Best practice in
MI care 2009
One-day meeting for health care professionals
Royal College of Physicians
Regent’s Park, London
Chair: Professor Martin R. Cowie
Delegate Booklet
17 June 2009
Accredited by Royal College of Physicians (5 hours) and Royal College of Nursing (6 hours)
Supported by Pfizer Ltd
1
Chairman’s introduction
09
Professor Martin R. Cowie
SURVIVAL AFTER MYOCARDIAL
infarction (MI) has improved markedly in
recent years, largely due to faster reperfusion treatment and better prescribing of evidence-based secondary prevention treatment.
However, many challenges remain
regarding the optimum care of all patients
with MI. The purpose of today’s conference
is to provide an update on the achievements
to date and to highlight where service
improvement is still needed and how this
might be achieved.
We have a distinguished panel of speakers whose presentations will cover treatment
of acute MI pre-hospital and in-hospital and
the appropriate continuing care after discharge.
In terms of emergency treatment of MI,
the conference is timely given the
Department of Health’s recent recommendation of primary percutaneous coronary intervention (PCI) as the main treatment for STelevation MI in England, with pre-hospital
thrombolysis encouraged where primary
PCI is not possible.1 We will hear about the
opportunities and logistic challenges of primary PCI services, UK guidelines on MI
care, and strategies for minimising delay
between symptom onset and reperfusion,
which is central to improved outcome.
Another key issue to be discussed is
heart failure, which often develops in the
context of MI. Left ventricular dysfunction
must be identified promptly so that early
treatment can be initiated, as this has been
shown to influence outcome. Specialist
nurses have an important role in helping to
screen MI patients for heart failure, particularly when patients are not being treated on a
cardiology ward.
We will also hear how the recent
changes in acute MI care – as well as pressures to limit length of hospital stay – impact
on work in district general hospitals and
what systems can be put in place to optimise
patient care in response to these changes.
A further presentation will highlight cur-
Professor Martin R. Cowie
Professor of Cardiology, Imperial College London and
Honorary Consultant Cardiologist, Royal Brompton Hospital,
London
rent deficiencies in care for elderly patients
with MI. These patients still tend to miss out
on the improvements in MI care that have
been achieved in other groups.
One major point that is likely to be
emphasised by today’s speakers is the
importance of collaborative multidisciplinary working between primary and secondary care as a key component of best practice
in MI care.
The conference is accredited for
Continuing Professional Development by
the Royal College of Physicians and the
Royal College of Nursing. It is intended to
be an interactive meeting and there will be
plenty opportunity for questions. Please do
not hold back from contributing to the discussion sessions. „
Reference
1. Treatment of heart attack national guidance: final report of the National Infarct
Angioplasty Project (NIAP). Department
of Health, 2008.
