myocardial ischaemia national audit project minap · the myocardial ischaemia national audit...

How

the NH

S cares for patients with heart attack

MIN

AP Tenth P

ublic Report 2011

Myocardial IschaemiaNational Audit Project


myocardial ischaemia national audit project [minap]

How the NHS cares for patients with heart attack

Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group

NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH

MINAP 2011 Cover 5mm spine.indd 1 16/08/2011 13:35

heart attacks recorded in minap in 2010/11This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11.

Report prepared by: Lucia Gavalova, Project co-ordinator MINAP

With assistance from:Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinatorLynne Walker, MINAP Programme managerProfessor Tom Quinn, MINAP Steering Group memberProfessor Adam Timmis, Chairman MINAP Academic GroupMrs Sirkka Thomas, MINAP Patient/carer representativeMr David Geldard, MINAP Patient representative

Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap

For further information about this report, contact:

Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes ResearchInstitute of Cardiovascular ScienceUniversity College London175 Tottenham Court RoadLondon W1T 7NU

Tel: 0203 108 3931 Email: [email protected]

University College London (media enquiries)Media Relations Manager Ruth Howells Tel: 020 3108 3845Email: [email protected]

Acknowledgements

Department of Health Enquiries to the Department should be directed to the Customer Service CentreTel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform

In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS

Welsh Assembly Government Ms Cathy WhiteHead of Adult & Children’s HealthMedical DirectorateDepartment for Health, Social Services & ChildrenWelsh GovernmentCathays Park,Cardiff CF10 3NQ

Tel: 029 20826108Email: [email protected]

Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

The MINAP team would like to thank all the hospitals and ambulance services that have collected data.

This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.

The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.

MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk.

This report may not be published or used commercially without permission.

Designed and published by:

| www.padcreative.co.uk


3MINAP Tenth Public Report 2011

contents

By the National Director for Heart Disease and Stroke

1. Background to heart attacks 7

1.1 ST elevation myocardial infarction 7 and non ST elevation myocardial infarction

1.2 Aims of management 7

1.3 Reperfusion therapy 8

2. Background to MINAP 8

2.1 A look back 8

2.2 Organisation of MINAP 10

2.3 How the data are collected 10

2.4 Security and patient confidentiality 10

2.5 Case ascertainment 10

2.6 Data quality 10

3. Improving quality, improving outcomes 11

3.1 Use of MINAP data to inform the British 11 Cardiovascular Society working group on the use of the cardiac care unit

3.2 Use of primary angioplasty 11

3.3 Access to coronary angiography 12 for patients with non ST elevation myocardial infarction

3.4 International comparisons 13

4. MINAP: a patient’s perspective 14

1. Characteristics of patients with heart attack 16 in 2010/11

2. Hospitals that perform primary angioplasty 18

3. Hospitals using thrombolytic treatment 19

4. Angiography for ST elevation infarction 20 patients not having primary angioplasty

5. Reperfusion treatment by hospital 20

6. Ambulance service performance 21

7. Use of secondary prevention medication 21

8. Cardiac networks 21

9. Care for patients with non ST elevation infarction 22

10. Change in mortality of heart attack patients 23

11. Results by hospitals, ambulance services 24 and cardiac networks

Table 1 Primary angioplasty in hospitals in 24 England, Wales & Belfast

Table 2 Thrombolytic treatment in hospitals 28 in England

Table 3 Thrombolytic treatment in hospitals 36 in Wales & Belfast

Table 4 Ambulance services in England & Wales 37

Table 5 Secondary prevention medication 38 in England

Table 6 Secondary prevention medication 50 in Wales & Belfast

Table 7 Cardiac networks in England & Wales 52

Table 8 Care of patients with non ST elevation 54 infarction in England

Table 9 Care of patients with non ST elevation 66 infarction in Wales & Belfast

12. Difference in performance in England 68 and Wales

Implementing a Primary PCI service in Oxford 69

MINAP, promoting prevention 70

Establishing a primary angioplasty service in 71 Lincolnshire

Improvement in call-to-balloon times at London 72 Chest Hospital, Barts & the London NHS Trust

Using data from MINAP to model a PPCI Service 73 in the Chesire & Merseyside network area

Use of MINAP data to analyse and improve 74 the PPCI service

1. MINAP Academic Group - 5 year overview 75

2. Use of MINAP data to evaluate the impact of 75 acute coronary syndrome care by patient age

3. Enriching MINAP through linkage to primary 76 care & investigator led cohorts

4. Management of hyperglycaemia in acute 76 coronary syndromes

foreword 4

executive summary 5

part two: results 16

part five: appendices 78

part four: research use of 75 minap data

part three: case studies 69

part one: introduction 7

MINAP Public Report Part 1 and 2 blue.indd 3 16/08/2011 14:02

title

4 MINAP How the NHS cares for patients with heart attack

This is quite an achievement and reflects on the hard work of staff across the NHS both in the ambulance services and in hospitals supported by the improvement programmes led by NHS Improvement and implemented locally by cardiac networks.

As more patients with heart attack have primary angioplasty these reports increasingly will also rely on information from the British Cardiovascular Intervention Society’s (BCIS) database, and future reports are likely to include analyses from this source.

We would like to thank all those that have been involved.

Professor Sir Roger Boyle, CBE, FRCP

National Director for Heart Disease and Stroke [to August 2011]

foreword

This year we celebrate the 11th anniversary of the initial roll out of MINAP in October 2000. During this time, we have witnessed a series of transformations in the management of heart attack which have long-term benefits for individual patients and the NHS as a whole. In the first few years we saw thrombolytic treatment provided with high levels of expertise, timeliness and efficiency by hospitals and by ambulance services. Over the last four years primary angioplasty has rapidly replaced thrombolytic treatment as the preferred treatment for heart attack, centralising acute care in specialist heart attack centres. At present, over 80% of heart attack patients receive primary angioplasty which is associated with shorter hospital stays, is safer and provides better outcomes. The chances of survival after heart attack have improved year on year despite an ageing population so that the outcomes in this country match the best in the world. Data show that death rates after heart attack have fallen faster in the UK than in any other European country.


title

This is the tenth annual MINAP Public Report. It presents analyses from all hospitals and ambulance services in England and Wales that provided care for patients with suspected heart attack between April 2010 and March 2011 (2010/11). For the first time we present data from hospitals in Belfast. The report also presents some data from previous years. Its purpose is to inform the public about the quality of local care for heart attack patients.

Heart attack is common and remains a major cause of death and ill health. Importantly, prompt and appropriate treatment reduces the likelihood of death and recurrent heart attack. Good treatment coupled with cardiac rehabilitation promotes optimal recovery. Heart attack, or myocardial infarction, is part of the spectrum of conditions known as acute coronary syndromes (ACS). This term includes both ST elevation myocardial infarction (STEMI), for which emergency reperfusion treatment with primary angioplasty or thrombolytic drugs is beneficial, and non ST elevation myocardial infarction (nSTEMI), which represent the majority and for which a different approach is required.

Initial treatment of patients with ST elevation myocardial infarction

High quality care for STEMI includes early diagnosis and rapid treatment to re-open the blocked coronary artery responsible for the heart attack. Two forms of treatment are available; primary angioplasty, where the artery is re-opened mechanically using a balloon catheter inserted into the blocked artery, and thrombolytic treatment, where the clot is dissolved by a drug given by ambulance or hospital staff. Delay to providing either treatment is associated with poorer outcomes.

Patients who received primary angioplasty for ST elevation myocardial infarction

Primary angioplasty is the preferred treatment if it can be provided promptly. Once a patient is recognised as having a heart attack, ambulance staff take the patient directly to the catheter laboratory of the nearest heart attack centre, often bypassing smaller hospitals and the Accident and Emergency (A&E) department.

� This year, in England, 82% of patients who received any reperfusion treatment received primary angioplasty compared to 63% in 2009/10. In Wales the increase was from 22% to 30%. In the Belfast hospitals 99% of patients who received any reperfusion treatment received primary angioplasty compared to 59% in 2009/10.

� This year 90% of eligible patients in England, 68% in Wales and 87% in Belfast were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre.

� 81% of eligible patients in England, 75% in Wales and 90% in Belfast were treated with primary angioplasty within 150 minutes of calling for professional help.

� Access to primary angioplasty is variable. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5% and 93%; in 6 cardiac networks fewer than 50% of patients received primary angioplasty.

� 75% of patients that were treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in the Belfast hospitals.

executive summary

The Myocardial Ischaemia National Audit Project (MINAP) is a national clinical audit of the management of heart attack. It supplies participating hospitals, ambulance services and commissioners with a record of their management and compares this with nationally and internationally agreed standards. MINAP provides comparative data to help clinicians and managers monitor and improve the quality and outcomes of their local services.




Patients who received thrombolytic treatment for ST elevation myocardial infarction

As the number of patients having primary angioplasty has increased, the number having thrombolytic treatment, either before or on arrival at hospital, has fallen.

� 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help in England; 53% in Wales. Thrombolytic treatment is not used in the Belfast hospitals.

� 69% of patients who received thrombolytic treatment or who had no reperfusion treatment had, or were later referred for, coronary angiography in England; 83% in Wales and 50% in Belfast.

Thrombolytic treatment given by paramedics before the patient reaches hospital

For many ambulance services, the focus has shifted from provision of early pre-hospital thrombolytic treatment to identifying those patients with a heart attack who might benefit from primary angioplasty, and transferring these patients rapidly to a heart attack centre. This means that for many ambulance services the number of patients receiving pre-hospital thrombolytic treatment has declined.

� 824 patients received pre-hospital thrombolytic treatment in England in 2010/11 compared to 1633 in 2009/10, a decrease of 50%. In Wales 219 patients received pre-hospital thrombolytic treatment compared to 250 in 2009/10. Pre-hospital thrombolytic treatment is not used in Belfast.

Care of patients with non ST elevation myocardial infarction

Patients with nSTEMI have a lower early risk of death (within the first month), but appear to be at similar or even greater long-term risk than patients with STEMI. Perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to cardiac care units and are not always cared for by cardiologists. However, specialist involvement has been shown to lead to better outcomes. The performance of angiography and coronary intervention soon, within the first 2-4 days, is an

important facet of treatment for the majority of these patients. Ideally, admission should be to a cardiac facility where nursing staff have cardiac expertise and there is easy access to cardiological advice. This year:

� 50% of nSTEMI patients were admitted to a cardiac unit or ward in England, 59% in Wales and 81% in Belfast.

� 91% of nSTEMI patients were seen by a cardiologist or member of their team in England, 84% in Wales and 99% in Belfast. However the Welsh data are incomplete as 4/18 hospital did not enter data on their nSTEMI patients.

Prescription of secondary prevention medication

Taking secondary prevention drugs after the acute event (for both STEMI and nSTEMI patients) reduces the risk of death and further heart attack. The proportion of patients in England, Wales and Belfast who are suitable for treatment and in whom secondary prevention medication is prescribed on discharge from hospital continues at over 90% for each of the 5 drug classes monitored.

Falling mortality

There has been a year on year fall in the percentage of patients with STEMI and nSTEMI who die within 30 days of admission to hospital.


title


If ischaemia is sufficiently prolonged or complete, death of heart muscle results. This is myocardial infarction and is confirmed if evidence of heart muscle cell death is found on blood testing. Such evidence may take some hours to appear and, to be most effective, treatment must start before the results of such tests are available. Ischaemia is suggested by characteristic symptoms (for example central chest discomfort, sweating, breathlessness) and abrupt changes in blood pressure, heart rate and heart rhythm (sometimes leading to collapse or sudden death). Features of ischaemia often can be seen as electrical alterations on the electrocardiogram (ECG). At the onset of symptoms it is uncertain whether the ischaemia will be transient and of no long-term consequence, or whether it will progress to infarction and consequent failure of the heart to pump strongly. So all patients require urgent treatment to reverse ischaemia and prevent infarction.

1.1 ST elevation myocardial infarction and non ST elevation myocardial infarction

Based upon the ECG, patients are categorised into those with, and those without, ST segment elevation – leading to the final diagnosis of those with ST elevation myocardial infarction (STEMI) and those with non ST elevation myocardial infarction (nSTEMI). ST elevation usually indicates complete blockage of a coronary artery and warrants specific immediate treatment to re-open the artery – see Section 1.3 Reperfusion therapy. The absence of ST elevation usually indicates that any coronary thrombosis is only partially occluding the artery.

Although those with STEMI are at greater early risk, the medium to long-term outcome (in terms of recurrent heart attack or death) is similar, if not worse, for those with nSTEMI. Within the last two years the National Institute for Health and Clinical Excellence (NICE)1 has published guidelines for the management of patients with nSTEMI. NICE have a STEMI guideline and Quality Standard in development.2

1.2 Aims of management

The aims of management of acute coronary syndrome are presented in Figure 1 together with examples of some interventions that have been shown to be associated with better outcomes for patients and have therefore been included in various guidelines. Not all patients require all the interventions and some interventions are unsuitable – contraindicated – in some patients. Therefore, clinicians involved in providing care do not blindly follow protocols of treatment but must use their clinical judgement to determine when particular treatments should be used, and when best avoided, in individual patients.

Aims Examples of interventions

Prompt recognition of symptoms

Public education

Education of professionals

Provision of heart monitoring & resuscitation

Ambulance ‘999’ response

Hospital Cardiac Care Units

Restoration of coronary blood flow

Reperfusion treatment

� Primary angioplasty

� Thrombolytic therapy

Nitrates

Elective angioplasty/surgery

Prevention of further coronary thrombosis

Anticoagulants

Antiplatelet agents

Reduction & reversal of ischaemia

Reperfusion treatment

Anti-anginal drugs

e.g. beta blockers, nitrates

Stabilisation of coronary artery Statins

Optimise healing ACE inhibitors

Prevention of future myocardial infarction

Secondary prevention drugs

Lifestyle changes

Education & support, promotion of healthy lifestyles

Hospital cardiac nurse specialists

Cardiac Rehabilitation classes

Patient support groups

Fig 1. Aims of management of acute coronary syndrome

part one: introduction

1. Background to heart attacks

The term ‘heart attack’, while used widely in discussions between clinicians and their patients, and therefore in this public report, is too imprecise to define the clinical condition that is the subject of this national audit. The preferred term is acute coronary syndrome. This covers the symptoms and clinical features that occur when there is an abrupt reduction in the blood supply to a segment of heart muscle. Usually this is a consequence of a gradual build-up of fibro-fatty material (atheroma) within the wall of the coronary artery, which may have happened over years and often without symptoms, followed by sudden disruption of the internal artery wall at this site. This causes blood to clot within the artery – a coronary thrombosis – and leads to a state of myocardial ischaemia, in which the demands of the effected heart muscle for oxygen-rich blood exceed the supply of such blood down the clot-containing artery.

1. www.nice.org.uk/guidance/CG94

2. http://guidance.nice.org.uk/CG/WAVE25/8



1.3 Reperfusion therapy

These are treatments that re-open the blocked coronary artery that is causing the ACS; thereby reducing the amount of heart damage. If re-opening the artery is to be of benefit it needs to happen as quickly as possible, before all the heart muscle at risk has been damaged. These therapies are therefore used in the immediate management of those with STEMI (see above). If patients delay too long after the start of their symptoms reperfusion therapy may be of no value and would not then be advised.

Two forms of treatment exist, primary angioplasty (percutaneous coronary intervention (PCI) – where the artery is opened mechanically using a balloon catheter and a stent is then left in the artery to prevent re-occlusion – and thrombolytic therapy – where the clot is dissolved by a drug. Thrombolytic therapy is given by intravenous injection and can therefore be delivered rapidly, preferably even before arriving at hospital. While the drug can be given quickly its effect on the blood clot is not immediate and varies from person to person – in some failing to re-open the artery at all. Primary angioplasty requires specialised equipment and highly-trained clinical staff within the hospital. Patients tend to wait longer for primary angioplasty than they would for thrombolytic treatment, but the final results are more reliable in terms of complete restoration of coronary blood flow, see Fig 2.

Advantages Disadvantages

Thrombolytic drugs

Established treatment

Simple administration (intravenously)

Potentially available in all hospitals

Pre-hospital use by ambulance paramedics

Fails in at least 20%

Risk of bleeding and stroke

Primary angioplasty

Successful in at least 95%

Lower stroke risk

Allows visualisation of all coronary arteries

Cardiologist necessarily involved in care of all patients

Randomised trials suggest primary angioplasty more effective than thrombolytic therapy

Not available in all centres

Treatment must be delayed until arrival at hospital

Risk of bleeding

Fig 2. Reperfusion therapy in ST elevation myocardial infarction

2. Background to MINAP

2.1 A look back

It is only by collecting data and using them that you get senseWilliam Osler, 1928

The publication of the tenth annual report of MINAP provides an opportunity to reflect on the development of the audit project, and to consider its future role in supporting and assuring good quality care for patients with ACS.

The concept of collecting a common dataset of

information on geographically distinct groups of people with heart attack was proposed by the European Regional Office of the World Health Organisation in 1968, and led to the promotion of Myocardial Infarction Community Registers, (and later to the WHO MONICA research project). In Britain, early community registers were developed in Oxford, Edinburgh and Tower Hamlets.

The primary purpose of such registers was ‘educational’ – to more precisely report the incidence of coronary events in a community; both within and without hospital, to describe the manifestations of heart attacks and to allow a comparison of fatality rates between localities. Little information was collected about the care provided within hospital. To be of more practical use to clinicians and the general population a change of emphasis was needed. As Hugh Tunstall Pedoe commented in 1978.

“The collection of information for its own sake is of doubtful value unless it is acted upon. Community registers should not become the equivalent of village war memorials.” 3

He also recognised that such information could be used in “monitoring the effects of treatment” and ensuring that it was “reaching those who needed it”. Here was recognition that data collection could be used to assure appropriate treatment; to go beyond a register toward an audit function.

Clinicians have for many years maintained hospital-based cardiac care unit registers. Perhaps the most enduring is the Nottingham Heart Attack Register, which began in simple form in 1972, and has collected more definitive data since 1982 4.

3. Tunstall Pedoe H. Uses of coronary heart attack registers. Br Heart J 1978;40:510-5.

4. Rowley JM, Mounser P, Harrison EH, et al. Management of myocardial infarction: implications for current policy derived from the Nottingham Heart Attack Register. Br Heart J 1992;67:255-62.



Such registers have been of great value in showing variation over time in the presentation and outcome of patients with heart attacks. Being unique to each hospital, they are of limited value in revealing and quantifying variation between hospitals.

By the end of the 1980s large randomised trials, in carefully selected groups of patients, confirmed the effectiveness of clinical treatments of heart attack, and provided robust evidence upon which to base recommendations for best management. In particular, the recognition that thombolytic drugs had substantial benefits when given early after the onset of symptoms led to the realisation that it also mattered how and when a treatment was given as well as whether it was given. Measurable standards for treatment, such as door-to-needle time and call-to-needle time appeared in national guidelines, together with advice that hospitals “should provide audit data of delays to treatment” (against agreed standards)5.

Some cardiologists actively lobbied for a common audit in which all hospitals would participate. They believed that a truly national audit would lead to a more rapid implementation of evidence-based clinical practice and thus to improved outcomes for patients with heart attack. Beginning with paper records and later using portable pre-programmed Psion organisers, these cardiologists formed the Myocardial Infarction Audit Group and began, from 1992, to share their (anonymised) data, providing evidence of significant variation in practice6. A regionwide comparative audit conceived by Dr John Birkhead and Professor Rod Griffiths, the West Midlands Thrombolysis Project, reported significant improvement in call-to-needle time as a result of this approach7 . Around this time certain significant advances facilitated the aspiration of the group. Anthony Rickards and David Cunningham conceived and developed the Central Cardiac Audit Database (CCAD) to which data from all participating hospitals could be sent electronically, with automatic encryption8.

Government policy emphasised the potential gain to health from the optimum management of heart attack. Setting, delivering and monitoring standards became an imperative, resulting in much professional and public engagement in describing both potential health outcome indicators9 and the standards of care expected by patients with coronary disease10. This latter document, a National Service Framework (NSF), mandated every acute hospital to have available clinical audit data that was no more than 12 months old and suggested that “where relevant” these should be “derived from participation in national audits”.

The Myocardial Infarction (later, Ischaemia) National Audit Project (MINAP) was established in 1999. It was founded on the following propositions:

� The audit should be a complete record of care rather than a snapshot – all (rather than a sample of) patients being included

� The audit should be prospective – information being collected as soon after treatment as possible

� Participating hospitals should agree both common definitions of clinically important variables and common standards of good quality care against which to audit their practice

� Standards of care should be chosen that have a proven link to improved outcome – i.e. those aspects of care being audited, whilst capable of being expressed as measures of process or performance, should link directly to better patient outcomes

� The practices of individual hospitals should be aggregated into a national figure – a hospital could audit against agreed standards and compare against the national aggregate

� Sufficient data should be recorded to allow for case-mix adjustment and other techniques for investigating differences in outcomes between hospitals,

� The dataset should be revised periodically to account for the introduction of newer treatments

� The audit should maintain its credibility and validity by being guided and supported by relevant professional and patient groups and be managed by a small project team

� A publicly accessible report should be published annually.

The standards presented in the NSF became the standards against which care was compared and a core dataset was prepared for participating hospitals11. Data collection began in October 2000 and by mid-2002 all acute hospitals in England and Wales were participating in the audit.

5. Weston CFM, Penny WJ, Julian DG. Guidelines for the early management of patients with myocardial infarction. BMJ 1994;308:767-71.

6. Birkhead JS. Thrombolytic treatment for myocardial inraction: an examination of practice in 39 United Kingdom hospitals. Myocardial Infarction Audit Group. Heart 1997;78:28-33

7. Quinn T, Allan TF, Birkhead J et al. Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project. Eur J Cardiovasc Nurs 2003 Jul;2(2):131-9.

8. Rickards A, Cunningham D. From quantity to quality: the Central Cardiac Audit Database Project. Heart 1999;82:II18-II22.

9. Birkhead J, Goldacre M, Mason A, et al. Health Outcome Indicators: Myocardial Infarction. Oxford, Centre for Health Outcomes Development, 1999.

10. National Service Framework for Coronary Heart Disease. Modern standards and service models. Accessed on 25 June 2011 at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf

11. Birkhead JS. Responding to the requirements of the National Service Framework for coronary disease: a core data set for myocardial infarction. Heart 2000;84:116-7.



2.2 Organisation of MINAP

MINAP is one of 7 national cardiac clinical audits that are now managed by the National Institute for Cardiovascular Outcomes Research (NICOR) which is part of the Institute for Cardiovascular Science at University College London (UCL).

MINAP is overseen by a Steering Group that represents key stakeholders including professional bodies, national government and patient representation, in conjunction with the British Cardiovascular Society (Appendix 1). MINAP is commissioned by the Healthcare Quality Improvement Partnership (HQIP) who hold commissioning and funding responsibility for MINAP and other national clinical audits. An academic group, which reports to the Steering Group, has been established to facilitate research use of the data, see part 4.

2.3 How the data are collected

The current dataset v9.1 contains 122 fields and includes information on pre- and in- hospital treatment, patient demographics and previous medical history. The dataset is revised every 2 years to meet the requirements of users and to respond to developments in the management of ACS. The dataset is available on the MINAP web pages12.

Data are collected by nurses and clinical audit staff and entered in a dedicated data application (either on-line or web based). Alternatively hospitals can also use commercial software that is able to collect the data. The project uses a highly secure electronic system of data entry, transmission and analysis developed by the CCAD team that is now part of NICOR. The audit has been running continuously since 2000 and all hospitals in England and Wales that admit patients with ACS contribute data.

