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Myocardial infarction with ST-segment elevation overview

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These are the paths in the Myocardial infarction with ST-segment elevation pathway:

Myocardial infarction with ST-segment elevation HAI

About

What is covered

This pathway covers the acute management of myocardial infarction with STEMI.
STEMI occurs when a coronary artery becomes blocked by a blood clot, causing the heart muscle supplied by the artery to die. It belongs to a group of heart conditions known as acute coronary syndromes.
Nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds are lost within 3 hours. Apart from resuscitation from any cardiac arrest, the highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible.
Administering a fibrinolytic drug used to be the best way to restore flow. However, fibrinolysis was not suitable for use in some people because of bleeding complications. To improve outcomes, attention turned to mechanical techniques to restore coronary flow (for example, coronary angioplasty, thrombus extraction catheters and stenting), which are grouped under the overarching term primary PCI.
The National Infarct Angioplasty Project concluded that primary PCI is both feasible and cost effective, and that it should become the treatment of choice for STEMI, provided it could be delivered 'in a timely fashion'.
Primary PCI 'timeliness' is a key part of this pathway. This is addressed in detail, so commissioners and professionals delivering services for people with STEMI can plan their configuration in such a way that outcomes are optimal. This pathway also covers procedural primary PCI issues, the use of antiplatelet and antithrombin agents, and improving outcomes for the minority of people still receiving fibrinolysis.
The recommendations in this pathway relate only to people with a diagnosis of STEMI. The NICE clinical guideline on chest pain of recent onset covers the diagnosis of STEMI and should be read in conjunction with this pathway. The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Updates

Updates to this pathway

4 September 2014 'Acute coronary syndromes (including myocardial infarction)' (NICE quality standard 68) added to this pathway..
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to treatment with primary percutaneous coronary intervention.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to treatment with primary percutaneous coronary intervention.
25 March 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
20 December 2013 Minor maintenance updates.
12 November 2013 Link added to Myocardial infarction: secondary prevention pathway
20 August 2013 Minor maintenance updates.
18 July 2013 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Myocardial infarction with ST-segment-elevation: the acute management of myocardial infarction with ST-segment-elevation

What is covered

This pathway covers the acute management of myocardial infarction with STEMI.
STEMI occurs when a coronary artery becomes blocked by a blood clot, causing the heart muscle supplied by the artery to die. It belongs to a group of heart conditions known as acute coronary syndromes.
Nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds are lost within 3 hours. Apart from resuscitation from any cardiac arrest, the highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible.
Administering a fibrinolytic drug used to be the best way to restore flow. However, fibrinolysis was not suitable for use in some people because of bleeding complications. To improve outcomes, attention turned to mechanical techniques to restore coronary flow (for example, coronary angioplasty, thrombus extraction catheters and stenting), which are grouped under the overarching term primary PCI.
The National Infarct Angioplasty Project concluded that primary PCI is both feasible and cost effective, and that it should become the treatment of choice for STEMI, provided it could be delivered 'in a timely fashion'.
Primary PCI 'timeliness' is a key part of this pathway. This is addressed in detail, so commissioners and professionals delivering services for people with STEMI can plan their configuration in such a way that outcomes are optimal. This pathway also covers procedural primary PCI issues, the use of antiplatelet and antithrombin agents, and improving outcomes for the minority of people still receiving fibrinolysis.
The recommendations in this pathway relate only to people with a diagnosis of STEMI. The NICE clinical guideline on chest pain of recent onset covers the diagnosis of STEMI and should be read in conjunction with this pathway. The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Updates

Updates to this pathway

4 September 2014 'Acute coronary syndromes (including myocardial infarction)' (NICE quality standard 68) added to this pathway..
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to treatment with primary percutaneous coronary intervention.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to treatment with primary percutaneous coronary intervention.
25 March 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
20 December 2013 Minor maintenance updates.
12 November 2013 Link added to Myocardial infarction: secondary prevention pathway
20 August 2013 Minor maintenance updates.
18 July 2013 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Myocardial infarction with ST-segment-elevation. NICE clinical guideline 167 (2013)
Ticagrelor for the treatment of acute coronary syndromes. NICE technology appraisal guidance 236 (2011)
Drug-eluting stents for the treatment of coronary artery disease. NICE technology appraisal guidance 152 (2008)
Guidance on the use of coronary artery stents. NICE technology appraisal guidance 71 (2003)
Bioresorbable stent implantation for treating coronary artery disease. NICE interventional procedure guidance 492 (2014)
Optical coherence tomography to guide percutaneous coronary intervention. NICE interventional procedure guidance 481 (2014)

Quality standards

Quality statements

Diagnosis of acute myocardial infarction

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with a suspected acute coronary syndrome are assessed for acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Rationale