2 | Best practice in MI care 2009
Faculty
Dr Huon Gray
Deputy National Director for Heart Disease and
Stroke, Department of Health (England), and
Consultant Cardiologist, Southampton University
Hospital
E-mail: huon@cardiology.co.uk
Dr Clive Weston
Reader in Clinical Medicine, Swansea University,
and Honorary Consultant Cardiologist,
ABM University Trust
E-mail: c.f.m.weston@swansea.ac.uk
Dr Iain Findlay
Consultant Cardiologist,
Greater Glasgow and Clyde Health Board
E-mail: findli@aol.com
Professor Adam Timmis
Professor of Clinical Cardiology,
London Chest Hospital
E-mail: adamtimmis@mac.com
Professor Martin R. Cowie
Professor of Cardiology,
Imperial College London and Honorary Consultant
Cardiologist, Royal Brompton Hospital, London
E-mail: m.cowie@imperial.ac.uk
Professor Richard Hobbs
Professor and Head of Primary Care Clinical
Sciences, University of Birmingham
E-mail: f.d.r.hobbs@bham.ac.uk
Dr Jackie Taylor
Consultant Physician,
Department of Medicine for the Elderly,
Glasgow Royal Infirmary
E-mail: jackie.taylor@ggc.scot.nhs.uk
Bernie Downey
Cardiac Nurse Specialist, Mater Hospital Site,
Belfast Health and Social Care Trust
E-mail: bernie.downey@belfasttrust.hscni.net
Dr Tim Gray
Consultant Cardiologist,
Pennine Acute Hospitals NHS Trust
E-mail: tim.gray@pat.nhs.uk
3
Programme
9.30
Welcome and introduction
Professor Martin R. Cowie
The big picture
9.45
MI care: National progress and challenges
Page 4
Dr Huon Gray
10.15
MINAP: Painting the picture
Page 5
Dr Clive Weston
10.45
UK guidelines: NICE and SIGN
Page 6
Dr Iain Findlay
11.15
Panel Discussion
11.30
Coffee
Key areas
12.00
Minimising the delay to reperfusion
Page 7
Professor Adam Timmis
12.20
Heart failure – detection and treatment
Page 8
Professor Martin R. Cowie
12.40
Hand-over to primary care: Don’t drop the ball
Page 9
Professor Richard Hobbs
1.00
Panel discussion
1.30
Lunch
Time for action
2.30
Don’t forget the many – issues for the elderly
Page 10
Dr Jackie Taylor
2.50
Joining up care: Evolving role of the nurse in MI care
Page 11
Bernie Downey
3.10
How to make it happen in real life
Dr Tim Gray
3.30
Panel discussion
4.00
Summary and close
Page 12
4 | Best practice in MI care 2009
MI care: National progress and challenges
Notes:
09
Dr Huon Gray
DR HUON GRAY trained in cardiology at the
Brompton and St George’s Hospitals, London,
and was appointed Consultant Cardiologist at
Southampton University Hospital in 1989. He has
been Honorary Secretary of the British
Cardiovascular Intervention Society, President of
the British Cardiovascular Society, and cochaired the UK National Infarct Angioplasty
Project (NIAP).
Dr Gray is currently clinical adviser to NICE
on acute coronary syndromes and Deputy
National Director for Heart Disease and Stroke at
the Department of Health (England). He chairs
the International Council of the American College
of Cardiology.
THE MANAGEMENT OF patients with
myocardial infarction, both ST elevation
(STEMI) and non-ST elevation (NSTEMI),
has been transformed over the last 25 years,
from conditions often associated with an inhospital mortality of over 20% in the early
1980s to a current day average mortality
approaching 5%. These acute coronary syndromes are all part of a single spectrum and
the factors associated with the dramatic
improvement in outcome owe much to the
success of intervening at different pathophysiological points in their development.
These interventions include the use of pharmacotherapy (such as antithrombins and
antiplatelet agents), the uptake of earlier
coronary angiography and appropriate coronary revascularisation, greatly increased
use of secondary prevention intervention,
and thrombolytic agents and primary PCI
for the management of patients with
STEMI.
The mortality from cardiovascular diseases has been falling for many years but
there is a risk of complacency unless we
remind ourselves that cardiovascular diseases are still the number one cause of death
worldwide and carry with them an associated high morbidity. With the alarming rate of
increase in obesity and diabetes there is a
risk of these positive trends being reversed.
This talk will present an overview of
these developments, the importance of data
collection and analysis, some of the
Department of Health policy initiatives that
have encouraged change,1-4 and a brief summary of the challenges still to be overcome. „
References
1. National Service Framework for Coronary
Heart Disease. Department of Health,
2000.
http://www.dh.gov.uk/en/Publicationsands
tatistics/Lettersandcirculars/Healthservice
circulars/DH_4004813
2. The Coronary Heart Disease National
Service Framework: Building on excellence, maintaining progress. Progress
Report for 2008. Department of Health,
2009.