Participating hospitals are requested to enter all patients with suspected myocardial infarction. About 90,000 records are created annually and in June 2011 the database contained over 873,000 records.

2.4 Security and patient confidentiality

All data uploaded by hospitals are encrypted on transmission and stored encrypted on the CCAD servers. CCAD manages access control to the servers via user IDs and passwords. All patient identifiable data are pseudonymised by CCAD before release to NICOR via a secure drop box on the CCAD server. Data held within NICOR are managed within a secure environment for storage and processing provided by the UCL network and within the UCL information governance and security policy.

The national cardiac audit data held by CCAD are registered under the Data Protection Act. NICOR has support under section 251 of the National Health Service (NHS) Act 2006. (Ref: NIGB: ECC 1-06 (d)/2011).

In addition, NICOR staff recognise that confidentiality is an obligation and regularly undergo information governance training to ensure understanding of the duty of confidentiality and how it relates to patient data.

2.5 Case ascertainment

In practice MINAP records the great majority of patients having STEMI in England and Wales. However it is accepted that a number of hospitals do not enter all their nSTEMI patients mainly due to lack of resources. The true number is difficult to establish as it is not possible to compare MINAP data with Hospital Episode Statistics (HES), the only possible comparator, except in aggregate. Although HES reports approximately 105,000 hospital admissions annually with myocardial infarction, it is not possible to separate this number into the clinical categories used within MINAP. MINAP records about 30,000 STEMIs, but only about 50,000 nSTEMIs annually. From internal data we consider that approximately 80,000 nSTEMIs per year would be an appropriate number.

Where all patients with ACS are admitted to the same ward or area it is easy to identify patients. It is much harder where patients are not all cared for in one area, and are looked after in several wards. Under-reporting of nSTEMIs varies between hospitals and reflects variation in resources allocated to data collection. Many hospitals do not have the resource to identify and record all nSTEMIs as these may not be admitted to a cardiac facility. Instead, patients with nSTEMI may be cared for in many areas in a hospital, and identification is difficult.

2.6 Data quality

Assessment of data completion and validation is presently based on patients with nSTEMI. The completeness of 20 key fields is continually monitored and is available to hospitals in an online view. Currently these fields are 99% complete.

MINAP performs an annual data validation study to assess the agreement of data held on the CCAD servers with data re-entered from the case notes. Hospitals are required to re-enter data from case notes in 20 key fields in 20 randomly selected nSTEMI records using an online data validation tool. Agreement between the original and the re-entered data is assessed for each variable and for each record. Reports

12. www.ucl.ac.uk/nicor/audits/minap



showing the agreement of each variable compared to national aggregate data

are sent to hospitals to allow them to

identify and act on areas of weakness with

respect to data collection and entry. 97.5% of eligible

hospitals in England and Wales participated in this year’s data

validation study. The median score for 2009/10 was 94.8% (IQR 90.0-

97.8). However the data are only as good as the data provided by hospitals

and there is no independent validation.

The MINAP data application contains error checking routines, including range and

consistency checks, designed to minimise common errors and online help. MINAP provides

detailed guidelines for data entry and provides a dedicated helpdesk to support problems regarding

data entry and clinical definitions.

3. Improving quality, improving outcomes

3.1 Use of MINAP data to inform the British Cardiovascular Society working group on the use of the cardiac care unit.

MINAP data continue to be used at local level and nationally to inform the development of cardiac services. MINAP data have recently been used to provide a report to the British Cardiovascular Society’s (BCS) working group on the future of the cardiac care unit (CCU).

Cardiac or coronary care units have been in existence since the early 1960s –almost 50 years – and in that time the management for heart attack has evolved in a fashion that would be unrecognisable to those working at that time. Coronary care units, to use the term originally applied, were primarily for the care of STEMI, a group of infarctions with a high early mortality. Death was, in the main, due to primary ventricular fibrillation (VF), a lethal condition treatable by immediate electrical cardioversion. It made sense therefore to admit all patients with STEMI, at high risk of VF, to a CCU. For other ACS, the majority, who were at lesser risk of early sudden death it was not thought necessary to admit to a CCU. CCUs were expensive to staff, and tended to be small in size, with 4 - 8 beds being typical. Units changed little over the next 40 years, and continued to provide excellent care for the limited number of patients that could be managed there.

Pressure for change has recently come from a number of directions. The first has been the rapid development of primary angioplasty performed in a limited number of hospitals for a number of surrounding hospitals. CCUs are no longer admitting the patients with STEMI that they had cared for over more than 40 years. At the same time there has been increased awareness of the opportunities for care for nSTEMI, previously often cared for in general medical facilities and by non-specialist physicians. In addition the value of specialised nursing and medical management for cardiac arrhythmias and severe forms of heart failure has long been apparent. However, a short term financially driven view of a CCU that no longer admits the patients for which it was designed almost 50 years ago is to close it, and deploy nursing staff elsewhere. This disturbing approach has been noted in a number of parts of the country.

It was in the light of reports of pressures to close CCUs, and an awareness that the facilities of existing CCUs might potentially be put to very good use that led to the setting up of the working group of the BCS. MINAP was invited to comment to the working group, and produced a report based on MINAP data for the care of patients with nSTEMI. This report, the contents of which will inform part of the report of the working group, indicated very clearly the benefits of admission of patients with nSTEMI to a CCU in terms of more appropriate care, the economic benefit of a shortened length of stay, and improvement in early mortality.

3.2 Use of primary angioplasty

The number of patients having STEMI who receive reperfusion treatment has declined slightly in the last few years. This decline appears to be associated with the increased use of primary angioplasty and, on reflection, might have been expected as primary angioplasty is preceded by a detailed radiographic examination of the coronary arteries.

When thrombolytic treatment was the reperfusion treatment of choice for STEMI the decision to use thrombolytic treatment was based on clinical findings and crucially on the appearances of the ECG. The appearances of the ECG do not always allow for a clear cut treatment decision; sometimes the appearances on which thrombolytic treatment is based are borderline and the clinician must make a judgement on the available evidence. This approach can potentially result in a small number of patients receiving thrombolytic treatment where clinical benefit is unlikely. By contrast all patients having primary angioplasty undergo a coronary angiogram as part of the procedure, and this provides detailed information on the presence of a coronary artery occlusion, it’s site, and likely impact on outcome. An additional benefit to patients admitted for primary angioplasty is that they come under the care of a consultant cardiologist almost immediately.



MINAP data allow an analysis of what procedure was ultimately performed for patients who present with ECG appearances of STEMI and who are therefore considered suitable candidates for primary angioplasty.

In 2010/11 MINAP data show that 8.6% of patients for whom it was intended to perform primary angioplasty did not receive it. Of those, 6.4% received an angiogram after which it was decided not to proceed to angioplasty. The commonest reasons for this was that the infarct related vessel had re-opened spontaneously or, that the coronary disease was too severe for angioplasty and that coronary artery bypass grafting was a more suitable treatment option. Another 1.8% of patients were not thought to require an angiogram.

Thus, the adoption of primary angioplasty, now provided for more than 80% of the population of England has resulted in reperfusion treatment for STEMI being more accurately tailored to those who might benefit most.

3.3 Access to coronary angiography for patients with non ST elevation myocardial infarction

In 2010 NICE published a guideline on the management of patients with nSTEMI13. A significant part of this report was written based on data from MINAP. One of the recommendations was that patients having infarctions of moderate severity, and those in whom it is possible to demonstrate residual ischaemia

on testing (evidence of persisting narrowing of a coronary artery) should have a coronary angiogram within 96 hours of admission, in order to determine the need for further treatment, typically coronary angioplasty or in a minority of cases, coronary artery bypass grafting.

During the last 10 years there has been a very substantial expansion of the number of catheterisation laboratories, with 141 hospitals in England (133) and Wales (8) having catheter laboratories compared with 86 in England and 2 in Wales 10 years ago.14

Since 2004, the percentage of patients with a final diagnosis of nSTEMI (broadly reflecting the NICE classification of moderate or greater severity) who have angiography during the admission has increased from just under 45% in 2004 to 71% in 2010. It should be recognised that angiography is not appropriate for all patients with nSTEMI. The average age of patients having a first nSTEMI is 70 years, and where performance of angiography is unlikely to alter longer term outlook because of co-morbidity, it may not be appropriate to perform it.

The improved access to angiography for patients with nSTEMI has resulted in a significant fall in the median length of stay for patients having angiography from 7.4 days in 2004/5 to 5.5 days in 2010/11. Over the same time the length of stay of patients not having angiography has fallen from 7.1 to 6.6 days.

13. The early management of unstable angina and non-ST-segment-elevation myocardial infarction. CG 94. National Institue for Health and Clinical Excellence. London 2010.

14. Birkhead J, Pearson J and Walker L. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians 2007. ISBN 978-1-86016-314-2.

Coronary angiogram of blocked left anterior descending artery before PCI Coronary angiogram of left anterior descending artery after PCI



3.4 International comparisons

Outcomes from heart attack have been a source of controversy in the ongoing debate about proposals for NHS reform in England. The Prime Minister has stated that “Someone [in this country] is twice as likely to die from a heart attack as someone in France”15. Statements from other Ministers have subsequently given a similar message.

The comparison with France appears to have been based on an Organisation for Economic Co-operation and Development (OECD) report using data from 200616 and includes the whole of the UK, rather focusing on than the NHS in England. MINAP has demonstrated in this and previous reports that mortality for both main types of heart attack –STEMI and nSTEMI- has fallen significantly in recent years in England and Wales, not least because of the success of the NSF for coronary heart disease17, the rapid introduction of primary angioplasty services with around 80% of the population of England now having access to this ‘gold standard’ treatment, and better uptake of evidence-based therapies for secondary prevention. Others, including the highly respected Kings’ Fund have suggested that the rate of improvement in outcomes from heart attack has been the fastest in Europe18.

Comparing outcomes between different countries is a complex undertaking, with evidence of miscoding and misclassification of the cause of death, variation in the entry criteria for national registries and completeness of data19 20. An international consensus on the definition of a heart attack is expected to improve the quality of comparison for the future.21

The MINAP team are working with our international partners in heart attack registries and professional societies to provide more robust international comparisons for the future, to help inform ongoing debate about the quality of cardiovascular care.

15. BBC News 16 March 2011 http://www.bbc.co.uk/news/uk-politics-12760865

16. Organisation for Economic Cooperation and Development. Health data 2010—October. www.ecosante.org/index2.

17. Department of Health. Evaluation of the Coronary Heart Disease National Service Framework. 2010 http://www.dh.gov.uk/en/FreedomOfInformation/Freedomofinformationpublicationschemefeedback/FOIreleases/DH_126679

18. Appleby J. Does poor health justify NHS reform? BMJ 2011; 342: d566

19. Lozano R, Murray CJL, Lopez AD, et al. Miscoding and misclassification of ischaemic heart disease mortality. Global Programme on Evidence for Health Policy Working Paper No 12. World Health Organisation; 2001. p. 1-19

20. Widimsky P, Wijns W, Fajadet J, et al European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J. 2010 31(8):943-57

21. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525-38



4. MINAP: a patient’s perspective

Sirkka Thomas, Cardiac nurse, Health visitor, Cardiac carer and patient, member of Patient Network for London Cardiovascular Project 2011, member South West London Cardiac and Stroke Network and member of Healthcare Quality Improvement Partnership Patient Panel

MINAP has become a major influence in my life in my demanding passage of nurse, carer, and finally cardiac patient. I turned to Cardiac nursing and trained at the Royal Brompton Hospital because I was inspired by the efforts of my native country Finland in managing such high incidence of heart conditions and I wanted to join the campaign against Britain’s greatest killer disease.

That knowledge was to help me so much when my husband suffered a heart attack 14 years ago followed by heart failure and the need for an Implantable Cardioverter Defibrillator (ICD). I was able to support him, medically as a nurse and psychologically as a carer.

It is only being a close partner that one can understand the problems of a patient with a serious illness. Doctors are highly qualified to diagnose and give treatment and my husband and I have received first class therapy. However, it is our view that only the patient and close partner know the pain, physical and psychological, and the stress of their illness. That is when a carer’s understanding presence is so vital.

We first became aware of MINAP when my husband recovered sufficiently to join the MINAP Steering Group, as he put it, “to repay in some way the high class cardiac treatment I had received from so many branches of the NHS”. MINAP was no magic remedy but it did provide a recovery incentive for me as a carer and for my husband as a patient.

MINAP is not a Government target for heart treatment. But it is an encouragement for hospitals and ambulance services to demonstrate their performances in standards for coronary artery disease as set out by the National Service Framework of 2000.Those standards include the time from onset of heart symptoms until appropriate treatment, clot-busting drugs and now primary angioplasty, is received. They also include the use of secondary medication on hospital discharge.

It was so important for my husband and me to learn from MINAP about hospital performances, the speed of immediate treatment and the attention given to the prescribing of drugs on discharge.

Mortality rates due to coronary heart disease have been falling since the 1970s. Surely MINAP has helped in some way with its pursuit of excellence. MINAP has definitely contributed with its

data to encourage speed of treatments and guidance to improve drug provision on discharge, (see the data in this 10th Report).

Unfortunately, I turned from carer to patient two years ago, having experienced a non-STEMI which has required a pacemaker. Fortunately, I had MINAP to lift me up, along with that wonder treatment for heart patients, a caring, understanding husband.

David Geldard, MINAP Patient representative and Steering Group member, past president Heart Care Partnerships (UK)

At a recent national conference, Celebrating Leadership in Heart Disease and Stroke in London on 4th July, 2011, MINAP was frequently mentioned in the context of developing standards of care in the treatment of people with heart disease. Equally pleasing, and for the tenth year running, this Report is a record of steady change and improvement.

With the advent of primary angioplasty as the preferred treatment for people suffering an ST elevation myocardial infarction, the need to treat these people at centres where round-the-clock equipment and appropriately trained staff are available is paramount. This shift in treatment from localised Accident and Emergency facilities, to heart attack centres that can provide 24/7 response is often a cause of concern to communities that feel they are losing a vital and local resource. People want the best treatment, but they also want it at their local hospital, and that is no longer realistic. This Report will do much to allay concerns. This year, with the assistance of NHS Improvement Heart, and the thirty two cardiac networks in England and Wales, and of Heart Care Partnership (UK), the patient arm of the British Cardiovascular Society, copies of this Report will be sent to local patient representatives at the time of publication. In this way patient representatives will be able to examine how things are going



in their locality. Hopefully they will see improvement, and this will provide them with evidence to dispel local anxieties. They will discover many causes for passing on congratulations, and some, but not too many, “could do betters”. These local patient representatives will be the local banner bearers for their local heart attack services.

Despite the success of hounding smoking and smoke from public places, tobacco smoking is still a significant contributing factor to poor health and heart attack. This report also provides evidence that shows how some heart attack victims and their companions are misjudging the event and neglecting to seek assistance in timely fashion. The success of primary angioplasty in hastening the recovery of victims has an unusual side effect in that many patients quickly seem to forget the seriousness of their condition and the responsibility they owe to themselves and their families to pay heed to the advice they receive concerning their future lifestyle, their medication, and their cardiac rehabilitation. It is extraordinary that nearly three times as many cardiac surgery patients participate in cardiac rehabilitation as do heart attack patients.

On the bright side, it is ten years after the first Public Report and it is wonderful to observe the continuing commitment of the ambulance services, the hospital services, primary care and the rehabilitation services, along with the those of the central support of Professor Sir Roger Boyle, National Clinical Director for Heart Disease and Stroke and his team, and all those colleagues on the front line and behind the scenes, for they have all gone “above and beyond” in their service to people who have suffered heart attack.

It is through audit that one can objectively observe the success or otherwise of any activity, and it is to John Birkhead, the pioneer of MINAP, and the MINAP team who now bring it all together, that the heart patient community owes such a warm vote of thanks.

I encourage all patient representatives for people with heart disease to read this Report carefully, and to share their joy and their aspirations; it is a good news story, in fact it is a great news story, and with their help it can get even better.



202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

25

30

35

40

45

50%

55

60

65

70

Fig 5. Hypertension in patients having first heart attack.

Females

Males

The number of records eligible for analysis from each hospital is shown in the tables. Where a hospital reports less than 20 cases for the year analyses may not be meaningful. The number of cases are shown but not the percentages. There are several reasons why hospitals may report less than 20 patients.

� In hospitals providing a primary angioplasty service, most patients receive primary angioplasty rather than thrombolytic treatment. Different audit standards apply for timeliness of treatment with primary angioplasty and thrombolytic treatment, and delays for the two treatments cannot be combined.

� Hospitals that do not provide primary angioplasty may report few, if any, cases having thrombolytic treatment, as patients from their area will be admitted directly to a primary angioplasty centre.

� About 18% patients make their own way to hospital without involving either the ambulance service or their GP. These patients are excluded from analyses of call-to-needle time and may account for small numbers in some hospitals.

� Smaller hospitals manage few heart attack patients.

� Hospitals may have only recently started a primary angioplasty service or have performed primary angioplasty on an occasional basis.

1. Characteristics of patients with heart attack in 2010/11

In 2010/11, 89,511 records in England and Wales were submitted to the MINAP database and 79,863 were records of patients with a final diagnosis of myocardial infarction. Of these some 40% had STEMI. [Fig 3] MINAP recognises that not all patients having nSTEMI are entered into the database and that the true ratio for nSTEMI to STEMI should be at least 2:1.

The average age for patients having a first heart attack in England and Wales was 69 years, for men 66 years and for women 74 years. Heart attack is more common in men, with two men having a heart attack for every woman. STEMI tends to present in younger age groups than nSTEMI. The average age for a first STEMI is 65 years, while that of nSTEMI is 70 years. Overall more than 52% of all heart attacks recorded in MINAP were in people over 70 years of age [Fig 4].

part two: results

All hospitals in England and Wales that treat heart attack patients submit data to MINAP. This year we also present data from 3 Belfast hospitals. The 204 hospitals in England and 18 hospitals in Wales are listed alphabetically in Tables 1-3, 5, 6, 8 and 9 with the location of the hospital alongside its name.

79863 admissions with heart attack

31765 (40%) STE MI

48098 (60%) nSTEMI

8859 (28%) had no reperfusion treatment

660 (2%) treatment option not clear

18042 (57%) referred for pPCI

4204 (13%) had thrombolytic treatment

1110 (27%) had thrombolytic treatment in an ambulance

3094 (73%) had thrombolytic treatment in hospital

Fig 3. Hearts attacks recorded in MINAP in 2010/11

There was a total of 89511 records, the others having either another confirmed diagnosis or chest pain of uncertain cause.

Fig 4. Frequency distribution of STEMI and nSTEMI in financial year 2011

0

5

10

15

25

20

30

%

Years

<30 >9030-39 40-49 50-59 60-69 70-79 80-89

STEMI

nSTEMI

Fig 4. Frequency distribution of STEMI and nSTEMI in 2010/11

STEMI is more common in younger age groups, while more than 60% of nSTEMI occur after age 70.

102003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

11

12

13

14

15

16%

17

18

19

20

Fig 6. Frequency of diabetes in patients having first heart attack

Females

Males



202003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

25

30

35

40

45

50%

55

60

65

70

Fig 5. Hypertension in patients having first heart attack.

Females

Males

Fig 5. Hypertension in patients having first heart attack

Patients with final diagnosis of AMI treated for hypertension at the time of admission.

Among those admitted with heart attack there is a continuing increase over time in the frequency of previously diagnosed hypertension and diabetes. The upwards trend for hypertension continues for females, but may be levelling out for males.[Fig 5] The increase in the frequency of diabetes on admission for first heart attacks continues in both males and females. Further analysis shows that the increase is limited to those having type 2 diabetes (non-insulin dependent diabetes) [Fig 6]. It is not clear to what extent this represents a real increase, or whether this in part reflects improved recognition of type 2 diabetes in primary care. The proportion already prescribed cholesterol lowering drugs (usually statins) at the time of admission may now be becoming constant at about 30% of those presenting with a first heart attack [Fig 7]. This may reflect more efficient recognition and treatment in primary care of those at risk.

Cigarette smoking remains a major contributor to heart attacks in younger people, being a risk factor present in more than half of men and women under 55 years of age having a first heart attack. While the smoking rate in younger males is stable or falling slightly, that in females of less than 55 years continues to increase [Fig 8].

102003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

11

12

13

14

15

16%

17

18

19

20


Females

Males


The large majority of the increase in frequency of diabetes is in type 2 (non-insulin dependent) diabetics.

02003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

5

10

15

20%

25

30

35

Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission

Hyperlipidaemia having treatment

Fig 7. Patients admitted with a first heart attack already receiving treatment for hyperlipidaemia at admission

Fig 8. Current smoking amongst patients admitted with heart attack.

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

Females

60

50

40

30

20

10

0

20-54 yrs

55-64 yrs

65-74 yrs

›75 yrs

Males

20-54 yrs

55-64 yrs

65-74 yrs

›=75 yrs

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

60

50

40

30

20

10

0

Fig 8. Current smoking amongst patients admitted with heart attack

Smoking amongst females presenting with first heart attack under 55 years continues to increase, against the generally decreasing trend for smoking rates.


2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

Females

60

50

40

30

20

10

0

20-54 yrs

55-64 yrs

65-74 yrs

›75 yrs

Males

20-54 yrs

55-64 yrs

65-74 yrs

›=75 yrs

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

60

50

40

30

20

10

0


2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

Females

60

50

40

30

20

10

0

20-54 yrs

55-64 yrs

65-74 yrs

›75 yrs

Males

20-54 yrs

55-64 yrs

65-74 yrs

›=75 yrs

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

%

60

50

40

30

20

10

0

Females

Males



2. Hospitals that perform primary angioplasty

National and international guidance22 23 24 recommend that in the emergency treatment of patients with STEMI, primary angioplasty should be performed within 90 minutes of arrival at the angioplasty site (door-to-balloon time) and within 150 minutes of a patient’s call for help (call-to-balloon time). Results are presented against these best practice standards in Table 1.

The use of primary angioplasty continued to increase in 2010/11. This year in England, 15,817 patients in England were treated by primary angioplasty compared to 12,505 in 2009/10, an increase of 26%. In Wales 301 patients were treated compared to 232 in 2009/10, an increase of 30%. Of patients who received reperfusion treatment in 2010/11, 82% of patients in England, 30% in Wales and 99% in Belfast received primary angioplasty. The overall median time from arrival at hospital to primary angioplasty was 43 minutes in 2010/11. In 25% of records this interval was less than 30 minutes and for 75% the interval was less than 64 minutes.

This year, 68 hospitals in England performed primary angioplasty. In Wales 3 hospitals performed primary angioplasty. Hospitals performing primary angioplasty may provide this for their own patients only or may do so for groups of other hospitals. Of 62 hospitals in England reporting that they were performing primary angioplasty on a routine basis, 43 provided the service throughout the 24 hour period. A small number shared a night time rota on an alternate basis. An additional 10 hospitals have started to provide a 24/7 service from April 2010. In Wales two hospitals perform primary angioplasty with 24 hour availability. In Belfast, two hospitals performed primary angioplasty.

The provision of primary angioplasty is complex and involves close collaboration between ambulance, portering, nursing, medical, and radiographic teams. This is particularly important for out of hours working. The percentage of patients with an admission diagnosis of STEMI who receive primary angioplasty within 90 minutes of arrival at the heart attack centre has increased from 52% in 2003/4 to 89% in 2010/11 and is a reflection of this close collaboration [Fig 9]. In particular direct transfer of the patient from ambulance to the catheter lab without involvement of other departments or wards, has reduced delays.

