10-year risk of CVD that is at least 20 per cent (Bernard 2009). Treatment may include medication to lower blood pressure, lipid lowering drugs or aspirin. A recent Cochrane review of whether health checks reduce total and disease specific mortality did not find any evidence in favour of health checks. However the age groups of the participants were younger than those seen through the current national screening programme and studies went back four decades covering periods when screening methods were different, therefore the review cannot be considered to be evaluating the current programme. The business case for the Greenwich health checks programme modelled that over a period of 5 years, 628 cardiovascular events could be prevented through the implementation of the programme. The cost of implementation was offset by the projected savings made through fewer interventions required in secondary care Integrating cardiovascular assessment The new CVD strategy emphasises the need to treat cardiovascular diseases as a family of diseases and encourages primary and secondary care physicians who diagnose a cardiovascular disease to look for other diseases, using a standard assessment tool. The family of diseases include: Hypertension Hypercholesterolemia Coronary heart disease Stroke 24

25 Type 2 diabetes Kidney disease Peripheral arterial disease Community based interventions for supporting people with CHD, specifically heart failure Multidisciplinary non pharmacological approaches have been shown to improve outcomes in chronic heart failure. A systematic review of the evidence found that interventions by a medical team plus a specialist nurse, dietician, pharmacist or social worker reduced all-cause mortality by 21% and all cause admission by 13%. Hospital admission for heart failure was reduced by 30% (Holland 2005). Specialised community based care for people with heart failure similarly improved outcomes. A systematic review found that there was a reduction in mortality and improved quality of life, but no significant reduction in hospital admissions and A+E visits (Bernard 2009). Extensive research is on-going into the effectiveness of remote monitoring models for delivering care, which incorporate information communication technology either as telemonitoring (transfer of physiological data such as blood pressure, weight, electrocardiographic details, and oxygen saturation through telephone or digital cable from home to healthcare provider) or as regular structured telephone contacts between patients and healthcare providers. A meta-analysis of the available evidence showed that multidisciplinary programmes for heart failure that included remote monitoring could reduce hospital admissions by 21% and mortality by 20% in this group (Clark 2007). 4. What do we know about local services? 4.1 Prevention Prevention at the population level involves taking measures to prevent ill health and disease in everyone. More aggressive, targeted prevention is provided to those at high risk of disease or with known established disease. For CHD this encompasses preventing the lifestyle risk factors for cardiovascular disease such as smoking, inactivity and obesity. Several prevention services are undertaken in RBG to meet the need: Greenwich Healthy Living Service provide stop smoking programmes, physical activity classes, community health trainer support and healthy eating clubs. The Greenwich Leisure Limited Health Wise is a low cost exercise referral programme which includes a weight management component in Greenwich leisure centres NHS Health checks PLUS programme for year olds is undertaken mainly in primary care to assess patients risk of cardiovascular disease (CVD). It is aimed at identifying those at high risk of CVD over the next 10 years in order to ensure they are appropriately 25

26 medically managed and provided with opportunities to make changes to their lifestyle. An outreach team assists in identifying those who are less likely to visit their GP. Patients with known atherosclerosis are referred to these behavioural change programmes, supported by the cardiac rehabilitation team and heart failure team where appropriate and followed in primary care through a disease register. 4.2 Health Care Costs In 2006 the health care costs of CHD in the UK were estimated to be 3.2 billion (British heart foundation 2013). The broader cost to the UK economy, which includes the cost of people leaving the workforce due to morbidity or death, was estimated to be 9.0 billion in Outcomes and Performance Primary care Primary care performance for CHD is monitored through the Quality & Outcomes Framework (QOF). The indicators measure whether people who have suffered a coronary heart disease event such as angina or a myocardial infarction are receiving the interventions to prevent them from suffering from further events. All these patients should be on a specific disease register and have their risk factors regularly assessed and managed. Predictive modelling of the disease burden estimates that there are 8,839 people living with CHD in Greenwich in Figure 14: Primary care secondary prevention outcome indicators for people on the CHD register in Greenwich & England 2012 Source of data: Quality & Outcomes Framework 26