http://www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyA
ndGuidance/DH_096555
3. Treatment of heart attack national guidance: final report of the National Infarct
Angioplasty Project (NIAP). Department
of Health, 2008.
http://www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyA
ndGuidance/DH_089455
4. High quality care for all: NHS Next Stage
Review final report. Department of
Health; 2008.
http://www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyA
ndGuidance/DH_085825
5
MINAP: Painting the picture
Notes:
09
Dr Clive Weston
DR CLIVE WESTON is Reader in Clinical
Medicine at the School of Medicine, Swansea
University, and Honorary Consultant Cardiologist
at ABM University Trust. He is also Chair of the
Steering Group of the Myocardial Ischaemia
National Audit Project (MINAP) within the
National Institute for Clinical Outcomes
Research, University College London.
THE
MYOCARDIAL
ISCHAEMIA
National Audit Project (MINAP) collects data
from all English and Welsh hospitals with
responsibility for the management of patients
with acute coronary syndromes. Although the
data are not exhaustive, and the emphasis,
until recently, has been the care of those presenting with ST-segment elevation, analysis
of the dataset allows important audit of hospi-
tal (and pre-hospital) management against a
limited number of agreed standards of care.
This forms part of the public assurance of the
quality of care provided by the health service
as well as being a useful tool for healthcare
workers and health service commissioners.
Additionally, analysis gives an insight
into the types of patient presenting with heart
attack, improvements in particular aspects of
care within individual hospitals and changes
in patterns of care across regions and nationally. Observational studies using the dataset
generate interesting hypotheses for later testing.
In my talk I will introduce the concept of
national registries and national audit and
present a mix of data as examples of the utility of MINAP. „
6 | Best practice in MI care 2009
UK guidelines: NICE and SIGN
Notes:
09
Dr Iain Findlay
DR IAIN FINDLAY is a Consultant Cardiologist
with Greater Glasgow and Clyde Health Board.
He was chair of the SIGN Acute Coronary
Syndromes guideline group and is currently chair
of the NHS Quality Improvement Scotland
(NHSQIS) Audit and Indicators Steering Group.
Dr Findlay’s principal clinical interest is in
inherited cardiac conditions. He is lead clinician
for the West of Scotland Regional Inherited
Cardiac Conditions.
THE NATIONAL INSTITUTE for Health
and Clinical Excellence (NICE) and the
Scottish Intercollegiate Guidelines Network
(SIGN) differ in the manner by which topics
are selected, in the evaluation of the evidence, with regard to economic analysis and
cost implication, but hopefully not on their
recommendations for patients.
SIGN 931 specifically addressed the
topic of acute coronary syndromes, starting
in 2005. The guideline members decided to
look at ACS under the following headings:
z Presentation, assessment and diagnosis
z Management in the first 12 hours
z Reperfusion therapy for ST-elevation
acute coronary syndromes
z Risk stratification and non-invasive testing
z Invasive investigation and revascularisation
z Early pharmacological intervention
z Treatment of hypoxia and cardiogenic
shock
z Patient support and information needs.
It is important to emphasise that a SIGN
guideline need not be a full review of a subject. Within ACS we looked at 24 specific
areas of interest to the group. The release of
new evidence during the guideline review
period was a problem and while it clarified
issues such as the place of primary percutaneous intervention (PCI), in other areas such
as antithrombotic therapy for non-ST elevation myocardial infarction (NSTEMI) this
was not the case.
Areas that gave us particular concerns
were the definition of myocardial infarction
and its implications for patients and for epidemiologists. The most appropriate use of
troponins was the subject of much debate.
Our recommendations on the duration of
clopidogrel following NSTEMI gave us the
most feedback and was one area where we
differed from published NICE guidance.
The interventionalists were overwhelming in their support for primary PCI and this
led to the most radical change in the management of myocardial infarction in Scotland
since the introduction of thrombolysis, leading to major changes in the delivery of care
for acute MI. „
Reference
1. SIGN. Acute Coronary Syndromes.
National Clinical Guideline 93; 2007.