In Belfast the Royal Victoria Hospital essentially provided a city wide service in 2010/11. In Northern Ireland routine use of primary angioplasty is presently limited to the Belfast area. Outside Belfast thrombolytic treatment is understood to be the primary reperfusion treatment of choice for STEMI, though primary angioplasty is occasionally available in some hospitals. The Northern Ireland cardiac network is currently developing a national strategy for the management of STEMI. We look forward to the other hospitals in Northern Ireland joining MINAP before long.

Door-to-balloon time

In England this year, 90% of eligible patients were treated with primary angioplasty within 90 minutes of arrival at the heart attack centre compared to 89% in 2009/10. In Wales 68% of eligible patients were treated within 90 minutes compared to 71% in 2009/10. In Belfast 87% of eligible patients were treated within 90 minutes compared to 53% in 2009/10.

Call-to-balloon time

This reflects the interval from a call for professional help to the time that the primary angioplasty procedure is performed. This involves ambulance crews making an accurate diagnosis, including skilled interpretation of the ECG. Ideally all patients with a diagnosis of STEMI confirmed by a paramedic crew should then be taken to a heart attack centre. This however is not always possible, particularly where there is diagnostic uncertainty, or in remoter parts of the country. In 2010/11 75% of patients treated with primary angioplasty were admitted directly to a heart attack centre in England, 79% in Wales and 60% in Belfast.

22. http://www.improvement.nhs.uk/heart/?TabId=66

23. Van de Werf F, Ardissino D et al. (2003) Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 24(1): 28–66.

24. Antman EM, Hand M, Armstrong PW et al. (2008) 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008; 51: 210–247.

Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital in E&W.

0

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50

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90100

%

2003-4 2010-112004-5 2005-6 2006-7 2007-8 2008-9 2009-10

52.856.5 58

72.3

79.784.5

88.2 89.3

Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital


In England, 81% of all eligible patients were treated within 150 minutes of calling for professional help compared to 80% in 2009/10. In Wales 75% of patients were treated within 150 minutes compared to 76% in 2009/10. In Belfast 90% of patients were treated within 150 minutes compared to 77% in 2009/10.

In England, 88% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help compared to 49% of patients taken first to a local hospital and then transferred to a heart attack centre. In Wales 76% of such patients were treated within 150 minutes. In Belfast 89% of patients taken directly to the heart attack centre were treated with primary angioplasty within 150 minutes of calling for professional help.

The proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help continues to improve [Fig 10]. There is a limit to how rapidly ambulance services can assess patients and transfer them safely to hospital. The scope for further improvement in this interval may be limited.

3. Hospitals using thrombolytic treatment

Thrombolytic treatment is now used for a rapidly diminishing number of patients. At present approximately 15% of those eligible for reperfusion treatment have thrombolytic treatment, and this occurs mainly in a few areas where timely access

to a heart attack centre is not yet available. This number is expected to fall further over the next 12 months.

The national standard for thrombolytic treatment is for this to be given within 60 minutes of a call for professional help. This is a joint responsibility of acute hospital trusts and ambulance services. Performance against this standard continues to be monitored as an existing commitment within the NHS Operating Framework for England in 2010/11. The aim is for at least 68% of cases to achieve this standard in England, and 70% in Wales.

Tables 2 and 3 show hospital thrombolytic treatment analyses for 2009/10 and 2010/11 for England and Wales respectively. The Belfast hospitals did not report use of any thrombolytic treatment in 2010/11.

Door-to-needle time

In England, 75% of eligible patients received thrombolytic treatment within 30 minutes of arrival at hospital compared to 79% in 2009/10. In Wales 62% of eligible patients received treatment with 30 minutes compared to 67% in 2009/10.

Call-to-needle time

As more patients have primary angioplasty fewer receive thrombolytic treatment. However, the percentage of patients receiving thrombolytic treatment who do so within 60 minutes of a call for help is essentially unchanged. In England 68% of eligible patients received thrombolytic treatment within 60 minutes of calling for professional help compared to 69% in 2009/10. In Wales 53% of eligible patients received treatment within 60 minutes compared to 55% in 2009/10.


Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help

50

55

60

65

70

75

80

85

90

%

Financial year

2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

Fig 10. Proportion of patients admitted directly to an interventional centre who receive primary angioplasty within 150 minutes of a call for professional help

The sudden improvement between 2005/6 and 2006/7 is likely to be due to the rapid increase in new cardiac units performing angioplasty and the influence of the National Infarct Angioplasty Project (NIAP)

Normal coronary angiogram



4. Angiography for STEMI patients not having primary angioplasty

It is recognised that despite timely thrombolytic treatment some patients are at early risk of further heart attack. This risk is reduced by performance of angiography to determine the extent and severity of disease in coronary arteries, and where appropriate, angioplasty to the affected artery. The performance of angiography for STEMI patients not having primary angioplasty is now considered to be routine, whereas in 2003/4 only about one third of patients had angiography for this indication (Fig 11).

Due to a database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the MINAP web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11.

In 2010/11, 69% of STEMI patients in England, 83% in Wales, and 50% in Belfast who received thrombolytic treatment, or who had no reperfusion treatment were referred for coronary angiography or, in a minority, had this arranged to take place after discharge.

5. Reperfusion treatment by hospital

Rates of reperfusion treatment by hospital have become difficult to present and interpret as so many patients who would previously have been treated with thrombolytic treatment in a local hospital now receive primary angioplasty in a heart attack centre, and may not even return to the local hospital after treatment. Performance of individual hospitals is not shown for 2010/11.

There has been a small increase in the number of patients with STEMI who do not receive reperfusion treatment, from about 25% in 2005/6 to 28.5% in 2010/11. The commonest reason why no reperfusion treatment is given is that the patient presents too late for treatment, which typically is not given more than 12 hours after onset of symptoms because of limited benefit by this time. In a small number of cases severe co-morbidity such as advanced malignancy or severe dementia may make reperfusion treatment inappropriate. These features do not change significantly over time. However, the performance of angiography before an intended primary angioplasty may demonstrate features that indicate that primary angioplasty is not required or is not feasible. These features can only be determined by angiography. Thus, angiography allows treatment to be offered only to those for whom benefit can be expected, and enables clinicians to exclude those where benefit is not anticipated. Trends in reperfusion treatment since 2003/4 are shown in Fig 12.

As the intention is to treat patients by primary angioplasty as quickly as possible, those initially referred to a hospital without facilities for primary angioplasty are assessed rapidly for possible onwards transfer to the interventional hospital (heart attack centre), and will not be admitted. If patients are not formally admitted to the non-interventional hospital before onward transfer they do not appear in MINAP analyses for the non-interventional hospital. Only those patients that are formally admitted to a non-interventional hospital, a small minority, are included in the columns referring to transfer elsewhere for primary angioplasty.

Fig 12. Use of reperfusion treatment for patients with a final diagnosis of STEMI

0

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%

70

80

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100

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

In-hospital lysis

Pre-hospital lysis

Primary angioplasty

Fig 12. Use of reperfusion treatment for patients with a final diagnosis of STEMI

Primary angioplasty makes up more than 80% of reperfusion treatment.

Fig 11. Use of angiography for patients having STEMI who did not receive primary angioplasty, but instead received receiving thrombolytic treatment or had no reperfusion treatment

0

10

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%

70

80

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-10

31.1

45.550.1

55.658.6

63.3

70.173.2

Fig 11. Use of angiography for patients having STEMI who do not receive primary angioplasty, but instead received thrombolytic treatment or had no reperfusion treatment.

Where angiography is thought inappropriate because of co-morbidity or the patient refused, these are excluded from analysis. All age groups are included.



6. Ambulance service performance

Ambulance services collaborate closely with receiving hospitals and networks to improve care. For many, the focus has shifted from provision of pre-hospital thrombolytic treatment to identifying those patients with heart attack who might benefit from primary angioplasty, and transferring them rapidly to a heart attack centre. So, for many ambulance services, the number of patients receiving pre-hospital thrombolytic treatment has declined.

Table 4 shows ambulance service performance in England and Wales. In England in 2010/11, 824 patients received pre-hospital thrombolytic treatment compared to 1,633 in 2009/10. In Wales 219 patients received pre-hospital thrombolytic treatment compared to 250 in 2009/10.

7. Use of secondary prevention medication

Use of secondary prevention medication after the acute event is proven to improve outcomes for patients. These benefits apply after both STEMI and nSTEMI.

NICE guidance25 recommends that all patients who have had an acute heart attack should be offered treatment with a combination of the following drugs:

� ACE inhibitor

� aspirin

� beta blocker

� statin.

Tables 5 and 6 show the percentage of patients prescribed secondary prevention medication on discharge by hospital in England, Wales and Belfast in 2010/11. For each hospital those patients surviving to be discharged home from that hospital are included but those transferred to another hospital and those patients in whom such drugs were contraindicated are excluded. Historically, we have used the NSF audit standard of 80% for aspirin, beta blockers and statins treatment. There are no national standards for the prescription of ACE inhibitors, Clopidogrel/thienopyridine inhibitors and newer antiplatelet agents.

Use of secondary prevention medication at discharge from hospital is very satisfactory, continuing to exceed the national standards, and there is little room for further improvement [Fig 13]. In England prescription of aspirin was 99%, beta blockers 96%, statins 97%, ACE inhibitors 94% and Clopidogrel/thienopyridine inhibitors 95%. In Wales prescription of aspirin was 98%, beta blockers 95%, statins 95%, ACE inhibitors 91% and Clopidogrel/thienopyridine inhibitors 92%. In the Belfast hospitals prescription of aspirin was 99%, beta blockers 99%, statins 99%, ACE inhibitors 97% and Clopidogrel/thienopyridine inhibitors 98%.

8.Cardiac networks

Cardiac networks (also known as ‘heart and stroke networks’ since they also now facilitate improvements in stroke care) are local NHS organisations that seek to improve the way that services are planned and delivered. Bringing together clinicians, managers, commissioners and patients, and aware of the entire ‘cardiac pathway’, the networks can provide a powerful voice in the local health economy to enable frontline staff to secure the changes needed to deliver best care. They provide a forum through which the public can influence their services. Some cardiac networks have patient carer representatives providing a voice among the professionals.

Table 7 shows the performance of the call-to-needle and call-to-balloon targets and the percentage of patients that received pre-hospital thrombolytic treatment, in-hospital thrombolytic treatment, primary angioplasty and no reperfusion treatment by cardiac network. The two cardiac networks in Wales are shown separately.

Countrywide access to primary angioplasty remains incomplete, although the picture is changing rapidly. The percentage of patients in English cardiac networks that received primary angioplasty ranged between 5-93% and in 6 cardiac networks less than 50% of their patients received primary angioplasty.

Fig 13. Use of secondary prevention medication.

All heart attacks, [transfers, deaths, contraindicated and patient refused are all excluded.]

Fig 13. Use of secondary prevention medication for myocardial infarction

Aspirin

Statin

Beta blocker

ACEI/ARB

Clopidogrel/thienopyridine inhibitors

2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2010-112009-1050

55

60

65

70

75%

80

85

90

95

100

25. http://guidance.nice.org.uk/CG48/QuickRefGuide/pdf/English



National audit lends itself to the demonstration of variation in practice and outcome. The MINAP Public Reports repeatedly have shown this. Variation in practice is an expected phenomenon in healthcare, and there is a difficulty determining whether such variation is simply the ‘play of chance’ or whether it represents some systematic difference in performance. One of the methods being considered, to more clearly describe such variation is the funnel plot.

Funnel plots were first introduced26 27 in 1984 as a means of estimating bias in meta-analysis of clinical trials that contained varying numbers of subjects. In essence, each individual value is compared to the overall mean, and the control limits around that mean diminish as the number of subjects (or admissions) increases (as one would expect). A value which falls outside the ‘funnel’ is considered an outlier, and can represent abnormally high performance as well as abnormally low performance.

The width of the control limits is determined by the statistical significance level from which they are calculated. To diminish the risk of a false positive ‘outlier’ we use +/- 3 standard deviations, which means that the chance of an outlier happening ‘accidentally’ (i.e. by random chance) is no more than 0.4%.

9. Care for patients with non ST elevation infarction

For some years the focus of heart attack management has been upon the early provision of reperfusion treatment to those patients presenting with STEMI, and MINAP Public Reports have reflected this. Patients with nSTEMI have a lower early risk of death and perhaps because they do not require very rapid emergency treatment (reperfusion therapy), they are not always admitted to CCUs, nor always cared for by cardiologists. However, specialist involvement is important, and it is recognised that performance of angiography and coronary intervention within the first 4 days is an important facet of treatment for the majority. Ideally admission should be to a cardiac facility where nursing staff have a cardiac background, and there is easy access to cardiological expertise.

As mentioned above the numbers of nSTEMI reported in MINAP are incomplete, and in particular it is likely that patients who are not admitted to a CCU are omitted. Failure to enter all cases often reflects a lack

26. RJ Light, DB Pillemer. Summing up: The Science of Reviewing Research. Cambridge, Massachusetts.: Harvard University Press. 1984. ISBN 0674854314.

27. Egger M, Smith GD, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 1997; 315:629–634.


UCL 99.6% LCL 99.6%

GMCN

South WalesNorth Wales

West Yorkshire

SE London

CTN60%National Average

100 200 300 400 500 6000

10

20

30

40

50%

60

70

80

90

100

Admissions


North EnglandCMCN

NEYNLLancs/Cumbria

NE London

NW LondonSE London

Kent

Peninsula

West Yorkshire

200 400 600 800 1000 120040

50

60

%70

80

90

100

PeninsulaPeninsula

NEYNLNEYNLLancs/Cumbria

Admissions

UCL 99.6% LCL 99.6% Avg of CTB150National Average


North England

SW LondonKent

Cov Warks

NC London West Yorkshire

50 100 150 200 250 300 350 400 450

40

30

20

10

0

60

50

70

80

%

Admissions

90100

UCL 99.6% LCL 99.6% Avg of CTB150National Average

Fig 14. Call-to-needle within 60 minutes by cardiac network

Fig 15. Call-to-balloon within 150 minutes for direct admissions only by cardiac network

Fig 16. Call-to-balloon within 150 minutes for inter-hospital transfers by cardiac network



of resources, but it remains the case that the quality of care for patients not entered into MINAP remains unknown. In addition the variable nature of recording nSTEMI between hospitals may distort some analyses.

Table 8 shows the percentage of nSTEMI patients that were admitted to a cardiac unit or ward and the percentage of nSTEMI patients seen by a cardiologist or member of their team, by hospital, in 2009/10 and 2010/11. The same analyses for hospitals in Wales and Belfast are shown in Table 9. In England in 2010/11, 50% of nSTEMI patients were admitted to a cardiac unit or ward compared to 47% in 2009/10. In Wales 59% of patients were admitted to a cardiac unit or ward compared to 55% in 2009/10. In the Belfast hospitals, 81% of patients were admitted to a cardiac unit or ward compared to 82% in 2009/10.

In England in 2010/11, 91% of nSTEMI patients were seen by a cardiologist or member of their team compared to 89% in 2009/10. In Wales 84% of nSTEMI patients were seen by a cardiologist or member of their team compared to 74% in 2009/10. In the Belfast hospitals 99% of nSTEMI patients were seen by a cardiologist or member of their team compared to 100% in 2009/10.

The frequency with which patients are referred for angiography for nSTEMI also continues to increase, [Fig 17]. Due to a database fault that could not be rectified in time for publication, this analysis excludes some data from hospitals using the web application. The national analyses are based on the remaining hospitals, and may be subject to revision in 2012. Individual hospital data are not presented for 2010/11. In 2009/10, 63% of nSTEMI patients in England were referred for angiography after nSTEMI, and 70% in 2010/11. In Wales 74% were referred in 2009/10, and 81% in 2010/11. In Belfast 82% were referred in 2009/10 and 85% in 2010/11.

10. Change in mortality of heart attack patients

Mortality data are obtained from the NHS Central Register by CCAD. The percentage of patients having STEMI and nSTEMI who die within 30 days of admission to hospital has fallen annually from 2003/4-2010/11 [Figs 18, 19].

Fig 17. Use of angiography for patients with a diagnosis of non ST segment elevation MI. [Inappropriate of refused (small numbers) excluded. All age groups.]

0

10

20

30

50

60

70

80

40%

2003-4 2010-112004-5 2005-6 2006-7 2007-8 2008-9 2009-10

35.1

44.847.8 49.6 51.6

54.4

64.1

71

Fig 17. Use of angiography for patients with a diagnosis of non ST segment elevation MI.

Inappropriate or refused (small numbers) excluded. All age groups.

Fig 19.

14

13

12

11

10

9

8

7

6

%

Financial year

2004-52003-4 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

Fig 19. 30 day mortality (with 95% confidence limits) for nSTEMI.

The data for 2010/11 are provisional and may be revised.

Fig 18.

14

13

12

11

10

9

8

7

%

Financial year

2004-52003-4 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11

Fig 18. 30 day mortality, (with 95% confidence limits) for all patients having STEMI.

The data for 2010/11 are provisional and may be revised.


table

1 pr

imar

y an

giop

last

y in

hos

pita

ls i

n england, wales and belfast

Pri

mar

y an

giop

last

y w

ithin

90

min

s of

arr

ival

at

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

fo

r pa

tient

s w

ith

dire

ct a

dmis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

for

pat

ient

s tr

ansf

erre

d to

in

terv

entio

nal

cent

re

% o

f pat

ient

s w

ith d

irect

ad

mis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

90

min

s of

arr

ival

at

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

fo

r pa

tient

s w

ith

dire

ct a

dmis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

for

patie

nts

tran

sfer

red

to

inte

rven

tiona

l ce

ntre

% o

f pat

ient

s w

ith d

irect

ad

mis

sion

to

inte

rven

tiona

l ce

ntre

Year

20

09/1

020

10/1

1

%n

%n

%n

%n

%%

n%

n%

n%

n%

24 MINAP

25MINAP

11. R

esul

ts b

y ho

spit

als,

am

bula

nce

serv

ices

and

car

diac

net

wor

ks -

perc

enta

ges

are

not s

how

n fo

r le

ss th

an 2

0 ca

ses

Engl

and

nati

onal

ave

rage

89%

11466

80%

10012

86%

8336

45%

1689

75%

90%

14545

81%

12868

88%

10713

49%

2157

75%

Bar

ts &

the

Lond

on, L

ondo

n80%

533

56%

500

78%

297

23%

203

56%

96%

485

80%

418

95%

330

25%

8868%

Bas

ildon

Hos

pita

l, B

asild

on97%

396

85%

347

86%

335

1484%

96%

609

84%

589

90%

457

61%

132

75%

Bas

ings

toke

& N

orth

Ham

pshi

re H

ospi

tal,

Bas

ings

toke

93%

8293%

6793%

670

81%

94%

104

95%

8595%

850

83%

Bir

min

gham

Hea

rtla

nds

Hos

pita

l, B

irm

ingh

am83%

278

77%

264

86%

192

50%

7269%

84%

262

85%

249

90%

209

58%

4080%

Bri

stol

Roy

al In

firm

ary,

Bri

stol

85%

328

70%

318

84%

241

27%

7873%

90%

559

74%

535

82%

415

48%

120

74%

Cas

tle H

ill H

ospi

tal,

Hul

l83%

139

75%

125

77%

122

393%

89%

348

89%

300

92%

285

1583%

Che

ltenh

am G

ener

al H

ospi

tal,

Che

ltenh

am81%

3685%

3388%

321

90%

93%

7486%

7386%

730

99%

City

Hos

pita

l, B

irm

ingh

am90%

6296%

5696%

560

91%

78%

6788%

5288%

520

79%

Con

ques

t Hos

pita

l, St

Leo

nard

s on

Sea

87%

6075%

5375%

530

88%

90%

6182%

5582%

550

91%

Der

rifo

rd H

ospi

tal,

Ply

mou

th83%

6984%

6484%

640

93%

81%

136

77%

136

77%

136

0100%

Dor

set C

ount

y H

ospi

tal,

Dor

ches

ter

86%

2219

190

95%

92%

2580%

2580%

250

96%

East

Sur

rey

Hos

pita

l, R

edhi

ll88%

4891%

4591%

450

94%

94%

5290%

5090%

491

94%

Pri

mar

y a

ngio

plas

ty w

ithi

n 90

min

utes

of a

rriv

al re

flec

ts t

he a

bilit

y of

a h

ospi

tal t

o pr

ovid

e tr

eatm

ent

in a

tim

ely

man

ner.

Pri

mar

y an

giop

last

y w

ithi

n 15

0 m

inut

es o

f cal

ling

for h

elp

refl

ects

ho

spit

al p

erfo

rman

ce a

nd t

hat

of t

he e

mer

genc

y se

rvic

es in

iden

tify

ing

STEM

I and

tak

ing

the

pati

ent

to t

he in

terv

enti

onal

cen

tre

(whi

ch m

ay n

ot b

e th

e cl

oses

t ho

spit

al).

Not

all

pati

ents

are

ta

ken

dire

ctly

to

an in

terv

enti

onal

cen

tre,

esp

ecia

lly w

here

the

re is

dia

gnos

tic

unce

rtai

nty.

Thi

s in

evit

ably

tak

es lo

nger

tha

n di

rect

tra

nsfe

r, bu

t ca

nnot

be

avoi

ded

in s

ome

case

s.