27 Greenwich General Practices are performing at a similar level to the national average. Patients are receiving aspirin or an equivalent if they are on the register, having their blood pressure controlled and having their risk modified after a heart attack. Those having suffered a myocardial infarction are expected to be on an ACE inhibitor (or angiotensin receptor blockers (ARBs) if contra-indicated), aspirin or oral alternative anti-platelet therapy, a beta blocker and a statin for control of cholesterol unless contraindicated. In addition, of those newly diagnosed with angina in Greenwich, 96.1% were referred for an exercise test or assessment in There is room for improvement of the management of cholesterol and the number of patients with CHD on beta blockers. NICE guidelines specify statin therapy as clinically cost effective for people with evidence of CVD (NICE guidelines CG48). Therefore all patients on the CHD register should be offered statins, and if there is a contraindication this should be documented. A recent study in the British Journal of Cardiology showed that 81.2% of those having suffered an acute coronary syndrome are started on a statin, but doses were lower than expected and only 43% were still taking their statin four years after the event (Bogon 2012). Figure 14 shows that only 75% of patients on Greenwich CHD registers have a cholesterol <5 mmol/l. Similarly beta blockers are first line treatment for CHD, but 25% of those on the register in Greenwich are not being offered a beta blocker. The prescription of beta blockers is similarly low in England and London. A study into prescribing in primary care in the UK found that older patients (over the age of 84 years) were prescribed fewer lipid modifying drugs and beta blockers than younger patients (aged 45-54) (Mathur 2011). This may explain why some patients who are on the register are not on lipid lowering drugs of beta blockers. GPs can exclude patients from the calculation of measures for the Quality Outcomes Framework, to allow practices to pursue the quality improvement agenda and not be penalised, where, for example, it is not appropriate to expect patients for example who are terminally ill at home to come in for a medication review. However, the number of exceptions varies between practices. In 2010/11, the exception rate in Greenwich was 4.6%. This compares favourably with the London Suburbs average of 4.8% and England average of 6.4%. Community Services Cardiac rehabilitation The current cardiac rehabilitation provision for those with a diagnosis of Coronary Heart disease is an 8 week Phase III (outpatient in the community) service, but not a comprehensive cardiac rehabilitation service as defined by the British Association for Cardiovascular Prevention & Rehabilitation (BACPR) standards. The Queen Elizabeth Hospital (QEH) identifies suitable patients who have had an MI, PCI or CABG for the programme which includes weekly group exercise sessions delivered in line with Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) guidelines for low to moderate risk patients. Each patient has an individual pre-exercise assessment to discuss any change in health status or any additional support needs. Health education and behaviour change support is integrated into the initial assessment, throughout the 8 week programme and via one to one discussions, provision of health promotion information, referral and signposting to other relevant services. The Cardiac Rehabilitation Practitioners are trained in motivational interviewing and incorporate this 27

28 approach in their work with patients to support long term behaviour change. The programme works closely with the Leisure Centres and community based programmes to facilitate long term condition management. A new comprehensive cardiac rehabilitation service was commissioned at the beginning of 2013 and will be launched over the year. This comprehensive programme includes seven components: 1. Health behaviour change and education 2. Lifestyle risk factor management: Physical activity and exercise Diet Smoking cessation 3. Psychosocial health 4. Medical risk factor management 5. Cardio-protective therapies 6. Long-term management 7. Audit and evaluation The emphasis of the new cardiac rehabilitation programme is referral within two weeks of diagnosis, to improve uptake and reduce unplanned re-admissions early in the discharge period. The new programme is also intended to provide a more structured service that gives more time for education and psychological support, to support the physical activity intervention. Community heart failure service The Greenwich Community Heart Failure Service has been in place since October 2011, extending the former home visiting service which had been established for many years. In addition to the home visiting service, there are 6 clinics per week held in GPs surgeries, including one Consultant Cardiologist session; the remaining five being nurse-led with a Cardiac Matron, Associate Matron, Lead Nurse, two Specialist Heart Failure Nurses, and a Healthcare Assistant. The team also has access to a Dietician and Clinical Psychologist, providing a multidisciplinary approach with individualised support to patients as outlined in the previous section on models of care. Since the service was established the number of patients with a diagnosis of heart failure seen has rapidly increased. The service has been assessed as compliant with the benchmark NICE 2011 quality standards for heart failure. In the 12 months to March 2013 there were 261 referrals into the service, 192 discharges, and 82 deaths. A total of 3,984 patient contacts were made, with 70% of patients being seen in the clinic setting and the remainder being visited at home. Three quarters of the patients are over the age of 70 years, the majority with heart failure as a result of ischaemic heart disease. A recent anonymous survey demonstrated a high level of patient satisfaction in the service. Secondary Care 28