7
Minimising the delay to reperfusion
Notes:
09
Professor Adam Timmis
PROFESSOR ADAM TIMMIS is Professor of
Clinical Cardiology at the London Chest Hospital.
He qualified from the University of Cambridge
and St Bartholomew’s Hospital Medical College
in 1973. His cardiology training was at
Massachusetts General Hospital, Boston, US,
and at Guy’s Hospital, London, where he was
Senior Registrar before taking up his current
post.
Professor Timmis has published extensively
in the cardiovascular literature, his major interests being angina and acute coronary syndromes. He is Editor of Heart and chair of the
Academic Group of the Myocardial Ischaemia
National Audit Project (MINAP).
IN ACUTE MYOCARDIAL infarction,
most deaths occur early after symptom onset,
often before the patient has gained access to
medical care. These deaths are usually
caused by ventricular fibrillation and are
therefore preventable once a suitably
equipped ambulance is to hand or the patient
has been delivered to hospital. Once in hospital, death is usually caused by heart failure,
largely dependent on the severity of myocardial injury which can be reduced by timely
reperfusion therapy.
The risk of primary ventricular fibrillation declines exponentially following onset
of symptoms and after 6-12 hours is very
low. The benefits of reperfusion therapy
exhibit a similar time course, being maximal
immediately after coronary occlusion and
declining over the next 12 hours. Thus the
most important means of saving lives in
acute myocardial infarction is to get the
patient to a defibrillator and to initiate antithrombotic and reperfusion therapy as soon
as possible after the onset of symptoms.
Three major components contribute to treatment delays in suspected myocardial infarction:
z Patient delay: time from pain onset to the
summoning of help
z Transport delay: time from the summoning of help to arrival at hospital
z Treatment delay: time from arrival at
hospital to delivery of reperfusion therapy.
The third component (“door-toneedle/balloon time”) has proved the most
amenable to modification, although evidence
is now emerging that current targets are overly modest and further efforts are needed to
deliver treatment more quickly. It is the first
two components, however, that most delay
the delivery of treatment. Patient delay is the
major factor but, even when the decision has
been made to seek medical help, many
patients fail to call an ambulance, choosing
instead less efficient methods of accessing
medical care.
This talk will discuss those factors that
are associated with delayed treatment of
myocardial infarction and will attempt to
quantify how additional lives might be saved
by reducing treatment delay. There is a lot
more to be done if further reductions in mortality from acute myocardial infarction are to
be achieved. „
8 | Best practice in MI care 2009
Heart failure – detection and treatment
Notes:
09
Professor Martin R. Cowie
PROFESSOR MARTIN R. COWIE is Professor of
Cardiology, Imperial College London and
Honorary Consultant Cardiologist, Royal
Brompton Hospital, London.
Professor Cowie has a longstanding clinical
and research interest in heart failure diagnosis
and management. He was Chair of the British
Society for Heart Failure from 2007 to 2009, and
acted as the clinical expert for the NICE guideline on chronic heart failure, published in 2003.
He advised the Healthcare Commission on its
recent national audit of heart failure. Since 2007,
Professor Cowie has chaired the Education
Committee of the Heart Failure Association of the
European Society of Cardiology, and sits on its
Board.
MUCH OF THE improvement in standards
of care for heart failure in the UK has arisen
from professional guidelines for chronic
heart failure (such as from NICE, SIGN and
the European Society of Cardiology) coupled with a workforce targeted on implementing good practice for such patients.
There has been little focus, however, on
acute heart failure such as that occurring in
the context of acute myocardial infarction
(MI). Despite improvements in the treatment of ST elevation MI, with more rapid
thrombolysis or access to primary percutaneous intervention, up to 20% of patients
still suffer from significant left ventricular
damage and/or heart failure peri-infarction.
Even transient signs of heart failure are
associated with a worse prognosis, and heart
failure is now the leading cause of death in
both the short and medium term after MI.