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

24

16/0

8/20

11

14:1

3

25MINAP

East

bour

ne D

GH

, Eas

tbou

rne

73%

3073%

3072%

291

97%

61%

3871%

3171%

310

84%

Free

man

Hos

pita

l, N

ewca

stle

99%

835

86%

750

96%

570

54%

181

68%

98%

765

90%

672

98%

527

62%

145

69%

Fren

chay

Hos

pita

l, B

rist

ol7

55

071%

22

20

100%

Frim

ley

Par

k H

ospi

tal,

Frim

ley

72%

5082%

3883%

353

70%

76%

140

81%

127

86%

9467%

3369%

Gle

nfiel

d H

ospi

tal,

Leic

este

r70%

215

67%

181

68%

180

186%

84%

267

85%

232

87%

227

585%

Ham

mer

smith

Hos

pita

l, Lo

ndon

91%

324

71%

286

86%

192

38%

9461%

90%

318

74%

284

89%

176

49%

108

63%

Har

efiel

d H

ospi

tal

99%

508

88%

421

90%

414

1293%

75%

408

85%

379

91%

329

48%

5081%

Jam

es C

ook

Uni

vers

ity H

ospi

tal,

Mid

dles

boro

ugh

93%

542

83%

500

92%

404

42%

9675%

95%

549

87%

476

92%

413

49%

6376%

John

Rad

cliff

e H

ospi

tal,

Oxf

ord

93%

224

75%

212

87%

148

48%

6465%

93%

347

78%

331

93%

244

38%

8770%

Ken

t & S

usse

x H

ospi

tal,

Tunb

ridg

e W

ells

11

10

100%

33

30

100%

Ket

teri

ng G

ener

al H

ospi

tal,

Ket

teri

ng71%

2871%

2471%

240

89%

83%

102

87%

9388%

921

93%

Kin

g's

Col

lege

Hos

pita

l, Lo

ndon

64%

270

64%

238

65%

235

393%

65%

316

68%

239

68%

239

090%

Leed

s G

ener

al In

firm

ary,

Lee

ds88%

833

80%

661

86%

503

61%

158

63%

85%

985

64%

793

75%

625

22%

168

66%

Linc

oln

Cou

nty

Hos

pita

l, Li

ncol

n0

00

011

1111

0100%

List

er H

ospi

tal,

Stev

enag

e96%

7490%

7097%

5812

77%

94%

7893%

6995%

636

81%

Live

rpoo

l Hea

rt &

Che

st H

ospi

tal,

Live

rpoo

l98%

400

84%

387

97%

217

68%

170

54%

98%

670

82%

601

98%

359

57%

243

53%

Man

ches

ter

Roy

al In

firm

ary,

Man

ches

ter

91%

341

77%

194

89%

140

46%

5441%

89%

326

74%

247

89%

169

42%

7853%

Med

way

Mar

itim

e H

ospi

tal,

Gill

ingh

am0

00

010

1010

0100%

New

Cro

ss H

ospi

tal,

Wol

verh

ampt

on89%

447

80%

369

90%

311

26%

5873%

91%

498

81%

385

89%

324

34%

6170%

Nor

folk

& N

orw

ich

Uni

vers

ity H

ospi

tal,

Nor

wic

h95%

365

85%

353

87%

329

54%

2491%

96%

402

86%

389

89%

357

53%

3289%

Nor

tham

pton

Gen

eral

Hos

pita

l, N

orth

ampt

on83%

3685%

2685%

260

75%

92%

3696%

2896%

280

78%

Nor

ther

n G

ener

al H

ospi

tal,

Shef

field

83%

289

70%

274

79%

217

39%

5764%

88%

606

75%

581

84%

422

51%

159

70%

Nor

thw

ick

Par

k H

ospi

tal,

Har

row

11

10

100%

33

30

100%

Not

tingh

am C

ity H

ospi

tal,

Not

tingh

am92%

9883%

9284%

893

92%

96%

188

86%

176

87%

173

393%

Pap

wor

th H

ospi

tal,

Cam

brid

ge97%

409

74%

372

87%

279

40%

9768%

98%

419

76%

413

90%

293

40%

120

70%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

25

16/0

8/20

11

14:1

3

26 MINAP

27MINAP

Pri

mar

y an

giop

last

y w

ithin

90

min

s of

arr

ival

at

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

fo

r pa

tient

s w

ith

dire

ct a

dmis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

for

patie

nts

tran

sfer

red

to

inte

rven

tiona

l ce

ntre

% o

f pat

ient

s w

ith d

irect

ad

mis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

90

min

s of

arr

ival

at

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

fo

r pa

tient

s w

ith

dire

ct a

dmis

sion

to

inte

rven

tiona

l ce

ntre

Pri

mar

y an

giop

last

y w

ithin

150

min

s of

cal

ling

for

help

for

patie

nts

tran

sfer

red

to

inte

rven

tiona

l ce

ntre

% o

f pat

ient

s w

ith d

irect

ad

mis

sion

to

inte

rven

tiona

l ce

ntre

Year

20

09/1

020

10/1

1

%n

%n

%n

%n

%%

n%

n%

n%

n%

Que

en A

lexa

ndra

Hos

pita

l, P

orts

mou

th95%

6395%

6195%

610

97%

88%

193

81%

176

92%

136

43%

4070%

Que

en E

lizab

eth

Hos

pita

l, B

irm

ingh

am99%

9962%

8463%

822

80%

68%

124

74%

109

76%

106

386%

Roy

al B

erks

hire

Hos

pita

l, R

eadi

ng94%

145

96%

137

96%

136

193%

96%

147

95%

134

95%

134

092%

Roy

al B

ourn

emou

th G

ener

al H

ospi

tal,

Bou

rnem

outh

90%

9395%

7894%

699

76%

92%

7296%

6895%

635

88%

Roy

al C

ornw

all H

ospi

tal,

Trur

o12

1010

092%

97%

3394%

3394%

321

97%

Roy

al D

erby

Hos

pita

l, D

erby

93%

2892%

2592%

250

89%

89%

6287%

5587%

550

89%

Roy

al D

evon

& E

xete

r H

ospi

tal,

Exet

er86%

196

86%

147

86%

147

091%

91%

176

79%

141

79%

141

089%

Roy

al F

ree

Hos

pita

l, Lo

ndon

93%

161

92%

155

93%

148

792%

93%

186

91%

184

91%

183

197%

Roy

al S

usse

x C

ount

y H

ospi

tal,

Bri

ghto

n71%

6378%

5878%

580

91%

94%

190

86%

176

86%

176

093%

Roy

al U

nite

d H

ospi

tal B

ath,

Bat

h100%

27100%

26100%

260

96%

92%

5192%

4891%

471

91%

Rus

sells

Hal

l Hos

pita

l, D

udle

y0

00

01

11

0100%

Sand

wel

l Dis

tric

t Hos

pita

l, W

est B

rom

wic

h75%

102

83%

8083%

800

79%

77%

9592%

7692%

760

80%

Sout

ham

pton

Gen

eral

Hos

pita

l, So

utha

mpt

on86%

166

82%

150

88%

138

1283%

91%

194

89%

170

91%

162

978%

St G

eorg

e's

Hos

pita

l, Lo

ndon

84%

303

87%

278

88%

269

993%

89%

342

90%

306

89%

218

91%

8867%

St P

eter

's H

ospi

tal,

Che

rtse

y16

1111

069%

96%

2796%

2696%

260

96%

St T

hom

as H

ospi

tal,

Lond

on61%

109

51%

101

62%

7127%

3068%

83%

132

73%

120

83%

8748%

3365%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

26

16/0

8/20

11

14:1

3

27MINAP

Sund

erla

nd R

oyal

Hos

pita

l, Su

nder

land

43

30

75%

22

20

89%

Taun

ton

& S

omer

set H

ospi

tal,

Taun

ton

94%

6693%

5692%

488

72%

99%

156

98%

145

98%

124

100%

2180%

The

Gre

at W

este

rn H

ospi

tal,

Swin

don

1814

140

89%

97%

3397%

2997%

290

88%

Torb

ay H

ospi

tal,

Torq

uay

85%

8988%

7388%

730

89%

87%

7793%

7093%

700

95%

Uni

vers

ity C

olle

ge H

ospi

tal,

Lond

on94%

154

55%

117

86%

5824%

5938%

93%

168

65%

126

85%

8818%

3853%

Uni

vers

ity H

ospi

tal C

oven

try,

Cov

entr

y86%

329

90%

274

90%

273

194%

88%

330

85%

304

85%

292

1291%

Uni

vers

ity H

ospi

tal o

f Nor

th S

taffo

rdsh

ire,

St

oke-

on-T

rent

83%

289

84%

240

86%

231

981%

89%

341

73%

282

85%

225

26%

5767%

Vict

oria

Hos

pita

l, B

lack

pool

77%

173

88%

144

88%

144

083%

87%

154

95%

140

96%

139

190%

Wat

ford

Gen

eral

Hos

pita

l, W

atfo

rd92%

6092%

6092%

600

100%

90%

4888%

4288%

420

87%

Wex

ham

Par

k H

ospi

tal,

Slou

gh3

22

050%

83%

4195%

3995%

390

93%

Will

iam

Har

vey

Hos

pita

l, As

hfor

d0

00

0100%

88%

519

75%

425

74%

381

84%

4475%

Wor

cest

ersh

ire

Roy

al H

ospi

tal,

Wor

cest

er0

00

0100%

1111

101

93%

Wor

thin

g H

ospi

tal,

Wor

thin

g19

1717

089%

77%

2219

190

86%

Wyc

ombe

Gen

eral

Hos

pita

l, H

igh

Wyc

ombe

90%

3172%

2972%

290

85%

93%

3090%

2190%

210

69%

Wyt

hens

haw

e H

ospi

tal,

Man

ches

ter

91%

257

78%

205

89%

122

60%

8350%

92%

312

73%

245

82%

201

36%

4467%

Bel

fast

ave

rage

53%

7277%

4775%

443

65%

87%

160

90%

124

89%

8960%

Bel

fast

City

Hos

pita

l16

77

044%

10

00

0%

Roy

al V

icto

ria

Hos

pita

l59%

5680%

4078%

373

71%

87%

159

90%

124

89%

8960%

Wal

es n

atio

nal a

vera

ge71%

215

76%

180

76%

178

285%

68%

283

75%

225

76%

221

479%

Gla

n C

lwyd

DG

H T

rust

, Bod

elw

ydda

n3

22

075%

43

30

80%

Mor

rist

on H

ospi

tal,

Swan

sea

72%

180

76%

159

76%

157

288%

76%

190

79%

159

81%

155

481%

Uni

vers

ity H

ospi

tal o

f Wal

es, C

ardi

ff72%

3219

190

69%

52%

8967%

6367%

630

75%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

27

16/0

8/20

11

14:1

3

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Year

2009

/10

2010

/11

%n

%n

%n

%n

table

2 th

romb

olyt

ic t

reat

ment

in

hosp

ital

s in england

28 MINAP

29MINAP

Engl

and

nati

onal

ave

rage

79%

2984

69%

3522

75%

1526

68%

1790

Aire

dale

Gen

eral

Hos

pita

l, St

eeto

n1

31

4

Arro

we

Par

k H

ospi

tal,

Wir

ral

89%

8977%

7518

17

Bar

nsle

y D

istr

ict G

ener

al H

ospi

tal,

Bar

nsle

y85%

2015

11

Bar

ts &

the

Lond

on, L

ondo

n1

11

1

Bas

ildon

Hos

pita

l, B

asild

on18

87%

391

77%

26

Bas

setl

aw D

istr

ict G

ener

al H

ospi

tal,

Not

tingh

am14

100%

250

3

Bed

ford

Hos

pita

l, B

edfo

rd7

93

1

Bir

min

gham

Hea

rtla

nds

Hos

pita

l, B

irm

ingh

am0

02

2

Bra

dfor

d R

oyal

Infir

mar

y, B

radf

ord

1212

55

Cal

derd

ale

Roy

al H

ospi

tal,

Hal

ifax

44

21

Cas

tle H

ill H

ospi

tal,

Hul

l70%

3076%

543

2

Cha

ring

Cro

ss H

ospi

tal,

Lond

on1

11

0

Che

ltenh

am G

ener

al H

ospi

tal,

Che

ltenh

am11

190

2

Che

ster

field

Roy

al, C

hest

erfie

ld86%

4476%

886

9

The

sm

all n

umbe

rs h

avin

g th

rom

boly

tic

trea

tmen

t re

flec

ts t

he d

omin

ance

of p

rim

ary

angi

opla

sty

as t

he re

perf

usio

n tr

eatm

ent

of c

hoic

e fo

r STE

MI.

In 2

009/

10 6

2 ho

spit

als

gave

thr

ombo

lyti

c tr

eatm

ent

to 2

0 or

mor

e pa

tien

ts, a

nd in

201

0/11

thi

s ha

d fa

llen

to 2

8. F

urth

er fa

lls c

an b

e an

tici

pate

d.

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

28

16/0

8/20

11

14:1

3

29MINAP

Cho

rley

Hos

pita

l, C

horl

ey77%

3183%

2379%

2819

Col

ches

ter

Gen

eral

Hos

pita

l, C

olch

este

r11

191

1

Con

ques

t Hos

pita

l, St

Leo

nard

s on

Sea

812

87

Cou

ntes

s of

Che

ster

Hos

pita

l, C

hest

er77%

4876%

4510

88%

24

Cou

nty

Hos

pita

l Her

efor

d , H

eref

ord

64%

2276%

2980%

3582%

45

Cum

berl

and

Infir

mar

y, C

arlis

le75%

4051%

4770%

3770%

53

Dar

ent V

alle

y H

ospi

tal,

Dar

tfor

d85%

3478%

322

3

Dew

sbur

y D

istr

ict H

ospi

tal,

Dew

sbur

y4

25

5

Dia

na, P

rinc

ess

of W

ales

Hos

pita

l, G

rim

sby

75%

2090%

2972%

2574%

31

Don

cast

er R

oyal

Infir

mar

y, D

onca

ster

79%

2495%

401

1

Dor

set C

ount

y H

ospi

tal,

Dor

ches

ter

1750%

3416

15

East

Sur

rey

Hos

pita

l, R

edhi

ll81%

3175%

2073%

3016

East

bour

ne D

GH

, Eas

tbou

rne

80%

2082%

2212

5

Epso

m H

ospi

tal,

Epso

m63%

2411

147

Fair

field

Gen

eral

Hos

pita

l, B

ury

86%

4378%

2715

12

Free

man

Hos

pita

l, N

ewca

stle

00

11

Fren

chay

Hos

pita

l, B

rist

ol2

51

1

Frim

ley

Par

k H

ospi

tal,

Frim

ley

82%

2214

01

Furn

ess

Gen

eral

, Bar

row

-in-

Furn

ess

100%

2763%

2718

77%

22

Geo

rge

Ellio

t Hos

pita

l, N

unea

ton

00

11

Gle

nfiel

d H

ospi

tal,

Leic

este

r14

74%

782

90%

52

Glo

uces

ters

hire

Roy

al H

ospi

tal,

Glo

uces

ter

1112

21

Gra

ntha

m &

Dis

tric

t Gen

eral

, Gra

ntha

m17

57%

21100%

2218

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

29

16/0

8/20

11

14:1

3

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Year

2009

/10

2010

/11

%n

%n

%

n%

n

30 MINAP

31MINAP

Har

efiel

d H

ospi

tal

00

11

Hill

ingd

on H

ospi

tal,

Uxb

ridg

e0

01

1

Hin

chin

gbro

oke

Hos

pita

l, H

untin

gdon

00

22

Hop

e H

ospi

tal,

Man

ches

ter

00

10

Hor

ton

Gen

eral

Hos

pita

l, B

anbu

ry2

20

1

Hud

ders

field

Roy

al In

firm

ary,

Hud

ders

field

87

11

Jam

es C

ook

Uni

vers

ity H

ospi

tal,

Mid

dles

boro

ugh

00

11

John

Rad

cliff

e H

ospi

tal,

Oxf

ord

00

11

Ken

t & C

ante

rbur

y H

ospi

tal,

Can

terb

ury

81%

3696%

241

0

Ket

teri

ng G

ener

al H

ospi

tal,

Ket

teri

ng18

81%

4710

19

Kin

g's

Col

lege

Hos

pita

l, Lo

ndon

32

19%

310%

26

Kin

gs M

ill H

ospi

tal,

Not

tingh

am88%

5169%

6875%

6772%

76

Leed

s G

ener

al In

firm

ary,

Lee

ds9

74

4

Leic

este

r R

oyal

Infir

mar

y, L

eice

ster

62%

2926%

232

2

Leig

hton

Hos

pita

l, C

rew

e84%

3258%

4386%

4373%

49

Linc

oln

Cou

nty

Hos

pita

l, Li

ncol

n92%

3965%

6384%

3171%

51

Mac

cles

field

Dis

tric

t Gen

eral

, Mac

cles

field

65%

2652%

2118

15

Mai

dsto

ne G

ener

al H

ospi

tal,

Mai

dsto

ne79%

3389%

272

1

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

30

16/0

8/20

11

14:1

3

31MINAP

Man

ches

ter

Roy

al In

firm

ary,

Man

ches

ter

21

22

Med

way

Mar

itim

e H

ospi

tal,

Gill

ingh

am91%

4393%

452

1

New

Cro

ss H

ospi

tal,

Wol

verh

ampt

on2

32

2

New

ark

Hos

pita

l, N

ewar

k14

103

4

Nor

folk

& N

orw

ich

Uni

vers

ity H

ospi

tal,

Nor

wic

h2

40

7

Nor

th D

evon

Dis

tric

t Hos

pita

l, B

arns

tabl

e18

74%

359

13

Nor

th M

anch

este

r G

ener

al H

ospi

tal,

Man

ches

ter

00

32

Nor

th M

iddl

esex

Hos

pita

l, Lo

ndon

00

11

Nor

tham

pton

Gen

eral

Hos

pita

l, N

orth

ampt

on88%

2582%

5712

90%

31

Nor

ther

n G

ener

al H

ospi

tal,

Shef

field

11

10

Not

tingh

am C

ity H

ospi

tal,

Not

tingh

am76%

2166%

4416

52%

23

Pap

wor

th H

ospi

tal,

Cam

brid

ge1

100

8

Pet

erbo

roug

h C

ity H

ospi

tal,

Pet

erbo

roug

h0

80

2

Pilg

rim

Hos

pita

l, B

osto

n79%

3967%

5287%

3963%

46

Pin

derfi

elds

Gen

eral

Hos

pita

l, W

akefi

eld

65

42

Pon

tefr

act G

ener

al In

firm

ary,

Pon

tefr

act

64

21

Poo

le H

ospi

tal,

Poo

le77%

2281%

2770%

2059%

27

Pri

nces

s R

oyal

Hos

pita

l, H

ayw

ards

Hea

th16

136

4

Pri

nces

s R

oyal

Hos

pita

l, Te

lford

88%

2475%

281

1

Que

en's

Hos

pita

l, B

urto

n-up

on-T

rent

80%

3081%

213

3

Que

en A

lexa

ndra

Hos

pita

l, P

orts

mou

th77%

8348%

8475%

2853%

30

Que

en E

lizab

eth

Hos

pita

l, B

irm

ingh

am1

11

1

Que

en E

lizab

eth

the

Que

en M

othe

r, M

arga

te78%

3217

44

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

31

16/0

8/20

11

14:1

3

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Year

2009

/10

2010

/11

%n

%n

%

n%

n

32 MINAP

33MINAP

Que

en's

Hos

pita

l, R

omfo

rd0

01

1

Roc

hdal

e In

firm

ary,

Roc

hdal

e98%

4693%

2816

13

Roy

al A

lber

t Edw

ard

Infir

mar

y, W

igan

96%

8567%

7294%

8488%

72

Roy

al B

erks

hire

Hos

pita

l, R

eadi

ng0

21

1

Roy

al B

lack

burn

Hos

pita

l, B

lack

burn

83%

115

74%

129

81%

9869%

95

Roy

al B

olto

n H

ospi

tal,

Bol

ton

89%

9574%

8085%

6667%

55

Roy

al B

ourn

emou

th G

ener

al H

ospi

tal,

Bou

rnem

outh

82%

5677%

5279%

2880%

35

Roy

al C

ornw

all H

ospi

tal,

Trur

o59%

4671%

104

68%

3467%

82

Roy

al D

erby

Hos

pita

l, D

erby

86%

3681%

7389%

4469%

74

Roy

al D

evon

& E

xete

r H

ospi

tal,

Exet

er0

02

2

Roy

al L

anca

ster

Infir

mar

y, L

anca

ster

69%

3958%

4577%

3055%

29

Roy

al O

ldha

m H

ospi

tal,

Old

ham

80%

5965%

4670%

2017

Roy

al P

rest

on H

ospi

tal,

Pre

ston

84%

4371%

3577%

4892%

38

Roy

al S

hrew

sbur

y H

ospi

tal,

Shre

wsb

ury

1465%

265

3

Roy

al S

urre

y C

ount

y H

ospi

tal,

Gui

ldfo

rd18

145

4

Roy

al S

usse

x C

ount

y H

ospi

tal,

Bri

ghto

n100%

2095%

210

2

Roy

al U

nite

d H

ospi

tal B

ath,

Bat

h79%

3354%

503

5

Roy

al V

icto

ria

Infir

mar

y, N

ewca

stle

33

11

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

32

16/0

8/20

11

14:1

3

33MINAP

Salis

bury

Dis

tric

t Hos

pita

l, Sa

lisbu

ry90%

3159%

3715

45%

20

Sand

wel

l Dis

tric

t Hos

pita

l, W

est B

rom

wic

h0

01

1

Scar

boro

ugh

Gen

eral

Hos

pita

l, Sc

arbo

roug

h89%

2857%

3018

18

Scun

thor

pe G

ener

al H

ospi

tal,

Scun

thor

pe18

85%

3418

89%

36

Sout

hend

Hos

pita

l, W

estc

liffe

on

Sea

1493%

272

2

Sout

hpor

t & F

orm

by D

istr

ict G

ener

al, S

outh

port

94%

3379%

297

7

St M

ary'

s H

ospi

tal,

New

port

87%

2374%

3812

84%

25

St P

eter

's H

ospi

tal,

Che

rtse

y94%

31100%

2390%

2014

St R

icha

rd's

Hos

pita

l, C

hich

este

r61%

3169%

2618

18

Step

ping

Hill

Hos

pita

l, St

ockp

ort

310

13

Stok

e M

ande

ville

Hos

pita

l, Ay

lesb

ury

129

107

Tam

esid

e G

ener

al H

ospi

tal,

Asht

on U

nder

Lym

e0

02

2

Taun

ton

& S

omer

set H

ospi

tal,

Taun

ton

1571%

280

1

The

Alex

andr

a H

ospi

tal,

Red

ditc

h87%

3852%

4896%

2674%

31

The

Gre

at W

este

rn H

ospi

tal,

Swin

don

1886%

433

6

The

Ipsw

ich

Hos

pita

l, Ip

swic

h18

72%

320

1

Torb

ay H

ospi

tal,

Torq

uay

59%

2258%

3116

58%

24

Uni

vers

ity C

olle

ge H

ospi

tal,

Lond

on0

01

1

Uni

vers

ity H

ospi

tal A

intr

ee, L

iver

pool

76

52

Uni

vers

ity H

ospi

tal C

oven

try,

Cov

entr

y0

24

3

Uni

vers

ity H

ospi

tal o

f Har

tlepo

ol, H

artle

pool

11

11

Uni

vers

ity H

ospi

tal o

f Nor

th S

taffo

rdsh

ire,

Sto

ke-o

n-Tr

ent

11

01

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

33

16/0

8/20

11

14:1

3

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Thro

mbo

lytic

trea

tmen

t with

in

30 m

ins

of

hosp

ital a

rriv

al

Thro

mbo

lytic

trea

tmen

t with

in

60 m

ins

of

calli

ng fo

r he

lp

Year

2009

/10

2010

/11

%n

%n

%

n%

n

34 MINAP

Uni

vers

ity H

ospi

tal o

f Nor

th T

ees,

Sto

ckto

n on

Tee

s0

01

1

Uni

vers

ity H

ospi

tal Q

ueen

s M

edic

al, N

ottin

gham

68%

5644%

7374%

2748%

33

Vict

oria

Hos

pita

l, B

lack

pool

55

63

War

ring

ton

Dis

tric

t Gen

eral

Hos

pita

l, W

arri

ngto

n83%

3583%

294

4

Wes

t Cor

nwal

l Hos

pita

l, P

enza

nce

74

50

Wes

t Cum

berl

and

Hos

pita

l, W

hite

have

n72%

2561%

3181%

3678%

41

Wex

ham

Par

k H

ospi

tal,

Slou

gh74%

3578%

402

1

Whi

ston

Hos

pita

l, P

resc

ott

33

21

Will

iam

Har

vey

Hos

pita

l, As

hfor

d90%

4286%

355

4

Wor

cest

ersh

ire

Roy

al H

ospi

tal,

Wor

cest

er81%

5753%

6483%

2959%

39

Wor

thin

g H

ospi

tal,

Wor

thin

g61%

2369%

2613

13

Wyc

ombe

Gen

eral

Hos

pita

l, H

igh

Wyc

ombe

76%

4935%

4611

10

Wyt

hens

haw

e H

ospi

tal,

Man

ches

ter

10

33

Yeov

il D

istr

ict H

ospi

tal,

Yeov

il9

82%

222

2

York

Dis

tric

t Hos

pita

l, Yo

rk10

112

1

35

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

34

16/0

8/20

11

14:1

3

“MIN

AP

dat

a is

a s

igni

fican

t too

l sup

port

ing

serv

ice

deve

lopm

ent,

iden

tifyi

ng a

reas

for

curr

ent a

nd fu

ture

wor

k.”