Acute myocardial infarction can have a poor prognosis so prompt and accurate diagnosis is important to ensure that appropriate treatment and care is offered as soon as possible. Treatment for adults with suspected acute coronary syndrome is often started before a diagnosis is confirmed. Confirming the diagnosis using the criteria in the universal definition of myocardial infarction is important to ensure that any ongoing treatment is appropriate and any inappropriate treatment is stopped.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Data source: Local data collection.
Process
Proportion of adults with a diagnosis of acute myocardial infarction who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Numerator – the number in the denominator who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Denominator – the number of adults with a diagnosis of acute myocardial infarction.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Healthcare professionals ensure that they are aware of the universal definition of myocardial infarction and assess adults with a suspected acute coronary syndrome for the presence of acute myocardial infarction using the criteria in the universal definition.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with expertise in using the criteria in the universal definition of myocardial infarction to diagnose acute myocardial infarction in adults with a suspected acute coronary syndrome.

What the quality statement means for patients, service users and carers

Adults with severe pain in the chest and/or in other areas (for example, the arms, back or jaw) that might be a heart attack (a suspected acute coronary syndrome) are only given a diagnosis of heart attack if their signs and symptoms meet an agreed definition.

Source guidance

Definitions of terms used in this quality statement

Universal definition of myocardial infarction
A rise in cardiac biomarkers (preferably cardiac troponin) with at least 1 value above the 99th percentile of the upper reference limit and/or a fall in cardiac biomarkers, together with at least 1 of the following:
  • symptoms of ischaemia
  • ECG changes indicating new ischaemia (new ST-segment-T wave changes or new left bundle branch block)
  • pathological Q wave changes in the ECG
  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
[NICE clinical guideline 95, recommendation 1.2.6.1]

Equality and diversity considerations

Symptoms of acute coronary syndromes should be assessed in the same way in men and women and among people from different ethnic groups.

Risk assessment for adults with NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Rationale

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment (for example, using the GRACE scoring system) in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment related adverse events. Failure to categorise future risk can lead to people being given inappropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Data source: Local data collection.
Process
Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Numerator – the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Denominator – the number of presentations because of NSTEMI or unstable angina.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 1.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.
Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for risk of future adverse cardiovascular events
Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
The formal risk assessment should include:
  • a full clinical history (including age, previous myocardial infarction and previous percutaneous coronary intervention or coronary artery bypass grafting)
  • a physical examination (including measurement of blood pressure and heart rate)
  • resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
[NICE clinical guideline 94, recommendations 1.2.1 and 1.2.2]
Categories for risk of future adverse cardiovascular events
Using 6-month mortality, the categories for the risk of future adverse cardiovascular events are:
Predicted 6-month mortality
Risk of future adverse cardiovascular events
1.5% or below
Lowest
>1.5 to 3.0%
Low
>3.0 to 6.0%
Intermediate
>6.0 to 9.0%
High
Over 9.0%
Highest
[NICE clinical guideline 94, recommendation 1.2.5]

Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) within 72 hours of first admission to hospital.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. In people with an intermediate or higher risk of future adverse cardiovascular events, coronary angiography within 72 hours of admission to hospital offers advantages over an initial conservative strategy, provided there are no contraindications to angiography (such as active bleeding or comorbidity). Services should provide coronary angiography (with follow-on PCI if indicated) as soon as it offers net clinical benefits; they should not wait until 72 hours if this is sooner.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Data source: Local data collection.
Process
Length of time taken for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to receive coronary angiography (with follow-on PCI if indicated).
Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.
Proportion of adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who receive coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Numerator – the number of people in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 72 hours of admission.
Denominator – the number of adults with NSTEMI or unstable angina with an intermediate or higher risk of future adverse cardiovascular events on admission to hospital.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 9.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to be seen by cardiac specialists and offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise to offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina who have a medium or higher risk of another heart attack are offered a test called coronary angiography, and treatment to improve blood flow to the heart if needed, within 72 hours of first being admitted to hospital.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 72 hours, rather than 96 hours as stated in the recommendation, is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Intermediate or higher risk of future adverse cardiovascular events
A predicted 6-month mortality above 3.0%. [NICE clinical guideline 94, recommendation 1.5.1]

Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who are clinically unstable have coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. The benefits of an early invasive strategy appear to be greatest in people at higher risk of future adverse cardiovascular events. In people with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) should be done as soon as possible so that appropriate treatment can be given. It may reduce lengthy hospital stays and prevent further cardiovascular events in both the short and long term. The timing of coronary angiography will be different for each person, but should be within 24 hours of becoming clinically unstable.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who are clinically unstable have coronary angiography (with follow-on PCI if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.
Data source: Local data collection.
Process
Length of time taken for adults with NSTEMI or unstable angina who are clinically unstable (on admission or during their hospital stay) to receive coronary angiography (with follow-on PCI if indicated).
Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.
Data source: Local data collection.
Proportion of adults with NSTEMI or unstable angina who are clinically unstable who receive coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Numerator – the number in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Denominator – the number of adults with NSTEMI or unstable angina who are clinically unstable.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (secondary care and cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina and whose condition is unstable are offered a test called coronary angiography and treatment to improve blood flow to the heart if needed, as soon as possible but within 24 hours of their condition becoming unstable.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 24 hours is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Clinically unstable
People who are clinically unstable are defined as those with:
  • ongoing or recurring pain despite treatment
  • haemodynamic instability (low blood pressure, shock)
  • dynamic ECG changes
  • left ventricular failure.
[Expert opinion]
As soon as possible
Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. [Expert opinion]

Level of consciousness and eligibility for coronary angiography and primary PCI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial infarction (STEMI) are not excluded from having coronary angiography (with follow–on primary percutaneous coronary intervention [PCI] if indicated).

Rationale

People who remain unconscious after cardiac arrest should not be treated differently from people who are conscious. They should be able to have the same treatments within the same timescales and should be admitted to centres capable of undertaking primary PCI. Carrying out immediate primary PCI, if successful, could stabilise the person’s heart and may reduce the risk of further complications.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated) because they are unconscious.
Data source: Local data collection.
Process
Proportion of adults who were unconscious after cardiac arrest caused by suspected acute STEMI who receive coronary angiography (with follow-on primary PCI if indicated).
Numerator – the number in the denominator receiving coronary angiography (with follow-on primary PCI if indicated).
Denominator – the number of adults who were unconscious after cardiac arrest caused by suspected acute STEMI.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (ambulance services and cardiac service providers) ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated). Providers should also raise awareness among healthcare professionals of the importance of not using level of consciousness to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Healthcare professionals ensure that they do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that can carry out coronary angiography (with follow–on primary PCI if indicated) in adults who are unconscious after cardiac arrest caused by suspected acute STEMI.

What the quality statement means for patients, service users and carers

Adults who are unconscious after a type of heart attack called STEMI can have a test called coronary angiography, and treatment to improve blood flow to the heart if needed, even though they are unconscious.

Source guidance

Primary PCI for acute STEMI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with acute ST-segment-elevation myocardial infarction (STEMI) who present within 12 hours of onset of symptoms have primary percutaneous coronary intervention (PCI), as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of the time when fibrinolysis could have been given.

Rationale

Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis. However, when performed early, primary PCI is more effective. To ensure the best outcomes for adults with STEMI, the ambulance service and hospitals delivering primary PCI should work together to minimise delays in treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with acute STEMI who present within 12 hours of onset of symptoms have primary PCI, as the preferred coronary reperfusion strategy, within 120 minutes of the time when fibrinolysis could have been given.
Data source: Local data collection.
Evidence of local arrangements to ensure that adults with acute STEMI have access to primary PCI 24 hours a day.
Data source: Local data collection.
Evidence that commissioners with their services providers have developed a single care pathway for coronary reperfusion.
Data source: Local data collection.
Process
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 120 minutes of when fibrinolysis could have been given.
Numerator – the number in the denominator receiving primary PCI within 120 minutes of when fibrinolysis could have been given.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Data source: Local data collection. Some fields on time to primary PCI collected in Myocardial Ischaemia National Audit Project (MINAP) and National audit of percutaneous coronary interventional procedures (BCIS).
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 150 minutes of the call for professional help.
Numerator – the number of people in the denominator receiving primary PCI within 150 minutes of the call for professional help.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (ambulance services, accident and emergency service provider and cardiac service providers) ensure that local pathways and transfer protocols are in place for adults with acute STEMI who present within 12 hours of the onset of symptoms to be offered primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given.
Healthcare professionals ensure that they offer primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given to adults with acute STEMI who present within 12 hours of the onset of symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have the capacity and expertise to provide primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given (and at any time of the day or night, including weekends) to adults with acute STEMI who present within 12 hours of onset of symptoms. Commissioners should work with their service providers to develop a single care pathway for coronary reperfusion.

What the quality statement means for patients, service users and carers

Adults with a type of heart attack called STEMI whose symptoms started no more than 12 hours before first contacting a healthcare professional are offered a procedure to improve blood flow to the heart (called percutaneous coronary intervention or PCI). They should be able to have this as soon as possible, but within 120 minutes of when they could have received fibrinolysis (a ‘clot-busting’ drug).

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

Percutaneous coronary intervention.
Myocardial infarction with ST-segment elevation.

Paths in this pathway

Pathway created: July 2013 Last updated: September 2014

© NICE 2014

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