Clive Weston

The Myocardial Ischaemia National Audit Project (MINAP)

Aims of MINAP To audit the quality of care of patients with acute coronary syndrome and provide a resource for academic research. Quality of care interventions Feedback to hospitals, ambulance services and cardiac networks regarding benchmarking of performance against national standards and targets. Setting All 230 acute hospitals in England and Wales. Years: 2000-present. Population Consecutive patients, unconsented. Current number of records: 735 000. Startpoints Any acute coronary syndrome, including non-ST-elevation myocardial infarction, ST-elevation myocardial infarction and unstable angina. Baseline data 123 fields covering demographic factors, co-morbid conditions and treatment in hospital. No blood resource. Data capture Manual entry by clerks, nurses or doctors onto Lotus Notes; non-financial incentives at hospital level. Data quality Hospitals perform an annual data validation study, where data are re-entered from the case notes in 20 randomly selected records that are held on the server. In 2008 data were >90% complete for 20 key fields, with >80% completeness for all but four of the remaining fields. Endpoints and linkages to other data All-cause mortality is obtained through linkage with Office for National Statistics. No other linkages exist at present. Access to data Available for research and audit by application to the MINAP Academic Group. http://www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx.

Evaluation Of Risk Scores For Risk Stratification Of Acute Coronary Syndromes In The Myocardial Infarction National Audit Project (MINAP) Database

To compare the discriminative performance of the PURSUIT, GUSTO-1, GRACE, SRI and EMMACE risk models, assess their performance among risk supergroups and evaluate the EMMACE risk model over the wider spectrum of acute coronary syndrome (ACS). Design: Observational study of a national registry. Setting: All acute hospitals in England and Wales. Patients: 100 686 cases of ACS between 2003 and 2005. Main outcome measures: Model performance (C-index) in predicting the likelihood of death over the time period for which they were designed. The C-index, or area under the receiver-operating curve, range 0–1, is a measure of the discriminative performance of a model. Results: The C-indexes were: PURSUIT C-index 0.79 (95% confidence interval 0.78 to 0.80); GUSTO-1 0.80 (0.79 to 0.81); GRACE in-hospital 0.80 (0.80 to 0.81); GRACE 6-month 0.80 (0.79 to 0.80); SRI 0.79 (0.78 to 0.80); and EMMACE 0.78 (0.77 to 0.78). EMMACE maintained its ability to discriminate 30-day mortality throughout different ACS diagnoses. Recalibration of the model offered no notable improvement in performance over the original risk equation. For all models the discriminative performance was reduced in patients with diabetes, chronic renal failure or angina. Conclusion: The five ACS risk models maintained their discriminative performance in a large unselected English and Welsh ACS population, but performed less well in higher-risk supergroups. Simpler risk models had comparable performance to more complex risk models. The EMMACE risk score performed well across the wider spectrum of ACS diagnoses.

Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP)

Objective: To describe the improvements in care that have followed the introduction of an electronic data entry and analysis system providing contemporary feedback on the management of acute coronary syndromes in 230 hospitals in England and Wales. Design: Observational study Methods: A secure electronic system was used to transfer encrypted data on patients with acute coronary syndromes from collaborating hospitals to central servers for analysis. Immediate online data entry to the central servers by hospitals allowed contemporary analyses of performance and immediate comparison with the national aggregate performance. Results: The records of 156 902 patients receiving a final diagnosis of acute coronary syndrome during three years between October 2000 and September 2003 were analysed. Of 69 113 patients with ST segment elevation infarction, 75.4% received thrombolytic treatment. Between the first and last years of the study the median interval from hospital arrival to treatment fell for eligible patients from 38 (interquartile range 22–58) to 20 (interquartile range 14–28) minutes. By mid 2003 77.6% were receiving thrombolytic treatment within 30 minutes of arrival. The proportion treated within two hours of onset of symptoms increased from 32.5% to 40.3% (a difference of 7.8 percentage points, p < 0.0001). The use of secondary prevention medication for acute coronary syndromes increased over this period: angiotensin converting enzyme inhibitors, 62.4% to 72.4%; β blockers, 76.3% to 82.6%; statins, 69.6% to 83.8%; and aspirin, 89.3% to 90.2%. Conclusion: The provision of contemporary online performance analyses has underpinned substantial improvement in the care of patients with acute coronary syndromes.