Jan

Kee

nan

Con

sult

ant N

urse

and

Dr

Rob

in C

houd

hury

,

Seni

or R

esea

rch

Fell

ow a

t Oxf

ord

Hea

rt C

entr

e

35MINAP

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

35

16/0

8/20

11

14:1

3

37MINAP

Thro

mbo

lytic

trea

tmen

t w

ithin

30

min

s of

ho

spita

l arr

ival

Thro

mbo

lytic

trea

tmen

t w

ithin

60

min

s of

ca

lling

for

help

Thro

mbo

lytic

trea

tmen

t w

ithin

30

min

s of

ho

spita

l arr

ival

Thro

mbo

lytic

trea

tmen

t w

ithin

60

min

s of

ca

lling

for

help

Year

2009

/10

2010

/11

%n

%n

%n

%n

table

3 th

romb

olyt

ic t

reat

ment

in

hosp

ital

s in wales and belfast

36 MINAP

Wal

es n

atio

nal a

vera

ge67%

356

55%

484

62%

298

53%

402

Bro

ngla

is G

ener

al H

ospi

tal,

Aber

ystw

yth

65

1313

Gla

n C

lwyd

DG

H T

rust

, Bod

elw

ydda

n84%

3258%

5097%

3059%

49

Llan

doug

h H

ospi

tal,

Llan

doug

h8

53

2

Llan

dudn

o G

ener

al H

ospi

tal,

Llan

dudn

o8

134

3

Mae

lor

Hos

pita

l, W

rexh

am71%

4946%

4866%

4456%

48

Mor

rist

on H

ospi

tal,

Swan

sea

00

11

Nea

th P

ort T

albo

t Hos

pita

l, N

eath

43

32

Nev

ill H

all H

ospi

tal,

Aber

gave

nny

59%

2949%

3966%

2946%

28

Pri

nce

Cha

rles

Hos

pita

l, M

erth

yr T

ydfil

1771%

3559%

2256%

32

Pri

nce

Phi

lip H

ospi

tal,

Llan

elli

148

106

Pri

nces

s of

Wal

es H

ospi

tal,

Bri

dgen

d13

67%

2414

60%

25

Roy

al G

lam

orga

n, L

lant

risa

nt74%

2751%

354

7

Roy

al G

wen

t Hos

pita

l, N

ewpo

rt57%

4656%

7060%

4052%

62

Sing

leto

n H

ospi

tal,

Swan

sea

20

00

Uni

vers

ity H

ospi

tal o

f Wal

es, C

ardi

ff55%

2969%

515

88%

32

Wes

t Wal

es G

ener

al, C

amar

then

74%

2342%

2672%

2946%

26

With

ybus

h G

ener

al H

ospi

tal,

Hav

erfo

rdw

est

82%

2259%

2711

18

Ysby

ty G

wyn

edd

, Ban

gor

56%

2744%

4544%

3642%

48

Bel

fast

ave

rage

46%

2648%

310

0

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

36

16/0

8/20

11

14:1

3

table

4 am

bula

nce

serv

ices

in

engl

and

and

wales

Pat

ient

s ha

ving

thro

mbo

lytic

tr

eatm

ent w

ithin

60

min

s of

ca

lling

for

help

Pat

ient

s ha

ving

thro

mbo

lytic

tr

eatm

ent w

ithin

60

min

s of

ca

lling

for

help

Pat

ient

s ha

ving

pr

e-ho

spita

l th

rom

boly

sis

Pat

ient

s ha

ving

pr

e-ho

spita

l th

rom

boly

sis

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp fo

r pa

tient

s w

ith d

irec

t adm

issi

on

to in

terv

entio

nal c

entr

e

Pri

mar

y an

giop

last

y w

ithin

15

0 m

ins

of c

allin

g fo

r he

lp

for

patie

nts

tran

sfer

red

to

inte

rven

tiona

l cen

tre

Year

20

09/1

020

10/1

120

09/1

020

10/1

120

10/1

1

%

n%

nn

n%

n%

n

Engl

and

nati

onal

ave

rage

70%

3473

69%

1732

1633

824

88%

9995

50%

1543

Isle

of W

ight

74%

3885%

2619

172

1

Lond

on10

81

288%

1375

51%

256

Gre

at W

este

rn71%

156

52%

2989

1484%

547

58%

79

Nor

th E

ast

68

11

97%

886

61%

192

Nor

th W

est

70%

837

74%

576

165

146

92%

865

47%

297

York

shir

e60%

198

37%

4189

1284%

1007

19%

104

East

Mid

land

s72%

820

72%

513

487

309

89%

675

22%

27

Wes

t Mid

land

s59%

212

66%

125

9965

88%

1189

46%

125

East

of E

ngla

nd79%

206

71%

48192

7690%

1300

52%

282

Sout

h Ea

st C

oast

81%

394

72%

103

215

4580%

823

74%

88

Sout

h C

entr

al50%

219

38%

5238

492%

861

29%

58

Sout

h W

este

rn70%

377

68%

203

238

133

89%

465

97%

34

Wel

sh55%

489

53%

406

250

219

75%

221

7

37MINAP

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

37

16/0

8/20

11

14:1

3

table

5 se

cond

ary

prev

enti

on m

edic

atio

n in

england

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

inhi

bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

38 MINAP

39MINAP

Engl

and

nati

onal

ave

rage

99%

52189

96%

47008

97%

52723

94%

48856

95%

49755

Adde

nbro

oke'

s H

ospi

tal,

Cam

brid

ge99%

170

99%

151

99%

179

99%

136

99%

142

Aire

dale

Gen

eral

Hos

pita

l, St

eeto

n98%

192

99%

169

99%

198

99%

179

89%

209

Arro

we

Par

k H

ospi

tal,

Wir

ral

100%

252

93%

201

90%

277

71%

241

89%

222

Bar

net G

ener

al H

ospi

tal,

Bar

net

100%

42100%

3998%

4397%

3997%

39

Bar

nsle

y D

istr

ict G

ener

al H

ospi

tal,

Bar

nsle

y96%

159

93%

151

97%

162

93%

146

96%

147

Bar

ts &

the

Lond

on, L

ondo

n99%

985

95%

950

99%

988

96%

962

96%

989

Bas

ildon

Hos

pita

l, B

asild

on99%

679

99%

655

99%

682

98%

658

96%

661

Bas

ings

toke

& N

orth

Ham

pshi

re H

ospi

tal,

Bas

ings

toke

100%

201

95%

188

100%

202

99%

197

99%

199

Bas

setl

aw D

istr

ict G

ener

al H

ospi

tal,

Not

tingh

am100%

230

100%

219

100%

251

100%

246

100%

213

Bed

ford

Hos

pita

l, B

edfo

rd96%

7797%

7897%

7996%

8092%

79

Bir

min

gham

Hea

rtla

nds

Hos

pita

l, B

irm

ingh

am100%

595

95%

529

100%

591

95%

573

99%

599

Bra

dfor

d R

oyal

Infir

mar

y, B

radf

ord

100%

547

98%

486

97%

553

97%

532

98%

537

Thes

e an

alys

es a

re b

ased

on

all p

atie

nts

disc

harg

ed fr

om h

ospi

tal w

ith

a di

agno

sis

of m

yoca

rdia

l inf

arct

ion.

Pat

ient

s ar

e ex

clud

ed if

the

y ar

e tr

ansf

erre

d fr

om t

he a

dmit

ting

hos

pita

l to

anot

her

hosp

ital

for f

urth

er t

reat

men

t. P

atie

nts

are

also

exc

lude

d fr

om a

naly

sis

if t

here

is a

con

trai

ndic

atio

n to

a d

rug,

if t

hey

refu

se t

reat

men

t, o

r hav

e se

vere

non

car

diac

co-

mor

bidi

ty t

hat

limit

s pr

ogno

sis.

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

38

16/0

8/20

11

14:1

3

39MINAP

Bri

stol

Roy

al In

firm

ary,

Bri

stol

98%

791

90%

790

96%

790

90%

789

92%

791

Bro

omfie

ld H

ospi

tal,

Che

lmsf

ord

94%

310

89%

256

91%

312

88%

250

88%

273

Cal

derd

ale

Roy

al H

ospi

tal,

Hal

ifax

99%

292

98%

245

97%

299

99%

256

99%

281

Cas

tle H

ill H

ospi

tal,

Hul

l95%

835

90%

844

94%

847

88%

846

92%

848

Cen

tral

Mid

dles

ex H

ospi

tal,

Lond

on98%

108

88%

9695%

110

92%

106

94%

107

Cha

ring

Cro

ss H

ospi

tal,

Lond

on95%

4192%

3893%

4194%

36100%

40

Cha

se F

arm

Hos

pita

l, En

field

97%

105

99%

97100%

108

100%

935%

106

Che

lsea

& W

estm

inis

ter

Hos

pita

l, Lo

ndon

100%

2217

100%

2295%

20100%

21

Che

ltenh

am G

ener

al H

ospi

tal,

Che

ltenh

am100%

178

100%

157

99%

172

100%

172

99%

174

Che

ster

field

Roy

al, C

hest

erfie

ld99%

274

99%

234

99%

279

97%

259

99%

265

Cho

rley

Hos

pita

l, C

horl

ey99%

8588%

9199%

9389%

9287%

94

City

Hos

pita

l, B

irm

ingh

am100%

216

100%

174

100%

219

100%

192

100%

216

Col

ches

ter

Gen

eral

Hos

pita

l, C

olch

este

r100%

354

98%

304

98%

361

99%

335

99%

346

Con

ques

t Hos

pita

l, St

Leo

nard

s on

Sea

100%

270

98%

229

99%

282

97%

261

100%

264

Cou

ntes

s of

Che

ster

Hos

pita

l, C

hest

er99%

211

99%

206

97%

236

99%

187

99%

179

Cou

nty

Hos

pita

l Her

efor

d, H

eref

ord

95%

2095%

2095%

2019

100%

20

Cum

berl

and

Infir

mar

y, C

arlis

le97%

191

97%

150

80%

199

78%

180

89%

196

Dar

ent V

alle

y H

ospi

tal,

Dar

tfor

d96%

206

93%

188

94%

208

90%

192

91%

197

Dar

lingt

on M

emor

ial H

ospi

tal,

Dar

lingt

on99%

125

98%

126

92%

133

90%

125

96%

125

Der

rifo

rd H

ospi

tal,

Ply

mou

th100%

2611

84%

2561%

2395%

42

Dew

sbur

y D

istr

ict H

ospi

tal,

Dew

sbur

y98%

286

96%

253

97%

298

94%

278

95%

270

Dia

na, P

rinc

ess

of W

ales

Hos

pita

l, G

rim

sby

99%

167

94%

159

98%

180

84%

166

95%

176

Don

cast

er R

oyal

Infir

mar

y, D

onca

ster

100%

296

100%

281

99%

315

100%

292

92%

309

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

39

16/0

8/20

11

14:1

3

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

inhi

bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

40 MINAP

41MINAP

Dor

set C

ount

y H

ospi

tal,

Dor

ches

ter

100%

236

97%

215

96%

235

94%

225

98%

234

Ealin

g H

ospi

tal,

Sout

hall

94%

6291%

6496%

6897%

6082%

60

East

Sur

rey

Hos

pita

l, R

edhi

ll99%

413

95%

360

94%

425

93%

383

95%

399

East

bour

ne D

GH

, Eas

tbou

rne

100%

226

100%

179

100%

231

99%

194

100%

187

Epso

m H

ospi

tal,

Epso

m100%

5998%

58100%

59100%

60100%

60

Fair

field

Gen

eral

Hos

pita

l, B

ury

100%

190

100%

178

100%

197

100%

185

99%

191

Free

man

Hos

pita

l, N

ewca

stle

100%

1505

100%

1414

100%

1504

100%

1454

100%

1506

Fren

chay

Hos

pita

l, B

rist

ol100%

256

92%

250

91%

264

86%

244

92%

251

Fria

rage

Hos

pita

l, N

orth

alle

rton

100%

22100%

20100%

22100%

2011

Frim

ley

Par

k H

ospi

tal,

Frim

ley

100%

402

97%

322

98%

397

95%

366

99%

398

Furn

ess

Gen

eral

, Bar

row

-in-

Furn

ess

96%

2581%

2192%

2687%

2392%

26

Geo

rge

Ellio

t Hos

pita

l, N

unea

ton

100%

134

98%

128

98%

139

93%

127

99%

120

Gle

nfiel

d H

ospi

tal,

Leic

este

r100%

573

100%

548

100%

573

100%

554

96%

584

Glo

uces

ters

hire

Roy

al H

ospi

tal,

Glo

uces

ter

100%

98100%

82100%

96100%

86100%

96

Goo

d H

ope

Gen

eral

Hos

pita

l, Su

tton

Col

dfiel

d100%

173

100%

148

99%

183

99%

173

99%

179

Gra

ntha

m &

Dis

tric

t Gen

eral

, Gra

ntha

m96%

7292%

6490%

8290%

6790%

70

Ham

mer

smith

Hos

pita

l, Lo

ndon

97%

374

89%

334

95%

371

89%

359

96%

373

Har

efiel

d H

ospi

tal

96%

838

87%

826

92%

835

83%

834

73%

829

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

40

16/0

8/20

11

14:1

3

41MINAP

Har

roga

te D

istr

ict H

ospi

tal,

Har

roga

te100%

280

99%

232

98%

283

99%

256

100%

260

Hex

ham

Gen

eral

Hos

pita

l, H

exha

m98%

4184%

3893%

4197%

3891%

35

Hill

ingd

on H

ospi

tal,

Uxb

ridg

e100%

222

100%

150

99%

205

100%

186

100%

170

Hin

chin

gbro

oke

Hos

pita

l, H

untin

gdon

108

99

11

Hom

erto

n H

ospi

tal,

Lond

on95%

2095%

2095%

2195%

2086%

21

Hop

e H

ospi

tal,

Man

ches

ter

99%

308

98%

287

97%

313

96%

294

94%

299

Hor

ton

Gen

eral

Hos

pita

l, B

anbu

ry100%

74100%

59100%

71100%

54100%

66

Hud

ders

field

Roy

al In

firm

ary,

Hud

ders

field

100%

245

99%

209

98%

248

96%

225

100%

237

Hul

l Roy

al In

firm

ary,

Hul

l85%

3453%

3859%

3753%

3865%

37

Jam

es C

ook

Uni

vers

ity H

ospi

tal,

Mid

dles

boro

ugh

100%

756

99%

712

99%

760

99%

736

99%

730

Jam

es P

aget

Hos

pita

l, G

reat

Yar

mou

th87%

3885%

3987%

3985%

3987%

38

John

Rad

cliff

e H

ospi

tal,

Oxf

ord

100%

764

100%

670

100%

729

100%

717

100%

730

Ken

t & C

ante

rbur

y H

ospi

tal,

Can

terb

ury

99%

184

94%

154

91%

195

98%

151

95%

178

Ken

t & S

usse

x H

ospi

tal,

Tunb

ridg

e W

ells

98%

8397%

6699%

8190%

7396%

81

Ket

teri

ng G

ener

al H

ospi

tal,

Ket

teri

ng100%

378

97%

329

99%

377

97%

340

99%

375

Kin

g G

eorg

e H

ospi

tal,

Goo

dmay

es100%

115

100%

100

99%

122

98%

105

100%

99

Kin

g's

Col

lege

Hos

pita

l, Lo

ndon

99%

629

95%

626

98%

628

96%

615

84%

627

Kin

gs M

ill H

ospi

tal,

Not

tingh

am97%

279

95%

252

95%

277

90%

262

97%

279

Kin

gsto

n H

ospi

tal,

Kin

gsto

n-up

on-T

ham

es100%

2217

96%

2791%

2219

Leed

s G

ener

al In

firm

ary,

Lee

ds100%

861

97%

777

99%

848

96%

788

97%

67

Leic

este

r R

oyal

Infir

mar

y, L

eice

ster

100%

40100%

4698%

41100%

3968%

41

Leig

hton

Hos

pita

l, C

rew

e98%

281

97%

245

97%

313

95%

286

97%

277

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

41

16/0

8/20

11

14:1

3

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

inhi

bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

42 MINAP

43MINAP

Linc

oln

Cou

nty

Hos

pita

l, Li

ncol

n96%

351

85%

341

95%

354

86%

346

90%

346

List

er H

ospi

tal,

Stev

enag

e98%

271

98%

262

100%

271

97%

266

98%

265

Live

rpoo

l Hea

rt &

Che

st H

ospi

tal,

Live

rpoo

l100%

741

100%

719

100%

743

100%

735

99%

743

Luto

n &

Dun

stab

le H

ospi

tal,

Luto

n100%

189

99%

146

100%

206

99%

166

100%

187

Mac

cles

field

Dis

tric

t Gen

eral

, Mac

cles

field

96%

198

88%

171

92%

197

85%

185

82%

194

Mai

dsto

ne G

ener

al H

ospi

tal,

Mai

dsto

ne97%

124

88%

106

96%

116

84%

111

97%

124

Man

ches

ter

Roy

al In

firm

ary,

Man

ches

ter

98%

226

92%

215

97%

233

83%

222

94%

225

Man

or H

ospi

tal,

Wal

sall

96%

8284%

7696%

8486%

7884%

80

May

day

Uni

vers

ity H

ospi

tal,

Cro

ydon

86%

7682%

6789%

7979%

7283%

71

Med

way

Mar

itim

e H

ospi

tal,

Gill

ingh

am100%

312

100%

301

99%

323

100%

303

100%

316

Milt

on K

eyne

s G

ener

al H

ospi

tal,

Milt

on

Key

nes

98%

4286%

42100%

4188%

4086%

35

Mon

tagu

Hos

pita

l, M

exbo

roug

h19

1590%

2014

19

New

Cro

ss H

ospi

tal,

Wol

verh

ampt

on100%

827

99%

714

99%

832

93%

745

98%

803

New

ark

Hos

pita

l, N

ewar

k97%

3589%

3692%

3997%

3694%

36

New

ham

Gen

eral

Hos

pita

l, Lo

ndon

100%

133

100%

102

100%

133

100%

84100%

119

Nor

folk

& N

orw

ich

Uni

vers

ity H

ospi

tal,

Nor

wic

h98%

1115

100%

957

100%

1085

100%

1023

96%

1120

Nor

th D

evon

Dis

tric

t Hos

pita

l, B

arns

tabl

e100%

179

100%

119

100%

170

100%

142

100%

146

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

42

16/0

8/20

11

14:1

3

43MINAP

Nor

th M

anch

este

r G

ener

al H

ospi

tal,

Man

ches

ter

99%

192

99%

169

99%

190

97%

186

98%

185

Nor

th M

iddl

esex

Hos

pita

l, Lo

ndon

94%

121

86%

110

92%

123

87%

120

81%

116

Nor

th T

ynes

ide

Gen

eral

Hos

pita

l, N

orth

Sh

ield

s100%

168

100%

149

100%

174

98%

129

99%

158

Nor

tham

pton

Gen

eral

Hos

pita

l, N

orth

ampt

on100%

440

100%

380

100%

425

100%

367

100%

410

Nor

ther

n G

ener

al H

ospi

tal,

Shef

field

99%

909

99%

741

99%

875

98%

736

99%

644

Nor

thw

ick

Par

k H

ospi

tal,

Har

row

99%

292

89%

261

97%

303

89%

289

92%

293

Not

tingh

am C

ity H

ospi

tal,

Not

tingh

am99%

353

93%

325

98%

352

94%

344

95%

353

Pap

wor

th H

ospi

tal,

Cam

brid

ge99%

541

95%

524

99%

541

96%

531

77%

539

Pet

erbo

roug

h C

ity H

ospi

tal,

Pet

erbo

roug

h100%

260

100%

191

100%

264

100%

224

100%

255

Pilg

rim

Hos

pita

l, B

osto

n90%

198

79%

201

83%

208

81%

205

82%

204

Pin

derfi

elds

Gen

eral

Hos

pita

l, W

akefi

eld

100%

295

99%

286

99%

308

96%

285

99%

289

Pon

tefr

act G

ener

al In

firm

ary,

Pon

tefr

act

100%

206

99%

196

99%

215

94%

204

97%

203

Poo

le H

ospi

tal,

Poo

le17

1216

1512

Pri

nces

s Al

exan

dra

Hos

pita

l, H

arlo

w88%

199

76%

200

91%

203

85%

202

91%

203

Pri

nces

s R

oyal

Hos

pita

l, H

ayw

ards

Hea

th99%

142

98%

121

93%

137

90%

120

92%

121

Pri

nces

s R

oyal

Hos

pita

l, Te

lford

100%

8199%

6995%

8486%

7796%

72

Pri

nces

s R

oyal

Uni

vers

ity H

ospi

tal,

Orp

ingt

on86%

218

81%

218

83%

218

81%

218

68%

218

Que

en A

lexa

ndra

Hos

pita

l, P

orts

mou

th98%

550

96%

541

97%

543

88%

504

92%

547

Que

en E

lizab

eth

Hos

pita

l, B

irm

ingh

am100%

442

99%

367

100%

439

100%

400

100%

428

Que

en E

lizab

eth

Hos

pita

l, G

ates

head

96%

241

95%

198

94%

247

86%

197

90%

233

Que

en E

lizab

eth

Hos

pita

l, K

ing'

s Ly

nn93%

274

85%

245

86%

274

80%

254

83%

261

Que

en E

lizab

eth

Hos

pita

l, W

oolw

ich

100%

104

99%

90100%

103

94%

9099%

98

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

43

16/0

8/20

11

14:1

3

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

inhi

bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

44 MINAP

45MINAP

Que

en E

lizab

eth

II H

ospi

tal,

Wel

wyn

Gar

den

City

99%

6993%

7297%

7095%

6490%

62

Que

en E

lizab

eth

the

Que

en M

othe

r, M

arga

te98%

146

90%

126

86%

157

83%

117

84%

135

Que

en M

ary'