Detection of significant left ventricular
damage post-infarction should not be difficult, with a key role for echocardiography in
addition to good clinical examination.
Neglected groups include the elderly, those
with diabetes, and those with non-ST elevation infarction. “MI detectives” have been
used to good effect at some hospitals – these
are heart failure nurse specialists who systematically screen new patients admitted to
hospital with a troponin rise to identify
those with left ventricular damage or heart
failure.
What is more difficult is to ensure that
such patients are considered for appropriate
drug therapy and monitoring over the days
and weeks after their infarction. This
requires good communication between different services in hospital and in the community, and a sense of ownership of the
process by a local champion. Rehabilitation
services, chronic heart failure services, the
coronary care unit, and primary care all have
a role to play. Too many patients still do not
gain the full benefits of modern therapy with
appropriate doses of renin-angiotensin system blockers, beta-blockers and eplerenone,
titrated upwards in the early period after
infarction when the ventricle is likely to be
remodelling and the risk of arrhythmia and
progressive heart failure is at its highest. „
9
Hand-over to primary care: Don’t drop the ball
Notes:
09
Professor Richard Hobbs
PROFESSOR RICHARD HOBBS is Professor and
Head of Primary Care Clinical Sciences at the
University of Birmingham. He is co-Director of the
Quality and Outcomes (QOF) Review Panel and
Deputy Director of the NIHR National School for
Primary Care Research. He sits on the Board of the
British Primary Care Cardiovascular Society. He
currently Chairs the Council for Cardiovascular
Primary Care, European Society of Cardiology; the
Prevention and Care Board, British Heart
Foundation; and the European Primary Care
Cardiovascular Society.
Professor Hobbs’ research interests focus on
cardiovascular epidemiology and trials, especially
relating to vascular and stroke risk, and heart failure. He consulted on the National Service
Framework for coronary heart disease and several
NICE reviews. He has provided clinical care in
inner-city general practice for more than 25 years.
FOR SURVIVORS OF myocardial infarction (MI) and acute coronary syndrome,
guidelines advise clinicians on priorities for
ongoing preventative and treatment goals.
For example, the NICE guideline on secondary prevention after MI (guideline 48) recognises the importance of treating dyslipidaemia, hypertension and smoking as the
main risk factors for cardiovascular disease,
plus additional preventive therapies including antiplatelet and beta-blocker therapy.
Despite the availability of highly effective medication, numerous studies show that
at-risk patients often fail to reach the treatment goals recommended in the guidelines.
The prevalence of poorly controlled hypertension is still high. Lipid targets are easier to
achieve than blood pressure targets; however, the EUROASPIRE II study1 of 5,556
patients hospitalised with coronary artery
disease revealed that only 61% received
statin treatment after discharge, and only
51% of these had total cholesterol levels
below goal. A similarly low incidence of eli-
gible patients attaining lipid treatment goals
was found in the US L-TAP study.2
There are governmental, physician and
patient factors that can either detract from or
improve implementation of guidelines. Lack
of awareness and understanding of cardiovascular disease and cholesterol management among the general public may contribute to this treatment gap. Adherence with
prescribed drug therapy is especially important in patients at high risk for cardiovascular
disease, ie, those with co-morbid hypertension and dyslipidaemia. Several medication
factors have been shown to play a role in
influencing patient adherence to therapy,
especially adverse effects of medication,
number of medications (lower pill burden is
associated with better adherence with antihypertensive and lipid-lowering therapy), order
of medications (initiating antihypertensive
treatment and lipid-lowering treatment concomitantly is associated with better adherence), and combination treatment.