Predicting survival from out-of-hospital cardiac arrest: a multivariate analysis

From 954 attempts to resuscitate patients from out-of-hospital cardiac arrest two datasets were derived, namely 861 cases of cardiac arrest and 906 cases of either cardiac or primary respiratory arrest. For each dataset, multivariate analysis was performed by fitting a number of explanatory variables with respect to the outcomes of admission to hospital and discharge home in logistic regression models. There were numerous interactions between these variables. Being conscious at the time of the arrival of the ambulance crew and subsequently having cardiac arrest strongly predicted survival, as did both the presence of a witness to the arrest and the initiation of cardiopulmonary resuscitation (CPR) by a bystander; this latter effect was a marker for early CPR. The strongest predictor of a poor outcome was delay to CPR or delay to advanced cardiac life support.

Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited

OBJECTIVE To identify factors associated with the uptake of cardiac rehabilitation following acute myocardial infarction. DESIGN Retrospective analysis using multivariate logistic regression modelling. SETTING Two large teaching hospitals in Nottingham. PATIENTS Cohorts of patients admitted with acute myocardial infarction in 1992 and 1996. INTERVENTIONS None. MAIN OUTCOME MEASURES Factors in multivariate analysis found to be associated with attendance at cardiac rehabilitation. Use of secondary prevention in those who were and were not invited and those who did and did not attend cardiac rehabilitation. RESULTS 58% of all patients were offered cardiac rehabilitation. Attendance rates were 60% in 1992 and 74% in 1996. Invitations were more likely to be offered to younger patients, those who had received thrombolysis, and to patients admitted to one of the two Nottingham hospitals. Use of secondary prevention was only 48% in 1992 but this increased to 80% in 1996. Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no difference in the use of secondary prevention between those who did and did not attend cardiac rehabilitation. CONCLUSION Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.

The need for wider dissemination of CPR skills: are schools the answer?

The value of instructing members of the public in CPR is now widely recognised, but community training schemes which rely largely on volunteers may fail to reach their targets. CPR training for lay people is often a once only activity and it has been shown that, without revision, skills deteriorate rapidly. By teaching CPR in secondary schools all social classes and ethnic groups could be reached, and retention of skills improved by regular revision. Health education has shown that it may be beneficial to use older pupils as instruction assistants.

Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study

Abstract Objective To examine process of care and outcome for patients admitted with acute myocardial infarction to hospitals in England and Wales in relation to type of consultant care and type of hospital. Design Observational study of 88 782 patients admitted with myocardial infarction during 2004-5, using records from the national audit of myocardial infarction project (MINAP) database. Outcome measures Use of reperfusion treatment and secondary prevention drugs, use of angiography, and 90 day mortality of patients admitted under the care of cardiologists and non-cardiologists in hospitals with and without facilities for coronary intervention. Findings 36% of patients were admitted under the care of a cardiologist and 20% to a hospital with coronary interventional facilities. Patients admitted under cardiologists had fewer comorbidities than other patients and were more likely to have reperfusion treatment (12 266/14 433 (85%) v 13 682/17 064 (80%)) and appropriate secondary prevention drugs. Overall, 27 431/79 374 (35%) of patients had angiography. Relatively more patients admitted to interventional hospitals (8167/14 661; 56%) than to other hospitals had angiography (19 264/64 713; 30%). The adjusted risk of death by 90 days for patients treated in interventional compared with non-interventional hospitals was 0.93 (95% confidence interval 0.82 to 1.06). The adjusted risk of death at 90 days for patients admitted under cardiologists compared with non-cardiologists was 0.86 (0.81 to 0.91). Conclusions Patients cared for by cardiologists had less comorbidity than other patients. They were more likely to receive proved treatments and angiography, and they had a lower adjusted 90 day mortality. Large differences existed in the use of angiography between interventional and non-interventional hospitals. These findings show wide variations in the management and outcome of patients with myocardial infarction in England and Wales.