s H

ospi

tal,

Sidc

up12

1213

1312

Que

en's

Hos

pita

l, R

omfo

rd100%

182

100%

162

100%

195

99%

185

99%

142

Que

en's

Hos

pita

l, B

urto

n-up

on-T

rent

100%

108

100%

88100%

106

98%

8699%

100

Roc

hdal

e In

firm

ary,

Roc

hdal

e100%

192

97%

158

100%

195

100%

184

99%

170

Rot

herh

am G

ener

al H

ospi

tal,

Rot

herh

am100%

321

100%

244

99%

323

100%

280

99%

309

Roy

al A

lber

t Edw

ard

Infir

mar

y, W

igan

100%

379

100%

356

100%

388

100%

368

100%

367

Roy

al B

erks

hire

Hos

pita

l, R

eadi

ng100%

412

99%

392

99%

412

95%

380

98%

401

Roy

al B

lack

burn

Hos

pita

l, B

lack

burn

99%

538

96%

500

96%

560

94%

523

97%

535

Roy

al B

olto

n H

ospi

tal,

Bol

ton

99%

442

94%

397

98%

441

89%

403

86%

420

Roy

al B

ourn

emou

th G

ener

al H

ospi

tal,

Bou

rnem

outh

100%

199

95%

181

98%

200

96%

197

96%

203

Roy

al C

ornw

all H

ospi

tal,

Trur

o100%

651

100%

483

100%

595

100%

478

98%

622

Roy

al D

erby

Hos

pita

l, D

erby

100%

483

100%

409

100%

463

100%

390

100%

449

Roy

al D

evon

& E

xete

r H

ospi

tal,

Exet

er100%

411

99%

376

97%

423

96%

400

96%

417

Roy

al F

ree

Hos

pita

l, Lo

ndon

97%

306

97%

306

97%

306

97%

304

97%

305

Roy

al H

amps

hire

Cou

nty

Hos

pita

l, W

inch

este

r100%

112

100%

7099%

99100%

94100%

91

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

44

16/0

8/20

11

14:1

3

45MINAP

Roy

al L

anca

ster

Infir

mar

y, L

anca

ster

99%

99100%

9199%

100

98%

9997%

99

Roy

al L

iver

pool

Uni

vers

ity H

ospi

tal,

Live

rpoo

l99%

138

100%

141

100%

150

100%

8699%

137

Roy

al L

ondo

n H

ospi

tal,

Lond

on4

24

100%

2017

Roy

al O

ldha

m H

ospi

tal,

Old

ham

99%

281

98%

252

99%

290

95%

273

96%

281

Roy

al P

rest

on H

ospi

tal,

Pre

ston

95%

105

90%

102

92%

105

90%

107

88%

107

Roy

al S

hrew

sbur

y H

ospi

tal,

Shre

wsb

ury

99%

100

98%

8697%

9785%

7193%

89

Roy

al S

urre

y C

ount

y H

ospi

tal,

Gui

ldfo

rd19

1618

96%

2588%

26

Roy

al S

usse

x C

ount

y H

ospi

tal,

Bri

ghto

n100%

311

97%

280

98%

308

95%

291

97%

302

Roy

al U

nite

d H

ospi

tal B

ath,

Bat

h100%

260

97%

231

99%

252

96%

220

99%

232

Roy

al V

icto

ria

Infir

mar

y, N

ewca

stle

100%

103

100%

85100%

108

100%

97100%

97

Rus

sells

Hal

l Hos

pita

l, D

udle

y99%

183

93%

167

93%

185

92%

180

92%

170

Salis

bury

Dis

tric

t Hos

pita

l, Sa

lisbu

ry100%

205

98%

185

99%

204

98%

197

96%

194

Sand

wel

l Dis

tric

t Hos

pita

l, W

est B

rom

wic

h100%

236

99%

187

100%

245

100%

218

100%

233

Scar

boro

ugh

Gen

eral

Hos

pita

l, Sc

arbo

roug

h98%

138

92%

121

97%

142

93%

137

92%

146

Scun

thor

pe G

ener

al H

ospi

tal,

Scun

thor

pe95%

278

89%

263

95%

295

89%

266

96%

295

Selly

Oak

Hos

pita

l, B

irm

ingh

am1

11

11

Solih

ull G

ener

al H

ospi

tal,

Bir

min

gham

96%

5294%

4996%

5294%

49100%

51

Sout

h Ty

nesi

de D

istr

ict H

ospi

tal,

Sout

h Sh

ield

s100%

141

100%

107

99%

136

100%

122

100%

116

Sout

ham

pton

Gen

eral

Hos

pita

l, So

utha

mpt

on99%

700

98%

663

99%

703

94%

689

95%

643

Sout

hend

Hos

pita

l, W

estc

liffe

on

Sea

100%

370

100%

340

100%

385

100%

324

100%

350

Sout

hmea

d H

ospi

tal,

Bri

stol

94%

252

94%

224

91%

253

83%

186

85%

233

Sout

hpor

t & F

orm

by D

istr

ict G

ener

al,

Sout

hpor

t100%

114

98%

8798%

119

92%

112

100%

117

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

45

16/0

8/20

11

14:1

3

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

inhi

bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

46 MINAP

47MINAP

St G

eorg

e's

Hos

pita

l, Lo

ndon

99%

444

94%

435

98%

445

93%

442

99%

444

St H

elie

r H

ospi

tal,

Car

shal

ton

100%

7097%

6799%

6997%

72100%

72

St M

ary'

s H

ospi

tal,

New

port

100%

6798%

51100%

59100%

5298%

56

St M

ary'

s H

ospi

tal,

Lond

on91%

138

74%

138

85%

138

69%

138

77%

138

St P

eter

's H

ospi

tal,

Che

rtse

y100%

215

100%

207

100%

215

100%

199

100%

201

St R

icha

rd's

Hos

pita

l, C

hich

este

r97%

114

90%

112

89%

123

85%

110

88%

97

St T

hom

as H

ospi

tal,

Lond

on100%

262

100%

244

100%

264

100%

248

100%

256

Staf

ford

shir

e G

ener

al H

ospi

tal,

Staf

ford

97%

152

91%

139

95%

161

90%

141

89%

132

Step

ping

Hill

Hos

pita

l, St

ockp

ort

96%

437

94%

435

95%

490

92%

443

81%

493

Stok

e M

ande

ville

Hos

pita

l, Ay

lesb

ury

100%

7198%

5198%

6597%

6497%

66

Sund

erla

nd R

oyal

Hos

pita

l, Su

nder

land

99%

170

95%

165

97%

172

95%

164

98%

166

Tam

esid

e G

ener

al H

ospi

tal,

Asht

on U

nder

Ly

me

99%

292

98%

258

95%

317

97%

280

89%

300

Taun

ton

& S

omer

set H

ospi

tal,

Taun

ton

99%

399

89%

376

94%

413

87%

386

95%

390

The

Alex

andr

a H

ospi

tal,

Red

ditc

h96%

164

86%

158

93%

164

87%

163

92%

164

The

Gre

at W

este

rn H

ospi

tal,

Swin

don

99%

368

96%

291

96%

365

93%

321

98%

337

The

Ipsw

ich

Hos

pita

l, Ip

swic

h92%

329

71%

319

78%

365

63%

350

77%

327

Torb

ay H

ospi

tal,

Torq

uay

99%

368

80%

316

96%

366

86%

339

95%

354

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

46

16/0

8/20

11

14:1

3

47MINAP

Traf

ford

Gen

eral

Hos

pita

l, M

anch

este

r19

1919

1918

Uni

vers

ity C

olle

ge H

ospi

tal G

ower

Str

eet,

Lond

on95%

5693%

5498%

5794%

5370%

57

Uni

vers

ity C

olle

ge H

ospi

tal,

Lond

on100%

173

98%

157

99%

179

99%

174

96%

175

Uni

vers

ity H

ospi

tal A

intr

ee, L

iver

pool

100%

287

99%

225

96%

324

94%

213

98%

231

Uni

vers

ity H

ospi

tal C

oven

try,

Cov

entr

y100%

436

96%

413

98%

439

96%

435

97%

436

Uni

vers

ity H

ospi

tal L

ewis

ham

, Lon

don

95%

6193%

5995%

6287%

6285%

61

Uni

vers

ity H

ospi

tal o

f Har

tlepo

ol, H

artle

pool

100%

102

100%

75100%

94100%

82100%

95

Uni

vers

ity H

ospi

tal o

f Nor

th D

urha

m, D

urha

m97%

9590%

9193%

9489%

8577%

102

Uni

vers

ity H

ospi

tal o

f Nor

th S

taffo

rdsh

ire,

St

oke-

on-T

rent

96%

1050

88%

921

95%

1052

83%

1051

90%

1053

Uni

vers

ity H

ospi

tal o

f Nor

th T

ees,

Sto

ckto

n on

Tee

s100%

88100%

7796%

8396%

6997%

72

Uni

vers

ity H

ospi

tal Q

ueen

s M

edic

al,

Not

tingh

am100%

5180%

4693%

5484%

4992%

52

Vict

oria

Hos

pita

l, B

lack

pool

100%

648

100%

606

98%

653

98%

591

98%

596

Wan

sbec

k G

ener

al H

ospi

tal,

Ashi

ngto

n100%

141

100%

121

100%

151

99%

134

100%

131

War

ring

ton

Dis

tric

t Gen

eral

Hos

pita

l, W

arri

ngto

n100%

270

100%

215

98%

285

98%

244

100%

250

War

wic

k H

ospi

tal,

War

wic

k100%

3282%

2897%

3294%

32100%

32

Wat

ford

Gen

eral

Hos

pita

l, W

atfo

rd99%

330

99%

301

97%

334

100%

309

98%

325

Wes

t Cor

nwal

l Hos

pita

l, P

enza

nce

23

20

3

Wes

t Cum

berl

and

Hos

pita

l, W

hite

have

n92%

9293%

8190%

9780%

8681%

95

Wes

t Mid

dles

ex U

nive

rsity

Hos

pita

l, Is

lew

orth

100%

48100%

46100%

4794%

4893%

44

Wes

t Suf

folk

Hos

pita

l, B

ury

St E

dmun

ds97%

152

94%

135

94%

161

92%

142

95%

149

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

47

16/0

8/20

11

14:1

3

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

even

tion

med

icat

ion

Asp

irin

Bet

a bl

ocke

rSt

atin

sAC

E in

hibi

tor

Clo

pido

grel

/Th

ieno

pyri

dine

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bito

r

Year

20

10/1

1

%n

%n

%n

%n

%n

48 MINAP

49

Wes

ton

Gen

eral

Hos

pita

l, W

esto

n-Su

perm

are

100%

127

98%

9098%

127

98%

114

99%

119

Wex

ham

Par

k H

ospi

tal,

Slou

gh96%

172

83%

169

88%

172

87%

170

93%

170

Whi

pps

Cro

ss H

ospi

tal,

Lond

on100%

205

97%

148

98%

206

97%

174

97%

174

Whi

ston

Hos

pita

l, P

resc

ott

100%

301

100%

255

99%

302

99%

278

99%

277

Whi

ttin

gton

Hos

pita

l, Lo

ndon

100%

59100%

58100%

59100%

59100%

58

Will

iam

Har

vey

Hos

pita

l, As

hfor

d99%

662

94%

602

98%

680

94%

619

96%

660

Wor

cest

ersh

ire

Roy

al H

ospi

tal,

Wor

cest

er99%

178

99%

157

100%

179

100%

172

100%

174

Wor

thin

g H

ospi

tal,

Wor

thin

g100%

228

96%

192

94%

218

98%

204

98%

210

Wyc

ombe

Gen

eral

Hos

pita

l, H

igh

Wyc

ombe

99%

175

99%

164

98%

179

99%

176

93%

178

Wyt

hens

haw

e H

ospi

tal,

Man

ches

ter

100%

307

99%

288

98%

308

96%

306

98%

304

Yeov

il D

istr

ict H

ospi

tal,

Yeov

il100%

8495%

5985%

8087%

6996%

77

York

Dis

tric

t Hos

pita

l, Yo

rk100%

422

99%

329

99%

411

99%

359

100%

410

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

48

16/0

8/20

11

14:1

3

49MINAP

“The

cha

nces

of s

urvi

val a

fter

hea

rt a

ttac

k

have

impr

oved

yea

r on

yea

r de

spite

an

agei

ng

popu

latio

n so

that

the

outc

omes

in th

is c

ount

ry

mat

ch th

e be

st in

the

wor

ld.”

Pro

fess

or S

ir R

oger

Boy

le C

BE

Nat

iona

l Dir

ecto

r fo

r H

eart

Dis

ease

and

Str

oke

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

49

16/0

8/20

11

14:1

3

table

6 se

cond

ary

prev

enti

on i

n wa

les

and

belfast

Pat

ient

s di

scha

rged

on

seco

ndar

y pr

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tion

med

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ion

Asp

irin

Bet

a bl

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rSt

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E in

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tor

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Year

20

10/1

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%n

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50 MINAP

51MINAP

Wal

es n

atio

nal a

vera

ge98%

1279

95%

1179

95%

1319

91%

1220

92%

1213

Bro

ngla

is G

ener

al H

ospi

tal,

Aber

ystw

yth

97%

3290%

3189%

3783%

3591%

33

Gla

n C

lwyd

DG

H T

rust

, Bod

elw

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n96%

309

87%

308

89%

317

75%

299

82%

310

Llan

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11

11

Llan

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o G

ener

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dudn

o9

99

89

Mae

lor

Hos

pita

l, W

rexh

am100%

135

100%

123

99%

152

99%

118

99%

92

Mor

rist

on H

ospi

tal,

Swan

sea

100%

193

99%

181

100%

199

99%

192

99%

194

Nea

th P

ort T

albo

t Hos

pita

l, N

eath

96%

26100%

2396%

25100%

2396%

24

Nev

ill H

all H

ospi

tal,

Aber

gave

nny

97%

7597%

6493%

7596%

7596%

70

Pri

nce

Cha

rles

Hos

pita

l, M

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ydfil

100%

22100%

2296%

2396%

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23

Pri

nce

Phi

lip H

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tal,

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elli

100%

3394%

3291%

3485%

3392%

36

Pri

nces

s of

Wal

es H

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tal,

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dgen

d100%

27100%

21100%

27100%

24100%

24

Roy

al G

lam

orga

n, L

lant

risa

nt3

34

33

Roy

al G

wen

t Hos

pita

l, N

ewpo

rt99%

127

100%

101

95%

130

98%

124

95%

119

Sing

leto

n H

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tal,

Swan

sea

96%

2386%

22100%

2419

86%

21

Uni

vers

ity H

ospi

tal o

f Wal

es, C

ardi

ff100%

163

99%

149

98%

162

97%

150

96%

164

MIN

AP P

ublic

Rep

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ands

cape

Visu

als

Blue

.indd

50

16/0

8/20

11

14:1

3

51MINAP

Wes

t Wal

es G

ener

al, C

amar

then

1112

1211

10

With

ybus

h G

ener

al H

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tal,

Hav

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rdw

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100%

5996%

4793%

5796%

5194%

49

Ysby

ty G

wyn

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, Ban

gor

100%

3197%

3097%

3193%

30100%

31

Bel

fast

ave

rage

99%

483

99%

459

99%

480

97%

408

98%

459

Bel

fast

City

Hos

pita

l99%

149

99%

141

98%

151

91%

121

98%

141

Mat

er In

firm

orum

Hos

pita

l100%

9998%

95100%

9998%

91100%

97

Roy

al V

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Hos

pita

l99%

235

100%

223

100%

230

100%

196

97%

221

MIN

AP P

ublic

Rep

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ands

cape

Visu

als

Blue

.indd

51

16/0

8/20

11

14:1

3

table

7 ca

rdia

c ne

twor

ks i

n en

glan

d an

d wa

les

52 MINAP

53MINAP

Thro

mbo

lytic

tr

eatm

ent w

ithin

60

min

s of

ca

lling

for

help

Pri

mar

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min

s of

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pr

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Pat

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tr

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Year

20

09/1

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Engl

and

nati

onal

ave

rage

69%

3458

1001280%

1646

6%5183

20%

1250549%

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25%

68%

1723

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848

3%2450

10%

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25%

Angl

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ardi

ac N

etw

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69%

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80%

100

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6%814

61%

348

26%

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20802

81%

463%

171%

897

67%

379

28%

Avon

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shir

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So

mer

set C

ardi

ac &

Str

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Net

wor

k70%

222

452

77%

137

11%

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22%

507

40%

329

26%

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38832

81%

181%

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917

69%

334

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Bed

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Net

wor

k10

130

91%

319

152

56%

9736%

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91%

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135

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Bir

min

gham

, San

dwel

l & S

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diac

Net

wor

k4

484

77%

118

638

80%

139

17%

4486

84%

17

680

81%

155

18%

Bla

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ardi

ac N

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3369

80%

102

476

77%

131

21%

2386

81%

73

537

83%

100

15%

Car

diac

& S

trok

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in C

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ia

& L

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shir

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264

144

88%

7810%

338

42%

195

24%

186

23%

73%

206

140

95%

568%

274

41%

173

26%

164

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Che

shir

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Car

diac

N

etw

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76%

190

387

84%

262%

412

31%

413

31%

499

37%

82%

55601

82%

1989

8%715

62%

326

28%

Cov

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War

wic

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Net

wor

k2

274

90%

21

368

92%

307%

4304

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07

370

93%

205%

Dor

set C

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ac &

Str

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Net

wor

k70%

113

9795%

4413%

163

47%

120

34%

226%

70%

7793

91%

4315%

102

37%

106

38%

2810%

East

Mid

land

s C

ardi

ac N

etw

ork

68%

613

348

75%

343

20%

628

36%

426

24%

345

20%

70%

429

595

87%

245

13%

462

24%

728

38%

468

25%

Esse

x C

ardi

ac N

etw

ork

87%

126

347

85%

110

13%

153

18%

382

44%

226

26%

72%

29589

84%

435%

71%

588

64%

278

30%

Gre

ater

Man

ches

ter

& C

hesh

ire

Car

diac

Net

wor

k70%

328

399

77%

322%

600

34%

628

36%

492

28%

74%

245

492

74%

262%

395

24%

679

41%

540

33%

Her

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dshi

re &

Wor

cest

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ire

Car

diac

Net

wor

k57%

141

067

18%

210

56%

21%

9425%

72%

115

1164

21%

183

60%

145%

4515%

Ken

t Car

diac

Net

wor

k82%

200

1106

14%

458

59%

51%

209

27%

13441

75%

20%

537%

555

69%

196

24%

Nor

th &

Eas

t Yor

kshi

re &

Nor

ther

n Li

ncol

nshi

re C

ardi

ac N

etw

ork

59%

105

125

75%

9513%

157

22%

155

22%

308

43%

57%

21300

89%

436%

548%

370

52%

249

35%

Nor

th C

entr

al L

ondo

n C

HD

Net

wor

k1

272

76%

15

357

83%

6515%

2310

81%

24

360

81%

7717%

Nor

th E

ast L

ondo

n C

ardi

ac N

etw

ork

1500

56%

04

554

86%

8513%

2418

80%

05

557

89%

6711%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

52

16/0

8/20

11

14:1

3

53MINAP

Nor

th o

f Eng

land

Car

diov

ascu

lar

Net

wor

k52%

841253

85%

271%

141

6%1410

64%

620

28%

71%

991150

89%

402%

137

7%1349

69%

437

22%

Nor

th T

rent

Net

wor

k of

Car

diac

Car

e82%

170

274

70%

105

10%

211

20%

371

35%

383

36%

14581

75%

101%

253%

570

60%

342

36%

Nor

th W

est L

ondo

n C

HD

Net

wor

k3

709

81%

09

829

84%

145

15%

2666

80%

09

950

78%

265

22%

Pen

insu

la C

ardi

ac M

anag

ed C

linic

al

Net

wor

k69%

205

294

84%

141

13%

216

20%

455

42%

260

24%

66%

121

380

82%

798%

124

13%

498

52%

264

27%

Shro

pshi

re &

Sta

fford

shir

e C

ardi

ac

Net

wor

k66%

87240

84%

365%

153

23%

353

53%

129

19%

8282

73%

122%

397%

410

71%

115

20%

Sout

h C

entr

al V

ascu

lar

Net

wor

k54%

252

658

85%

604%

352

22%

835

52%

365

23%

55%

76956

85%

342%

106

6%1189

72%

323

20%

Sout

h Ea

st L

ondo

n C

ardi

ac N

etw

ork

3339

60%

18

414

82%

8216%

0%26

359

70%

24

491

86%

7413%

Sout

h W

est L

ondo

n C

ardi

ac N

etw

ork

1278

87%

04

319

80%

7719%

0306

90%

11

346

89%

4211%

Surr

ey H

eart

& S

trok

e N

etw

ork

80%

8294

88%

469%

234

44%

134

25%

119

22%

83%

42203

85%

194%

124

23%

255

48%

135

25%

Suss

ex H

eart

Net

wor

k79%

120

158

77%

639%

242

36%

194

29%

181

27%

69%

49281

83%

264%

110

16%

346

50%

211

30%

Wes

t Yor

kshi

re C

ardi

ac N

etw

ork

25%

44661

80%

1289

6%999

66%

408

27%

13%

23793

64%

1044

3%1032

65%

502

32%

Wal

es n

atio

nal a

vera

ge55%

484

180

76%

239

18%

608

45%

232

17%

276

20%

53%

402

225

75%

212

17%

476

38%

301

24%

274

22%

Nor

th W

ales

Car

diac

Net

wor

k51%

156

271

20%

192

53%

493

26%

52%

148

372

21%

170

50%

689

26%

Sout

h W

ales

Car

diac

Net

wor

k57%

328

178

77%

168

17%

416

42%

228

23%

183

18%

54%

254

222

76%

140

15%

306

33%

295

32%

185

20%

Bel

fast

ave

rage

48%

3147

77%

137%

4123%

7845%

4325%

0124

90%

00%

10%

173

70%

7430%

99%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

53

16/0

8/20

11

14:1

3

table

8 ca

re o

f pa

tien

ts w

ith

non

st e

leva

tion infarction(nSTEMI) in england

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

54 MINAP

55MINAP

Engl

and

nati

onal

ave

rage

21843

47%

41269

89%

23286

50%

42555

91%

Adde

nbro

oke'

s H

ospi

tal,

Cam

brid

ge150

53%

282

100%

179

68%

263

100%

Aire

dale

Gen

eral

Hos

pita

l, St

eeto

n75

50%

122

81%

8453%

155

98%

Arro

we

Par

k H

ospi

tal,

Wir

ral

263

65%

352

87%

269

66%

341

83%

Bar

net G

ener

al H

ospi

tal,

Bar

net

3141%

7296%

2346%

50100%

Bar

nsle

y D

istr

ict G

ener

al H

ospi

tal,

Bar

nsle

y187

89%

190

90%

127

73%

153

88%

Bar

ts &

the

Lond

on, L

ondo

n85

99%

86100%

433

98%

440

100%

Bas

ildon

Hos

pita

l, B

asild

on229

93%

240

98%

356

97%

364

99%

Bas

ings

toke

& N

orth

Ham

pshi

re H

ospi

tal,

Bas

ings

toke

6064%

3537%

4542%

107

99%

Bas

setl

aw D

istr

ict G

ener

al H

ospi

tal,

Not

tingh

am168

79%

180

85%

181

72%

212

84%

Bed

ford

Hos

pita

l, B

edfo

rd50

47%

102

95%

5355%

9599%

Bir

min

gham

Hea

rtla

nds

Hos

pita

l, B

irm

ingh

am156

67%

233

100%

189

61%

308

99%

Bra

dfor

d R

oyal

Infir

mar

y, B

radf

ord

119

32%

369

99%

178

46%

381

99%

Bri

stol

Roy

al In

firm

ary,

Bri

stol

112

55%

203

100%

101

51%

193

97%

Bro

omfie

ld H

ospi

tal,

Che

lmsf

ord

7923%

281

81%

7319%

338

88%

It is

reco

gnis

ed t

hat

not

all n

STEM

I are

ent

ered

into

MIN

AP.

A nu

mbe

r of h

ospi

tals

repo

rt a

lack

of r

esou

rces

to

colle

ct d

ata

on n

STEM

I, an

d m

ore

gene

rally

tho

se p

atie

nts

not

adm

itte

d to

a c

ardi

ac

unit

are

less

like

ly t

o be

ent

ered

. Thu

s th

e pe

rcen

tage

s re

port

ed b

elow

do

not

take

into

acc

ount

eve

ry p

atie

nt a

dmit

ted

to h

ospi

tal w

ith

nSTE

MI.