Physician issues, especially in primary
care, include variable under-treatment and
under-titration of therapy. Government
endorsement of guidelines via national
health policy may help to reduce the burden
of cardiovascular disease and to change
physician and patient behaviour. Financial
incentives for reaching specific clinical indicators in the Quality and Outcomes
Framework have made a large impact. „
References
1. Lifestyle and risk factor management and
use of drug therapies in coronary patients
from 15 countries; principal results from
EUROASPIRE II Euro Heart Survey
Programme. Eur Heart J 2001;22:554-72.
2. Pearson TA, Laurora I, Chu H, Kafonek S.
The lipid treatment assessment project (LTAP): a multicenter survey to evaluate the
percentages of dyslipidemic patients
receiving lipid-lowering therapy and
achieving low-density lipoprotein cholesterol
goals.
Arch
Intern
Med
2000;160:459-67.
10 | Best practice in MI care 2009
Don’t forget the many – issues for the elderly
Notes:
09
Dr Jackie Taylor
DR JACKIE TAYLOR is a Consultant Physician in
the Department of Medicine for the Elderly,
Glasgow Royal Infirmary. After graduating from
Glasgow University and a period of general professional training, she became Lecturer in the
University Department of Geriatric Medicine and
then jointly accredited in General Internal and
Geriatric Medicine.
Dr Taylor represents Geriatric Medicine on
the Steering Group of the Cardiac Managed
Clinical Network and chairs the Heart Failure Subgroup. From a clinical perspective, her main interest is the development of comprehensive multidisciplinary services for heart failure patients, and
she has developed a Heart Failure Clinic and Day
Hospital programme specifically tailored to the
needs of older people. She is Honorary Secretary
of the Royal College of Physicians and Surgeons
of Glasgow.
THE INCIDENCE OF myocardial infarction (MI) rises steeply with age: the over 75
age group currently comprises 8% of the
population, but accounts for one-third of all
MIs and 60% of all MI deaths. The changing demography of our population will
result in a growing number of older individuals at risk of MI. While there have been
considerable advances in the management
of MI overall, these have not resulted in
tangible benefits for many older patients.
There are many potential factors that
may explain this phenomenon. Older
patients are more likely to present atypically and to present late.1 They more frequently have non-ST elevation MI, and complex
co-morbidity including other manifestations of vascular disease such as cere-
brovascular disease and cognitive dysfunction result in lower use of invasive strategies. Older patients are at high risk of
developing heart failure post MI: age and
presence of heart failure are the strongest
predictors of one-year mortality,2 but older
patients are less likely to have an assessment of left ventricular function.
Prescription of evidenced-based therapies is consistently lower in older patients
post MI3 and although there is growing evidence of the benefit of cardiac rehabilitation in this age group, both referral and
uptake are relatively poor.
There is no magic bullet to resolve
these problems; indeed, some factors are
not modifiable. What can be influenced is
the model of care to promote systematic
identification of patients, appropriate management of coronary artery disease and
other co-morbidity, multidisciplinary working and good communication. „
References
1. Rich MW. Epidemiology, clinical features, and prognosis of acute myocardial
infarction in the elderly. Am J Geriatr
Cardiol 2006;15:7-11.
2. Montalescot G, Dallongeville J, Van
Belle E, et al. STEMI and NSTEMI: are
they so different? 1 year outcomes as
defined by the ESC/ACC definition (the
OPERA registry). Eur Heart J
2007;28:1409-17.
3. Myocardial Ischaemia National Audit
Project (MINAP) data 2008.
11
Joining up care: Evolving role of the nurse in MI care
Notes:
09
Bernie Downey
BERNIE DOWNEY is a Cardiac Nurse Specialist
at the Belfast Health and Social Care Trust, with
responsibility for leading and co-ordinating the
cardiac rehabilitation service at the Mater site.
She is an independent nurse prescriber and runs
a nurse-led clinic for secondary prevention for
post-MI patients.
She is past President of the British
Association for Cardiac Rehabilitation (BACR).
During her time as President she was responsible for the publication of standards and core
components of cardiac rehabilitation. She has an
active interest in the care of heart failure patients
and has for many years promoted their inclusion
in streamline cardiac rehabilitation services. Ms
Downey is an honorary lecturer at Queen’s
University Belfast.