TEACHING SCHOOLCHILDREN CARDIOPULMONARY RESUSCITATION

Forty-one children aged 11-12 years received tuition in cardiopulmonary resuscitation (CPR) and subsequently completed questionnaires to assess their theoretical knowledge and attitudes their likelihood of performing CPR. Although most children scored well on theoretical knowledge, this did not correlate with an assessment of practical ability using training manikins. In particular only one child correctly called for help after the casualty was found to be unresponsive, and none telephoned for an ambulance before starting resuscitation. These omissions have important implications for the teaching of CPR and the resulting effectiveness of community CPR programmes.

Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome.

Objective: To determine the effect of insulin for the management of hyperglycaemia in non-diabetic patients presenting with acute coronary syndrome. Methods: An observational study from the MINAP (National Audit of Myocardial Infarction Project) database during 2003–5 in 201 hospitals in England and Wales. Patients were those with a final diagnosis of troponin-positive acute coronary syndrome who were not previously known to have diabetes mellitus and whose blood glucose on admission was ⩾11 mmol/l. The main outcome measure was death at 7 and 30 days. Results: Of 38 864 patients who were not previously known to be diabetic, 3835 (9.9%) had an admission glucose ⩾11 mmol/l. Of patients having a clear treatment strategy, 36% received diabetic treatment (31% with insulin). Mortality at 7 and 30 days was 11.6% and 15.8%, respectively, for those receiving insulin, and 16.5% and 22.1%, respectively, for those who did not. Compared with those who received insulin, after adjustment for age, gender, co-morbidities and admission blood glucose concentration, patients who were not treated with insulin had a relative increased risk of death of 56% at 7 days and 51% at 30 days (HR 1.56, 95% CI 1.22 to 2.0, p<0.001 at 7 days; HR 1.51, 95% CI 1.22 to 1.86, p<0.001 at 30 days). Conclusion: In non-diabetic patients with acute coronary syndrome and hyperglycaemia, treatment with insulin was associated with a reduction in the relative risk of death, evident within 7 days of admission, which persists at 30 days.

Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project

Objective To describe patterns of prehospital ECG (PHECG) use and determine its association with processes and outcomes of care in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI. Methods Population-based linked cohort study of a national myocardial infarction registry. Results 288 990 patients were admitted to hospitals via emergency medical services (EMS) between 1 January 2005 and 31 December 2009. PHECG use increased overall (51% vs 64%, adjusted OR (aOR) 2.17, 95% CI 2.12 to 2.22), and in STEMI (64% vs 79%, aOR 2.34, 95% CI 2.25 to 2.44). Patients who received PHECG were younger (71 years vs 74 years, P<0.0001); and less likely to be female (33.1% vs 40.3%, OR 0.87, 95% CI 0.86 to 0.89), or to have comorbidities than those who did not. For STEMI, reperfusion was more frequent in those having PHECG (83.5% vs 74.4%, p<0.0001). PHECG was associated with more primary percutaneous coronary intervention patients achieving call-to-balloon time <90 min (27.9% vs 21.4%, aOR 1.38, 95% CI 1.24 to 1.54) and more patients who received fibrinolytic therapy achieving door-to-needle time <30 min (90.6% vs 83.7%, aOR 2.13, 95% CI 1.91 to 2.38). Patients with PHECG exhibited significantly lower 30-day mortality rates than those who did not (7.4% vs 8.2%, aOR 0.94, 95% CI 0.91 to 0.96). Conclusions Findings from this national MI registry demonstrate a survival advantage in STEMI and non-STEMI patients when PHECG was used.