29 In the event of an acute coronary syndrome (ACS), patients in Greenwich will be assessed in the ambulance or on arrival at A+E, and management will depend on whether they are classified as a ST elevation myocardial infarction (STEMI) or non-stemi/ unstable angina. In 2011/12, there were 75 admissions for STEMI and nstemi in Greenwich residents at any hospital, 45 of them under the age of 75 years (Hospital Episode statistics). Two thirds of the patients were male and one third female. Seventy six per cent of patients received an angiogram and 85% of those eligible received primary percutaneous coronary interventions. STEMI STEMI on the ECG suggests complete blockage of the coronary artery, and such patients are redirected to Kings College Hospital or Guys & St Thomas (Figure 15). In 2012, patients would only receive reperfusion therapy (intervention to restore blood flow through blocked arteries) at QEH if they are an inpatient when the infarction occurs and it is inappropriate to transfer the patient. Figure 15: Admissions in Greenwich residents for STEMI at hospitals in SE London 2008/9-2011/12 Source data: Hospital Episode Statistics Over 99% of patients transferred to Kings get primary PCI compared to 94.7% nationally. Pharmacological intervention to break down blood clots (thrombolysis) is now conducted in very few instances and ambulance services will prioritise transferring patients for PCI rather than giving thrombolysis in the ambulance. The sooner a patient with STEMI receives PCI the better the outcomes. The time from calling for help to receiving this key intervention is therefore measured and reported, as shown in Figure 16 which compares the performance of King s and Guys & St Thomas s with the England average. Both hospitals have a lower percentage of patients receiving PCI within the European Society of Cardiology recommended 150 minutes compared to England (European Society of Cardiology, 2012). However the percentages have gone up in the last year, so all trusts are improving. At the time of writing the possible reasons 29

30 for the seemingly lower performance of King s and Guys & St Thomas s with the England average are under investigation, as this may be due to ambulance transfer or other reasons. Figure 16: Percentage of patients receiving Percutaneous Coronary Interventions within 150 minutes of calling for help from 2010/ /12 Source data: MINAP Audit Unfortunately the published MINAP data does not stratify information by gender or age, so it is not possible to comment on the proportion of men and women receiving primary PCI. After a myocardial infarction, between % of patients from the QEH, Kings and GSTT are being discharged on their secondary prevention drugs; aspirin or clopidogerol, ACE inhibitors, beta blockers and statins. nstemi Patients with myocardial infarction without ST elevation (nstemi) or unstable angina are taken by ambulance directly to the Queen Elizabeth Hospital. To optimise outcomes it is important that patients are seen by a cardiologist and receive an angiogram to help decide on the most effective treatment. Management of the patient on a cardiac ward has been associated with a shorter length of stay in hospital and reduced mortality at 30 days after the event (MINAP 2012). Figure 17 illustrates how effectively patients are managed locally compared with England. 30

31 Figure 17: Percentage of NSTEMI patients admitted to the Queen Elizabeth Hospital compared to England receiving the recommended care for 2010/11 to 2011/12 Source of Data: MINAP report Figure 17 shows that patients with nstemi admitted to QEH are being seen by a cardiologist and receiving an angiogram, but very few are being managed on a cardiac ward. QEH is currently under renovation and the cardiac ward is being relocated next to the coronary care unit. This reorganisation should increase the number of nstemi and unstable angina patients admitted to the cardiac ward and thus improve outcomes. It should also be noted that many hospitals lack the resources to report on nstemi and often these patients not admitted to coronary care units are therefore excluded from reporting (MINAP report). 4.2 Social Care The integration of community health and social care in Greenwich saw the development of Community Assessment and Rehabilitation Teams (CAR Teams) and a Joint Emergency Team (JET Team). The purpose of these teams is to prevent unnecessary admission to hospital, to assist people to stay independent in their own homes for longer and to facilitate discharge from hospital. The JET team is there as an emergency service to provide temporary support before the CAR team makes a full assessment. The JET team has access to intermediate care beds where necessary. Once it has made an assessment the CAR team will implement re-ablement or rehabilitation strategies. The CAR team will also liaise with other specialist teams such as the Neuro team and Falls team, who can provide any physiotherapy and occupational therapy support required. There are three CAR teams in Greenwich, based in Eltham, Woolwich and Greenwich. Since the implementation of this integrated community health and social care approach there have been fewer delayed discharges from hospital, an increase in intermediate care bed 31