In a

ddit

ion

som

e ho

spit

als

in t

he L

ondo

n ar

ea t

hat

have

no

nSTE

MI a

re p

arti

cipa

ting

in a

pro

ject

for d

irec

t ad

mis

sion

of t

hese

pat

ient

s to

a h

eart

att

ack

cent

re in

a m

anne

r sim

ilar t

o th

at fo

r pri

mar

y an

giop

last

y fo

r STE

MI.

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

54

16/0

8/20

11

14:1

3

55MINAP

Cal

derd

ale

Roy

al H

ospi

tal,

Hal

ifax

126

43%

254

86%

134

39%

291

85%

Cas

tle H

ill H

ospi

tal,

Hul

l317

94%

333

99%

383

90%

420

98%

Cen

tral

Mid

dles

ex H

ospi

tal,

Lond

on4

117

97%

5111

98%

Cha

ring

Cro

ss H

ospi

tal,

Lond

on8

43100%

540

100%

Cha

se F

arm

Hos

pita

l, En

field

118

99%

119

100%

155

100%

155

100%

Che

lsea

& W

estm

inis

ter

Hos

pita

l, Lo

ndon

2328%

82100%

982

100%

Che

ltenh

am G

ener

al H

ospi

tal,

Che

ltenh

am45

38%

109

93%

4031%

113

88%

Che

ster

field

Roy

al, C

hest

erfie

ld155

48%

295

91%

110

48%

216

95%

Cho

rley

Hos

pita

l, C

horl

ey7

221

25%

6781%

City

Hos

pita

l, B

irm

ingh

am39

20%

192

100%

3924%

163

100%

Col

ches

ter

Gen

eral

Hos

pita

l, C

olch

este

r300

57%

430

82%

220

56%

342

87%

Con

ques

t Hos

pita

l, St

Leo

nard

s on

Sea

177

86%

204

100%

163

72%

201

89%

Cou

ntes

s of

Che

ster

Hos

pita

l, C

hest

er167

41%

382

94%

126

29%

386

89%

Cou

nty

Hos

pita

l Her

efor

d, H

eref

ord

4637%

8366%

4029%

103

74%

Cou

nty

Hos

pita

l Lou

th, L

outh

2292%

170

0

Cum

berl

and

Infir

mar

y, C

arlis

le86

27%

283

89%

7630%

225

89%

Dar

ent V

alle

y H

ospi

tal,

Dar

tfor

d170

82%

203

98%

253

80%

311

98%

Dar

lingt

on M

emor

ial H

ospi

tal,

Dar

lingt

on64

27%

211

89%

5224%

193

91%

Der

rifo

rd H

ospi

tal,

Ply

mou

th3

311

3359%

Dew

sbur

y D

istr

ict H

ospi

tal,

Dew

sbur

y117

49%

165

69%

102

38%

217

82%

Dia

na, P

rinc

ess

of W

ales

Hos

pita

l, G

rim

sby

151

58%

250

96%

161

65%

229

93%

Don

cast

er R

oyal

Infir

mar

y, D

onca

ster

6927%

224

87%

9031%

268

92%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

55

16/0

8/20

11

14:1

3

56 MINAP

57MINAP

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

Dor

set C

ount

y H

ospi

tal,

Dor

ches

ter

9649%

186

94%

9751%

177

94%

Ealin

g H

ospi

tal,

Sout

hall

4291%

46100%

7091%

7699%

East

Sur

rey

Hos

pita

l, R

edhi

ll136

49%

9434%

177

46%

315

83%

East

bour

ne D

GH

, Eas

tbou

rne

157

72%

178

81%

170

81%

193

92%

Epso

m H

ospi

tal,

Epso

m165

84%

197

100%

121

85%

143

100%

Fair

field

Gen

eral

Hos

pita

l, B

ury

3625%

138

97%

3623%

151

97%

Free

man

Hos

pita

l, N

ewca

stle

707

95%

741

100%

776

99%

786

100%

Fren

chay

Hos

pita

l, B

rist

ol68

51%

118

88%

137

41%

263

78%

Fria

rage

Hos

pita

l, N

orth

alle

rton

8182%

99100%

6564%

101

100%

Frim

ley

Par

k H

ospi

tal,

Frim

ley

146

42%

332

95%

122

40%

290

95%

Furn

ess

Gen

eral

, Bar

row

-in-

Furn

ess

2740%

2537%

2850%

2138%

Geo

rge

Ellio

t Hos

pita

l, N

unea

ton

6449%

125

96%

7746%

162

96%

Gle

nfiel

d H

ospi

tal,

Leic

este

r148

75%

198

100%

144

77%

185

98%

Glo

uces

ters

hire

Roy

al H

ospi

tal,

Glo

uces

ter

7069%

9796%

8872%

115

94%

Goo

d H

ope

Gen

eral

Hos

pita

l, Su

tton

Col

dfiel

d84

30%

278

98%

5424%

229

100%

Gra

ntha

m &

Dis

tric

t Gen

eral

, Gra

ntha

m100

34%

284

98%

8243%

191

100%

Ham

mer

smith

Hos

pita

l, Lo

ndon

9664%

148

99%

101

62%

148

91%

Har

efiel

d H

ospi

tal

206

98%

207

99%

136

93%

119

82%

Har

roga

te D

istr

ict H

ospi

tal,

Har

roga

te291

86%

294

87%

288

91%

278

88%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

56

16/0

8/20

11

14:1

3

57MINAP

Hex

ham

Gen

eral

Hos

pita

l, H

exha

m17

927

24%

12

Hill

ingd

on H

ospi

tal,

Uxb

ridg

e263

80%

292

89%

359

84%

368

86%

Hin

chin

gbro

oke

Hos

pita

l, H

untin

gdon

3853%

6996%

2460%

40100%

Hom

erto

n H

ospi

tal,

Lond

on1

1520

80%

25100%

Hop

e H

ospi

tal,

Man

ches

ter

9027%

282

83%

7826%

278

92%

Hor

ton

Gen

eral

Hos

pita

l, B

anbu

ry17

8569%

958

48%

Hud

ders

field

Roy

al In

firm

ary,

Hud

ders

field

129

36%

313

86%

102

39%

237

91%

Hul

l Roy

al In

firm

ary,

Hul

l7

6118%

135

55%

Jam

es C

ook

Uni

vers

ity H

ospi

tal,

Mid

dles

boro

ugh

190

95%

201

100%

163

89%

183

100%

Jam

es P

aget

Hos

pita

l, G

reat

Yar

mou

th132

61%

203

94%

153

89%

172

100%

John

Rad

cliff

e H

ospi

tal,

Oxf

ord

110

25%

340

78%

172

36%

421

89%

Ken

t & C

ante

rbur

y H

ospi

tal,

Can

terb

ury

112

47%

153

65%

129

55%

162

69%

Ken

t & S

usse

x H

ospi

tal,

Tunb

ridg

e W

ells

2841%

6697%

3136%

8599%

Ket

teri

ng G

ener

al H

ospi

tal,

Ket

teri

ng120

48%

232

92%

149

63%

224

95%

Kin

g G

eorg

e H

ospi

tal,

Goo

dmay

es89

32%

265

94%

125

71%

156

88%

Kin

g's

Col

lege

Hos

pita

l, Lo

ndon

7339%

160

86%

162

45%

197

55%

Kin

gs M

ill H

ospi

tal,

Not

tingh

am85

21%

385

97%

6218%

336

100%

Kin

gsto

n H

ospi

tal,

Kin

gsto

n-up

on-T

ham

es9

113

97%

229

52%

Leed

s G

ener

al In

firm

ary,

Lee

ds475

80%

583

98%

508

84%

597

99%

Leic

este

r R

oyal

Infir

mar

y, L

eice

ster

6348%

129

98%

3449%

6797%

Leig

hton

Hos

pita

l, C

rew

e161

44%

344

95%

132

33%

374

94%

Linc

oln

Cou

nty

Hos

pita

l, Li

ncol

n91

30%

286

93%

7429%

236

93%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

57

16/0

8/20

11

14:1

3

58 MINAP

59MINAP

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

List

er H

ospi

tal,

Stev

enag

e122

46%

233

89%

143

58%

223

91%

Live

rpoo

l Hea

rt &

Che

st H

ospi

tal,

Live

rpoo

l6

95

5

Luto

n &

Dun

stab

le H

ospi

tal,

Luto

n84

19%

437

98%

7216%

443

98%

Mac

cles

field

Dis

tric

t Gen

eral

, Mac

cles

field

7123%

272

89%

5626%

196

92%

Mai

dsto

ne G

ener

al H

ospi

tal,

Mai

dsto

ne61

54%

109

97%

9057%

157

99%

Man

ches

ter

Roy

al In

firm

ary,

Man

ches

ter

2714%

181

93%

19139

99%

Man

or H

ospi

tal,

Wal

sall

108

48%

1128

59%

176

81%

May

day

Uni

vers

ity H

ospi

tal,

Cro

ydon

107

86%

117

94%

7299%

6488%

Med

way

Mar

itim

e H

ospi

tal,

Gill

ingh

am123

33%

340

92%

161

49%

293

90%

Milt

on K

eyne

s G

ener

al H

ospi

tal,

Milt

on K

eyne

s46

84%

4989%

3978%

4896%

Mon

tagu

Hos

pita

l, M

exbo

roug

h0

140

14

New

Cro

ss H

ospi

tal,

Wol

verh

ampt

on39

17%

225

100%

5019%

270

100%

New

ark

Hos

pita

l, N

ewar

k0

5268%

029

63%

New

ham

Gen

eral

Hos

pita

l, Lo

ndon

237

99%

227

95%

187

99%

188

99%

Nor

folk

& N

orw

ich

Uni

vers

ity H

ospi

tal,

Nor

wic

h490

61%

809

100%

387

55%

704

100%

Nor

th D

evon

Dis

tric

t Hos

pita

l, B

arns

tabl

e56

17%

286

89%

5517%

283

87%

Nor

th M

anch

este

r G

ener

al H

ospi

tal,

Man

ches

ter

3120%

155

99%

3821%

183

99%

Nor

th M

iddl

esex

Hos

pita

l, Lo

ndon

6050%

116

96%

101

62%

159

98%

Nor

th T

ynes

ide

Gen

eral

Hos

pita

l, N

orth

Shi

elds

124

35%

278

79%

110

34%

277

85%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

58

16/0

8/20

11

14:1

3

59MINAP

Nor

tham

pton

Gen

eral

Hos

pita

l, N

orth

ampt

on319

81%

381

97%

336

75%

434

97%

Nor

ther

n G

ener

al H

ospi

tal,

Shef

field

341

45%

592

78%

366

48%

686

90%

Nor

thw

ick

Par

k H

ospi

tal,

Har

row

11463

98%

2369

99%

Not

tingh

am C

ity H

ospi

tal,

Not

tingh

am1

144

51%

8599%

Pap

wor

th H

ospi

tal,

Cam

brid

ge10

816

15

Pet

erbo

roug

h C

ity H

ospi

tal,

Pet

erbo

roug

h107

38%

244

87%

175

49%

316

89%

Pilg

rim

Hos

pita

l, B

osto

n128

32%

346

85%

121

32%

323

86%

Pin

derfi

elds

Gen

eral

Hos

pita

l, W

akefi

eld

6020%

221

75%

6420%

266

84%

Pon

tefr

act G

ener

al In

firm

ary,

Pon

tefr

act

4717%

222

80%

3015%

175

86%

Poo

le H

ospi

tal,

Poo

le10

108

11

Pri

nces

s Al

exan

dra

Hos

pita

l, H

arlo

w137

67%

186

92%

144

59%

230

93%

Pri

nces

s R

oyal

Hos

pita

l, H

ayw

ards

Hea

th105

80%

100

76%

100

82%

9981%

Pri

nces

s R

oyal

Hos

pita

l, Te

lford

17188

88%

17116

92%

Pri

nces

s R

oyal

Uni

vers

ity H

ospi

tal,

Orp

ingt

on66

22%

258

87%

9735%

262

94%

Que

en A

lexa

ndra

Hos

pita

l, P

orts

mou

th147

38%

388

100%

5016%

310

100%

Que

en E

lizab

eth

Hos

pita

l, B

irm

ingh

am15

7229

99%

231

100%

Que

en E

lizab

eth

Hos

pita

l, G

ates

head

228

57%

351

88%

252

66%

338

89%

Que

en E

lizab

eth

Hos

pita

l, K

ing'

s Ly

nn13

190

80%

246%

305

73%

Que

en E

lizab

eth

Hos

pita

l, W

oolw

ich

100

43%

217

94%

2722%

119

97%

Que

en E

lizab

eth

II H

ospi

tal,

Wel

wyn

Gar

den

City

109

53%

187

91%

108

56%

169

88%

Que

en E

lizab

eth

the

Que

en M

othe

r, M

arga

te76

40%

118

62%

8037%

135

63%

Que

en M

ary'

s H

ospi

tal,

Sidc

up33

77%

4195%

3497%

35100%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

59

16/0

8/20

11

14:1

3

60 MINAP

61MINAP

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

Que

en's

Hos

pita

l, R

omfo

rd103

25%

386

93%

212

57%

282

75%

Que

en's

Hos

pita

l, B

urto

n-up

on-T

rent

212

82%

216

84%

190

79%

216

89%

Roc

hdal

e In

firm

ary,

Roc

hdal

e41

28%

142

97%

6646%

141

97%

Rot

herh

am G

ener

al H

ospi

tal,

Rot

herh

am41

16%

175

67%

104

33%

252

81%

Roy

al A

lber

t Edw

ard

Infir

mar

y, W

igan

172

70%

238

98%

203

65%

309

99%

Roy

al B

erks

hire

Hos

pita

l, R

eadi

ng178

76%

235

100%

210

77%

261

96%

Roy

al B

lack

burn

Hos

pita

l, B

lack

burn

237

40%

548

93%

245

45%

496

91%

Roy

al B

olto

n H

ospi

tal,

Bol

ton

118

35%

337

99%

135

41%

321

98%

Roy

al B

ourn

emou

th G

ener

al H

ospi

tal,

Bou

rnem

outh

30100%

30100%

5589%

6097%

Roy

al C

ornw

all H

ospi

tal,

Trur

o223

39%

389

69%

254

41%

419

68%

Roy

al D

erby

Hos

pita

l, D

erby

278

60%

458

99%

237

75%

316

100%

Roy

al D

evon

& E

xete

r H

ospi

tal,

Exet

er117

37%

293

92%

115

45%

240

94%

Roy

al F

ree

Hos

pita

l, Lo

ndon

6475%

8296%

8998%

91100%

Roy

al H

amps

hire

Cou

nty

Hos

pita

l, W

inch

este

r55

16%

315

94%

4316%

249

94%

Roy

al L

anca

ster

Infir

mar

y, L

anca

ster

7174%

9498%

6577%

8399%

Roy

al L

iver

pool

Uni

vers

ity H

ospi

tal,

Live

rpoo

l132

53%

232

92%

154

64%

231

95%

Roy

al L

ondo

n H

ospi

tal,

Lond

on0

012

0

Roy

al O

ldha

m H

ospi

tal,

Old

ham

3715%

234

96%

2811%

233

94%

Roy

al P

rest

on H

ospi

tal,

Pre

ston

1035

100%

652

87%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

60

16/0

8/20

11

14:1

3

61MINAP

Roy

al S

hrew

sbur

y H

ospi

tal,

Shre

wsb

ury

6651%

116

89%

3429%

108

92%

Roy

al S

urre

y C

ount

y H

ospi

tal,

Gui

ldfo

rd14

37100%

627

96%

Roy

al S

usse

x C

ount

y H

ospi

tal,

Bri

ghto

n73

95%

77100%

7574%

102

100%

Roy

al U

nite

d H

ospi

tal B

ath,

Bat

h75

54%

128

93%

111

49%

185

82%

Roy

al V

icto

ria

Infir

mar

y, N

ewca

stle

16347

100%

8277

99%

Rus

sells

Hal

l Hos

pita

l, D

udle

y155

87%

178

100%

314

100%

315

100%

Salis

bury

Dis

tric

t Hos

pita

l, Sa

lisbu

ry79

42%

186

99%

9134%

268

100%

Sand

wel

l Dis

tric

t Hos

pita

l, W

est B

rom

wic

h50

27%

182

100%

4529%

155

99%

Scar

boro

ugh

Gen

eral

Hos

pita

l, Sc

arbo

roug

h95

88%

9386%

159

82%

191

98%

Scun

thor

pe G

ener

al H

ospi

tal,

Scun

thor

pe51

14%

246

68%

4113%

252

82%

Selly

Oak

Hos

pita

l, B

irm

ingh

am98

82%

119

99%

55

Solih

ull G

ener

al H

ospi

tal,

Bir

min

gham

6176%

80100%

4345%

9599%

Sout

h Ty

nesi

de D

istr

ict H

ospi

tal,

Sout

h Sh

ield

s65

24%

244

91%

5426%

196

94%

Sout

ham

pton

Gen

eral

Hos

pita

l, So

utha

mpt

on300

81%

367

99%

342

79%

428

98%

Sout

hend

Hos

pita

l, W

estc

liffe

on

Sea

251

77%

310

95%

301

79%

363

96%

Sout

hmea

d H

ospi

tal,

Bri

stol

115

55%

183

88%

136

41%

280

85%

Sout

hpor

t & F

orm

by D

istr

ict G

ener

al, S

outh

port

6241%

149

98%

6129%

207

100%

St G

eorg

e's

Hos

pita

l, Lo

ndon

8171%

110

96%

9175%

120

99%

St H

elie

r H

ospi

tal,

Car

shal

ton

129

75%

172

99%

9474%

127

100%

St M

ary'

s H

ospi

tal,

Lond

on147

80%

166

91%

114

85%

134

100%

St M

ary'

s H

ospi

tal,

New

port

127

77%

166

100%

112

82%

135

99%

St P

eter

's H

ospi

tal,

Che

rtse

y160

99%

159

98%

156

96%

161

99%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

61

16/0

8/20

11

14:1

3

62 MINAP

63MINAP

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

ard

nSTE

MI p

atie

nts

seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

St R

icha

rd's

Hos

pita

l, C

hich

este

r31

15%

201

97%

3820%

189

97%

St T

hom

as H

ospi

tal,

Lond

on48

48%

9798%

7568%

111

100%

Staf

ford

shir

e G

ener

al H

ospi

tal,

Staf

ford

8645%

178

93%

7437%

190

96%

Step

ping

Hill

Hos

pita

l, St

ockp

ort

303

44%

546

80%

217

39%

441

80%

Stok

e M

ande

ville

Hos

pita

l, Ay

lesb

ury

3227%

9580%

2320%

6456%

Sund

erla

nd R

oyal

Hos

pita

l, Su

nder

land

101

90%

108

96%

150

87%

171

99%

Tam

esid

e G

ener

al H

ospi

tal,

Asht

on U

nder

Lym

e13

326

98%

215%

375

97%

Taun

ton

& S

omer

set H

ospi

tal,

Taun

ton

7545%

164

99%

5523%

229

96%

The

Alex

andr

a H

ospi

tal,

Red

ditc

h22

19%

116

98%

3320%

163

96%

The

Gre

at W

este

rn H

ospi

tal,

Swin

don

116

26%

403

89%

8318%

402

86%

The

Ipsw

ich

Hos

pita

l, Ip

swic

h442

67%

537

81%

369

52%

479

67%

Torb

ay H

ospi

tal,

Torq

uay

190

68%

254

91%

188

70%

251

94%

Traf

ford

Gen

eral

Hos

pita

l, M

anch

este

r3

156

18

Uni

vers

ity C

olle

ge H

ospi

tal G

ower

Str

eet,

Lond

on2

6498%

857

93%

Uni

vers

ity C

olle

ge H

ospi

tal,

Lond

on17

2095%

2281%

2696%

Uni

vers

ity H

ospi

tal A

intr

ee, L

iver

pool

292

59%

417

85%

256

44%

516

89%

Uni

vers

ity H

ospi

tal C

oven

try,

Cov

entr

y49

100%

49100%

8287%

94100%

Uni

vers

ity H

ospi

tal L

ewis

ham

, Lon

don

1939

87%

3253%

5693%

Uni

vers

ity H

ospi

tal o

f Har

tlepo

ol, H

artle

pool

148

60%

152

62%

164

59%

205

74%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

62

16/0

8/20

11

14:1

3

63MINAP

Uni

vers

ity H

ospi

tal o

f Nor

th D

urha

m, D

urha

m180

62%

284

98%

160

63%

250

99%

Uni

vers

ity H

ospi

tal o

f Nor

th S

taffo

rdsh

ire,

Sto

ke-o

n-Tr

ent

483

93%

447

86%

498

94%

466

88%

Uni

vers

ity H

ospi

tal o

f Nor

th T

ees,

Sto

ckto

n on

Tee

s95

41%

203

88%

104

40%

235

90%

Uni

vers

ity H

ospi

tal Q

ueen

s M

edic

al, N

ottin

gham

34

8060%

103

77%

Vict

oria

Hos

pita

l, B

lack

pool

123

30%

338

83%

126

27%

375

81%

Wan

sbec

k G

ener

al H

ospi

tal,

Ashi

ngto

n219

47%

337

72%

191

52%

331

91%

War

ring

ton

Dis

tric

t Gen

eral

Hos

pita

l, W

arri

ngto

n114

23%

481

98%

129

31%

414

98%

War

wic

k H

ospi

tal,

War

wic

k16

42100%

1237

100%

Wat

ford

Gen

eral

Hos

pita

l, W

atfo

rd60

17%

335

96%

258%

294

99%

Wes

t Cor

nwal

l Hos

pita

l, P

enza

nce

00

00

Wes

t Cum

berl

and

Hos

pita

l, W

hite

have

n96

64%

139

92%

125

60%

181

87%

Wes

t Mid

dles

ex U

nive

rsity

Hos

pita

l, Is

lew

orth

5543%

103

81%

2149%

3888%

Wes

t Suf

folk

Hos

pita

l, B

ury

St E

dmun

ds73

28%

236

91%

6122%

254

93%

Wes

ton

Gen

eral

Hos

pita

l, W

esto

n-Su

perm

are

176

71%

189

77%

104

61%

142

83%

Wex

ham

Par

k H

ospi

tal,

Slou

gh47

30%

155

98%

111

100%

107

96%

Whi

pps

Cro

ss H

ospi

tal,

Lond

on27

11%

206

85%

3713%

262

90%

Whi

ston

Hos

pita

l, P

resc

ott

167

29%

531

93%

239

40%

551

92%

Whi

ttin

gton

Hos

pita

l, Lo

ndon

6689%

7095%

6689%

7399%

Will

iam

Har

vey

Hos

pita

l, As

hfor

d43

21%

178

85%

154

68%

195

86%

Wor

cest

ersh

ire

Roy

al H

ospi

tal,

Wor

cest

er73

44%

159

95%

2922%

128

99%

Wor

thin

g H

ospi

tal,

Wor

thin

g76

65%

113

97%

141

71%

194

98%

Wyc

ombe

Gen

eral

Hos

pita

l, H

igh

Wyc

ombe

152

92%

159

96%

162

92%

154

87%

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

63

16/0

8/20

11

14:1

3

64 MINAP

nSTE

MI p

atie

nts

adm

itted

to

card

iac

unit

or w

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by

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itted

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atie

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seen

by

a ca

rdio

logi

st o

r m

embe

r of

team

Year

2009

/10

2010

/11

n%

n%

n %

n %

Wyt

hens

haw

e H

ospi

tal,

Man

ches

ter

7130%

216

91%

4528%

155

98%

Yeov

il D

istr

ict H

ospi

tal,

Yeov

il63

37%

164

96%

4334%

125

98%

York

Dis

tric

t Hos

pita

l, Yo

rk117

26%

397

88%

103

23%

390

86%

65

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

64

16/0

8/20

11

14:1

3

“ D

urin

g th

e pa

st d

ecad

e, M

INA

P h

as

docu

men

ted

maj

or c

hang

es in

the

care

pro

vide

d

to p

eopl

e w

ho s

uffe

r he

art a

ttac

k. W

hat h

as

not c

hang

ed is

the

com

mitm

ent o

f ind

ivid

ual

clin

icia

ns, m

anag

ers

and

adm

inis

trat

ors

who

,

thro

ugh

thei

r pa

rtic

ipat

ion

in M

INA

P, c

ontin

ue to

prom

ote

the

valu

es o

f nat

iona

l clin

ical

aud

it.”