FOR A PATIENT who has had a myocardial
infarction (MI), admission to the coronary
care unit (CCU) should ensure immediate
contact with cardiac rehabilitation (CR) and
heart failure services. Specialist nurses
working within these areas ensure ongoing
assessment, investigation and optimisation
of treatment. They have a positive impact
on a patient’s care by improving compliance
and ensuring decision-making is evidence
based. They are often the focal point for
stimulating multi-professional care.
However, CCU beds are not always
available and MI patients can be admitted to
other wards where they are managed by a
non-cardiologist. This not only can result in
different treatment strategies being put into
place but also compromises the onward
referral to specialist nurses involved in CR
services. CR has been shown to reduce mortality1 and should be offered to all patients
who have had an MI.2
The patient’s journey following an MI
can be complex. Primary percutaneous
coronary intervention, day case angiography and “treat and return” have resulted in
shorter hospital stays with the patient being
more likely to transfer between different
hospitals on the same admission. Within the
same hospital, the patient can be placed in
several different care environments, which
can complicate continuity of care.
The experienced CR nurse is ideally
placed to screen for heart failure after MI.
The nurse can also influence prescribing
decisions and identify the need for investigations or follow-up of results. As a key
player in the team the nurse can ensure the
“joining up” of the infarct with the heart
failure.
Protocols to ensure all post-MI patients
are referred to CR services will result in
assessment by the nurse no matter where the
patient is placed and, if appropriate, onward
referral to heart failure or other services.
Referral to CR services from care of the eld-
erly and medical wards remains poor and
needs to be improved.
CR and heart failure services both work
on the interface between secondary and primary care and ensure a more structured
patient follow-up, often with protocols
common to both areas. CR can, if properly
resourced, provide the necessary vehicle to
allow nurses to drive forward the organisation of care required by the patient with an
MI complicated with heart failure. „
References
1. Taylor RS, Brown A, Ebrahim S, et al.
Exercise-based rehabilitation for patients
with coronary heart disease: Systematic
review and meta-analysis of randomized
controlled
trials.
Am
J
Med
2004;116:682-92.
2. NICE. Secondary prevention in primary
and secondary care for patients following
a myocardial infarction. Clinical guideline 48; 2007.
12 | Best practice in MI care 2009
How to make it happen in real life
Notes:
09
Dr Tim Gray
DR TIM GRAY graduated from St John’s College,
Cambridge University and completed his basic
medical training in Southampton. He then spent
two years in Papworth Hospital performing
research into chronic angina before moving to
the North West of England to complete his cardiology training. He was appointed Consultant
Cardiologist for the Pennine Acute Hospitals
NHS Trust, based at The Royal Oldham Hospital,
in May 2007.
Dr Gray is trained in all aspects of interventional cardiology which he carries out at
Rochdale Infirmary and Manchester Royal
Infirmary. He looks after patients with all aspects
of general cardiology in both inpatient and outpatient settings, but his interests lie particularly in
patients with acute coronary syndrome and the
medical and interventional treatments of this.
CARING FOR PATIENTS with myocardial infarction (MI) remains challenging in
real world practice. Although the number
of ST elevation MIs appears to be falling,
the evolution to primary angioplasty
means that many of these patients present
to their local hospital having already had
an angioplasty at their regional “heart
attack centre.” With an emphasis on getting these patients home more quickly, district general cardiologists often find themselves trying to initiate and titrate vital
medications, arrange important investigations like echocardiography, and start the
process of cardiac rehabilitation in everreducing time frames. Add to this the enor-
mous rise in patients who are now being
diagnosed with non-ST elevation MI since
the introduction of troponin testing, and
there are increasing pressures on our coronary care units.
This talk will describe the processes in
place to tackle these issues, as well as how
we monitor our performance. „
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