Dr

Cliv

e W

esto

n

Clin

ical

Dir

ecto

r of

MIN

AP

65MINAP

MIN

AP P

ublic

Rep

ort L

ands

cape

Visu

als

Blue

.indd

65

16/0

8/20

11

14:1

3

table

9 ca

re o

f pa

tien

ts w

ith

non

st e

leva

tion (nSTEMI) in wales and belfast

nSTE

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12. Difference in performance in England and Wales

In the last three reports we have commented on differences in performance between Wales and England. These differences have been felt to reflect the largely rural nature of Wales, and the effect this has had on the configuration of cardiac services – with an emphasis on the delivery of pre-hospital thrombolytic treatment. The move from thrombolytic therapy to primary angioplasty has occurred more slowly in Wales than in most (but not all) of the English regions. So, it is still the case that in Wales the majority (70%) of patients receiving reperfusion therapy for STEMI receive thrombolytic therapy rather than primary angioplasty – 53% within 60 minutes of calling for help. In keeping with best practice, most (81%) of those who receive thrombolytic treatment for STEMI, or have no reperfusion treatment at all, subsequently undergo coronary angiography.

Two cardiac centres (in Swansea and Cardiff) are now able to offer primary angioplasty to their local populations, with continuous availability, and there has been a 29% increase in the number of patients so treated. 75% of these patients were treated within 150 minutes of calling for help. The Welsh cardiac networks are working closely with the Welsh Ambulance Service and local hospitals to develop management strategies that promote the use of primary angioplasty. This will include an increase the number of centres providing continuously available primary angioplasty and the number of patients transported directly to these centres. These strategies will be put in place over the next 12 months.

Importantly, a review of 30-day mortality rate after STEMI and nSTEMI for both England and Wales is presented in Fig 20 and Fig 21. It should be noted that these data are unadjusted for known predictors of outcome, such as age and co-morbidity and so formal statistical analysis has not been performed. Reassuringly the figures show falling mortality rates in both countries and the mean 30 day mortality for STEMI is now virtually identical for England and Wales.

It is of continuing concern that, as shown within the relevant tables, some of the Welsh hospitals are not submitting data on the management they provide to patients with nSTEMI (the most common type of acute coronary syndrome). This weakens the capacity of the National Audit to assure good quality care is being provided in these hospitals. Fig 21 shows 30 day mortality following nSTEMI, though obviously this only reflects those patients managed in hospitals that enter data. For that group mortality rates have continued to fall and are similar to results from England.

The use of secondary preventive medication remains good and equivalent to English hospitals.

Fig 19.

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Fig 20. 30 day mortality for STEMI (mean and 95% confidence intervals) for England and Wales.

All age groups, and all treatment modalities

Fig 21. 30 day mortality for nSTEMI (mean and 95% confidence intervals) for England and Wales.

The wider confidence limits for Wales reflect the smaller numbers recorded

MINAP Public Report Part 3 to 5 Blue.indd 68 16/08/2011 14:06


Implementing a primary PCI service in Oxford

Oxford Heart Centre

Jan Keenan, Consultant Nurse Dr Robin Choudhury, Senior Research Fellow

The Oxford Heart Centre began developing a PPCI service in late 2006. Like other areas of the UK we began by introducing a daytime service, rolling out to develop a 24/7 service from the summer of 2007. With the opening of the new Heart Centre in October 2009 direct access to the angiography suite became possible, and further developments came in 2009/10 with the roll-out of a regional service to Buckinghamshire and parts of Northants and Wiltshire. Chart one shows the increase in activity over the three years to date, and it is interesting to reflect on the continuing achievements for people in our care.

To introduce a new service and roll this out to a 24/7 service places demands on the clinical teams to develop new ways of working across the patient pathway, and to give up conventional professional boundaries and to use and develop skills that best serve patient needs, at the point of presentation, often in an unfamiliar environment. We have seen our ambulance crews and CCU nursing team supporting patients and medical colleagues in the lab, focusing on more active management of the acute care team. Importantly we were able to use MINAP data to see developments over time as we focused our energies on improving team working and availability to see a significant reduction over time in door to balloon time (see chart two).

Alongside a rollout of PPCI across the region however, come longer transit times and to an extent this is understandable. However significant variation in call to door times for people arriving from the same areas, again seen within MINAP data, offers further opportunities for development in terms of transit time to hospital and, using the data, we are able to work closely with our ambulance service colleagues to expedite the patient pathway. Importantly however as also shown in chart two, we are also able to continue to progress important developments in the in-hospital pathway that allow us to continue to reduce the call to balloon time overall, particularly by making significant reductions in door to balloon time. In terms of national drivers in addition to this, we are able to examine trends in length of hospital stay (see chart three).

MINAP data is a significant tool supporting service development, identifying areas for current and future work. Achieving national standards offers no room for complacency in an era in which we know that the impact of early treatment means better survival, and whilst MINAP data demonstrates the achievement of national standards, for those interested in improving the lot of our patients it shows us where to focus our efforts.

Fig 9. Percentage of patients with an admission diagnosis of STEMI having primary angioplasty within 90 minutes of arrival in hospital in E&W.

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part three: case studies

How hospitals, ambulance services and cardiac networks have used MINAP data to improve patient care.

Chart one: Increase in total number of PPCI cases since 2008

Chart two: Increase in call-to-door time with increasing geo-graphical spread with concurrent decrease in door to balloon time with pathway development



MINAP, promoting prevention.

The Heart Hospital, University College London Hospitals Foundation Trust

Dr Costas O’Mahoney, Cardiology

Dr Clare Dollery, Clinical Director.

The Heart Hospital (University College Hospitals NHS trust) is a heart attack centre with an established 24 hour primary PCI service. Monthly multidisciplinary MINAP meetings, with the participation of cardiologists, nurses, physiologists, London Ambulance Service representatives, Accident and Emergency department staff and other support personnel scrutinise challenging cases in a constructive and transparent manner. Feedback is given to the primary PCI team and other stakeholders to maintain and improve the quality of the service. Analysis of data provided by MINAP have led to a number of interventions over the years which helped reduce the time to reperfusion (MINAP public report 2009).

Even though shortening the time to reperfusion remains a central aim of our service, review of routinely collected MINAP data has also been used in the local implementation of NICE guidelines on secondary prevention interventions in post MI patients. We use our monthly MINAP meetings to review

referrals to cardiac rehabilitation services, and the use of anti-platelet agents, statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers in patients post primary PCI. The interventional cardiology integrated care pathway was modified to include a checklist of secondary prevention interventions for the physicians responsible for discharging the patients (see figure below). A weekly feedback project also included discussion of these metrics in a multidisciplinary coronary care unit hand over. We also continue this surveillance after discharge via a quality scorecard owned by our heart failure team.

MINAP has thus helped shape the long term as well as the short term management of patients undergoing primary PCI at our unit.

0

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Establishing a primary angioplasty service in Lincolnshire

United Lincolnshire Hospitals NHS Trust

Dr David O’Brien, Interventional Cardiologist,

Alun Roebuck, Consultant Nurse Critical and Acute Care

A review by the East Midlands Strategic Health Authority considered the clinical case for change in primary reperfusion practice and established that a 24/7 primary angioplasty service must be provided within Lincolnshire; with the provision of a new heart attack centre based at Lincoln County Hospital. Without such service, Lincolnshire would remain the only region within England without a primary angioplasty service for its population. The decision and justifications to base such a service in Lincolnshire were largely based on assessment of the number of patients presenting with both

ST elevation and non-ST elevation myocardial infarction as recorded in MINAP.

The Lincolnshire Heart Attack Centre started a primary angioplasty service in December 2010. This new service is currently limited to a restricted geography on an 8 a.m. until 6 p.m. basis, five days a week. In order to realise our aspiration to provide the service 24/7 and county-wide, plans are currently underway to build a second cardiac catheter laboratory, a cardiac short stay unit and a larger recovery ward. These plans aim to deliver the service to all eligible patients within Lincolnshire in 2012.

This huge change in how cardiac care is delivered has only been achievable by team work between United Lincolnshire Hospitals NHS Trust, Lincolnshire Primary Care Trust, East Midlands Ambulance Service and the East Midlands Heart and Stoke Network. Initial feedback from patients and relatives needing to access this service has been overwhelmingly positive and we all look forward to rolling out the service fully next year.



Improvement in call-balloon times at the London Chest Hospital, Barts and the London NHS Trust

London Chest Hospital, Barts and the London NHS Trust

Eileen Ferguson, Heart attack centre coordinator

Ajay Jain, HAC lead clinician

Andrew Wragg, Clinical Effectiveness Lead

Anthony Mathur, Cardiology lead clinician

Charles Knight, CAU director

Andrew Archbold, North East London Cardiac Network lead

London Ambulance Service NHS Trust

Mark Whitbread, Clinical Practice Manager/ Cardiac Lead

Joanne Smith, Clinical Advisor to the Medical Director

The London Chest Hospital is the heart attack centre for North East London cardiac network and serves a large population spread over a large geographical area and receives referrals from 6 district general hospitals. This referral base posed significant logistical problems to get patients with STEMI treated in a timely manner. The MINAP and BCIS audits demonstrated that we had to evolve our service to achieve the important call-to-balloon standard (CTB) and improve the outcome of our patients with STEMI.

In 2010/11 Barts and the London NHS Trust was successful in achieving the national standard for call-to-balloon times and this was based on using MINAP/ BCIS data to drive a quality improvement program.

We initially invested in improving the quality and reporting of our audit data. The trust and local cardiac network invested significant manpower resources. This included a Heart Attack Centre (HAC) coordinator to manage the whole HAC pathway, a dedicated HAC team and investment in data analysis. This resulted in high quality audit data that could be analysed in real time and support a process of formal weekly reporting. Once this audit process was established we could then focus on improving the clinical pathway.

The first challenge was to increase the direct transfer rate as patients who came via the network A&Es rarely achieved the call-to-balloon national standard. Armed with accurate audit data of performance, the HAC team set about working in collaboration with the London Ambulance Service (LAS) and A&E departments. This was based around sharing audit data, education using case by case feedback and formal study days. A weekly HAC meeting was established with LAS where audit data was studied in great detail.

Simultaneously we worked on our internal pathway to improve our door-to-balloon times. Producing weekly reports from MINAP helped focus organisational and individual attention on performance. These weekly reports demonstrated the immediate benefit from locally implemented changes and the team members were encouraged by seeing the real time audit result. Changes that had positive effects included a policy of going direct to lab 24 hours a day (instead of going to CCU out of hours), employing a dedicated nurse to meet all heart attack patients and setting an internal door-to-balloon national standard of 60 minutes (the national standard being 90 minutes). To focus the team on the clock- every individual breach was investigated.

These improvements led to a marked transformation in our call-to-balloon performance for 2010-2011. 80% of STEMI patients now receive reperfusion within 150 minutes from call for help, a great achievement in view of the geographical challenges of North East Thames. This improvement has been associated with a reduction of mortality of our heart attack patients according to data from Dr Foster Intelligence.

MINAP and BCIS proved great tools to drive these changes but it was recognition by our Trust and local Network that service improvements of this kind do require significant investment to be successful, coupled with a lot of hard work by the entire HAC team.



Using data from MINAP to model a PPCI service in the Cheshire and Merseyside network area

Cheshire and Merseyside Cardiac and Stroke Network

Ruth Grainger, Clinical Information Analyst

Cheshire and Merseyside is now one of the largest Cardiac and Stroke Networks in England and covers a geographical area with a population of approximately 2.3 million. MINAP has been used in our network area for many years to audit and improve reperfusion times and numbers of those receiving the appropriate medication.

We have recently improved our services for patients who have a heart attack known as a ST elevation Myocardial Infarction (STEMI) by introducing a primary percutaneous coronary intervention (PPCI ) service. PPCI is the preferred treatment if it can be provided promptly, providing faster perfusion and better outcomes for patients. Whilst thrombolysis treatment offers benefits to patients suffering from a STEMI, PPCI is a far more effective and safer option, with the added benefits of shorter recovery times and reduced morbidity.

In 2008, working with management consultants, Cap Gemini, we used MINAP data to demonstrate how a new PPCI service would look. One of the main aims when setting up the service was to quantify the impact on current services. It was necessary to know how many patients would be accessing this service and by what method. In order to do this an extract of data was downloaded from MINAP to establish firstly, how many STEMIs would be expected at the tertiary centre, Liverpool Heart and Chest Hospital (LHCH), secondly, were there any trends in day/time of presentation and thirdly, what impact would the new service have on the North West Ambulance Service (NWAS). The intended outcome was to understand the balance of risks and benefits of service change.

Comparing with previous years’ data it was concluded that the numbers, channels and locations of STEMI presentations would continue to be similar in future years and that there would be no expected differences in ambulance handover and turnaround times. All data sources and assumptions used in the model were agreed during a series of meetings between LHCH, NWAS and the network.

Using both MINAP data and modelled ambulance journey times it was possible to establish an average extra journey time for each patient. This was then used to gauge both worst case and best case scenarios, and combined with financial information provided by NWAS, to establish how many extra ambulance shifts NWAS would need, how much this would cost, and using postcode information where to locate the extra ambulances.

Funds were secured and it was agreed that PPCI should be rolled out in two phases. Phase one would cover the three hospitals nearest to LHCH (Aintree, Whiston and Royal Liverpool) and was implemented on 26th January 2009. Phase two was then rolled out to the rest of the Cheshire and Merseyside area (Southport, Warrington, Wirral and Countess of Chester) on 1st June 2010.

MINAP data is still used to audit and improve services for STEMI patients. Staff from local district general hospitals, NWAS, LHCH and the network meet regularly as part of the PPCI monitoring group to discuss any local issues and suggest areas for improvement.

Since the full roll-out we have seen patient outcomes improve greatly, national standards are consistently being met and the service is running smoothly. After 1st June 2011 we will have one full year’s worth of complete Cheshire and Merseyside PPCI data and are looking forward to validating the model used to implement our PPCI service.


Use of MINAP data to analyse and improve the PPCI service

Papworth Hospital NHS Foundation Trust

Dr Sarah Clarke, Clinical Director for Cardiac Services

Hayley Dimmock, Cardiac Information Analyst

Papworth Hospital NHS Foundation Trust opened a Primary Percutaneous Coronary Intervention (PPCI) service in September 2008. Since then there have been over 1500 activations of the service and for the year 2010-11 Papworth averaged 60 PPCI patient activations per month. MINAP is used within Papworth hospital to accurately record data on each patient who arrives at the heart attack centre following a PPCI activation. We believe data accuracy is extremely important and ensure that each individual PPCI patient’s MINAP entry is validated and checked alongside their hospital notes post discharge to ensure excellent data completeness. MINAP is used as an analysis tool as much as for data collection in order to produce figures for activity, outcomes and especially to monitor Papworth hospital’s performance in achieving national standards.

In 2010-11 there were 702 activations of the PPCI service with two thirds of patients continuing to have an intervention and the remaining third either not going into the lab or not proceeding to PCI post angiogram for various reasons. The national standard of door to balloon time (90 minutes) was achieved in 98% of all cases with an average time of 37 minutes.

The use of MINAP was instrumental in improving communication with our colleagues from the East of England Ambulance Service NHS Trust (EEAST) and has been particularly helpful in increasing the accuracy of timings. This has helped facilitate information flow concerning the patients’ journey including any delays or complications encountered which could affect their overall outcome. Papworth hospital use the data collected in MINAP to look in detail at every patient who breaches either the national or local standards. These reports are discussed in multi-disciplinary team meetings on a bi-weekly basis and the information used to highlight ways of improving patient flow and patient’s clinical care.




1. MINAP Academic Group – five year overview

Professor Adam Timmis, Chairman, MINAP Academic Group

1.1 Background

We recognise the value of the MINAP data certainly in improving patient care but also in its secondary use for research. The MINAP Academic Group (MAG) was established in 2005 to maximise the research potential of MINAP database and to establish processes for the safe distribution and return of sub-sets of MINAP data to research groups. The MAG is responsible for ensuring that data are only accessed by researchers with bona fide projects of high scientific probity who respect the conditions of confidentiality and security. The MAG was delegated the responsibility for releasing MINAP data by the Health Quality Improvement Partnership (HQIP) through which MINAP is funded.

All datasets issued to research groups are sourced from the dataset that is collected from CCAD annually and cleaned in a way that it is not significantly changed by this process. Although NICOR (UCL) was granted Section 251 exemption of the NHS Act 2006 for all the cardiac audits, including MINAP to hold patient identifiable data without consent, this approval is not extended to release of patient identifiable data. We are however in a position to release data for research in anonymised, or pseudo-anonymised for and the linkage with other dataset(s) can be performed by the trusted 3rd party.

1.2 Current position

The last year has seen major developments driven by the MINAP Academic Group. We now have a truly nationwide programme incorporating many of the top cardiological and epidemiological research groups in the UK. In the last 12 months alone approvals have been given for data-sharing with researchers in London, Birmingham, Belfast, Leeds, Leicester, Surrey and Edinburgh Previous applications have already led to seven publications in major cardiovascular and general journals in 2010, more than ever before, with a further four publications by May 2011.

Particularly significant has been the establishment of international collaborations with the SWEDEHEART investigators in Upsalla (Sweden) to complement the international collaborative analysis of pre-hospital thrombolysis previously undertaken in Europe and North America.

The development that will underpin research activity through the next decade and beyond has been the successful bid by the NICOR executive to become responsible for the management of MINAP and five other national cardiovascular registries. Leaders within MINAP and MAG played a key role in securing the bid which will now allow direct involvement of the management and linkage of this unique data resource. Only in the UK are national registry data on this scale available providing opportunities for cardiovascular researchers that cannot be found elsewhere.

1.3 How to apply

For more information on how to make an application for MINAP data please email Lucia Gavalova, MINAP Project Co-ordinator at [email protected].

2. Use of MINAP data to evaluate the impact of acute coronary syndrome care by patient age: resolving inequities in care?

Dr Chris Gale, University of Leeds

Dr Robert West, University of Leeds

Professor Keith Fox, University of Edinburgh

Evidence suggests that primary percutaneous coronary intervention (pPCI) results in better outcomes than thrombolysis for the treatment of STEMI provided it is delivered promptly. Due to initial perceived risk of complications in pPCI in very elderly (80 years of age or older), pPCI was not considered to be a preferred treatment option in this age group. Recently Shelton28 and colleagues compared outcomes in patients aged ≥80 years presenting with STEMI who were treated pPCI with patients who received thrombolytic treatment. Their work suggested that primary PCI can be effectively delivered to very elderly patients resulting in a substantial reduction in mortality compared to patients treated by thrombolytic treatment. So is there inequality in care in patients presenting with ACS in England and Wales?

Current data suggest that elderly patients who are hospitalised with an ACS are less likely to receive the preferred treatment (PCI) and that they have higher mortality rates than their younger counterparts. We studied 616,011 ACS events at 255 hospitals in England and Wales recorded in MINAP between 2003 and 2010 to establish whether age-dependent inequalities in care existed and to measure effects on in-hospital mortality over time for ACS in different age groups.

This revealed that almost 40% admissions with ACS in England and Wales were elderly (≥75 years). They were less likely to receive specialist care and evidence-based treatments including pPCI for STEMI. As a result, the elderly were found to have significantly longer hospital lengths of stay and higher in-hospital mortality rates.

Although progressive improvements in risk of in-hospital mortality were noted, for example, STEMI ≥85 years, in-hospital mortality reduced from 30.1% in 2003 to 19.4% in 2010 and for nSTEMI ≥85 years from 31.5% in 2003 to 20.4% in 2010, overall rates of emergency reperfusion (primary PCI and thrombolysis) for STEMI in those <55 years of age were nearly a third higher than for those aged ≥85 years.

28. Shelton RJ, Crean AM, Somers K, et al. Real-world outcome from ST eleva-tion myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service. Am Heart J. 2010 Jun; 159(6):956-63.

part four: research use of minap data


Data also suggest that use of secondary prevention medication such as aspirin, clopidogrel, beta-blockers, ACE inhibitors, and statins are effective in secondary prevention of coronary heart disease in patients aged 65 years and over. This benefit is similar to, and often greater than that observed in younger patients. We have shown that older patients with heart attack were less likely to be discharged on aspirin, clopidogrel, beta-blockers, ACE inhibitors, and statins.

These findings support a notion of age-dependent inequality in ACS care – biases in elderly ACS care remain and the elderly do have significantly longer hospital lengths of stay and high in-hospital mortality. It therefore highlights gaps in key aspects of the management of elderly patients with ACS who benefit equally as much as their young counterparts from an early invasive strategy.

The causes for discrepancies in quality of care for elderly are multifactorial. In part, the shortfall in treatment may be due to lack of appropriate specialist care and inappropriate placement within the hospital. The elderly are more likely to present differently and less likely to have the same diagnosis on discharge from hospital as that which they were given on admission. It is also not very unlikely that that age dependent inequalities in treatments may be the legacy of a risk-adverse strategy to ACS care through lack of accurate estimate of ACS risk.

Despite this, we can report an improvements in the application of evidence-based ACS care across all age groups from 2003 to 2010, and year-on-year reductions in in-hospital mortality equally across all age groups, both sexes as well as for STEMI and nSTEMI.

3. Enriching MINAP through linkage to primary care and investigator led cohorts

Professor Harry Hemingway University College London

Internationally and nationally MINAP is a special resource. England and Wales along with Sweden are among the few countries which have a national registry of acute coronary syndromes in which all hospitals participate. Registries in the US do not have this coverage. Like SwedeHeart, MINAP has developed Information and Research Governance structures to facilitate access to and use of MINAP data for research purposes. Over the last years this has led to some success with 23 projects.

Further enhancement of the MINAP resource is made possible thought linkage to other forms of electronic health record data. One example of this has been the linkage of the general

practice research database (GPRD) with MINAP, carried out for the first time in 2010. Primary care data in the UK are in their own right a special research resource; offering a longitudinal record of diagnoses, symptoms, tests, drugs and procedures. Because nearly every adult in the UK is registered with a GP there is an opportunity for population based studies.

Linking MINAP to primary care electronic health records allows two different types of question to be addressed. First, what is the quality of care across the ‘patient journey’. In other words examining care before, during and after a MINAP event can lead to a better understanding of what needs to change.

Second, what is the aetiology and prognosis of specific forms of coronary syndrome? Most epidemiological enquiry to date has investigated broad aggregates of coronary heart disease or heart attack and there are few prospective studies which examine whether risk factors for STEMI and nSTEMI are qualitatively or quantitatively different. Because MINAP distinguishes these ‘endpoints’, there are new possibilities for analysis.

Examination of genetic, biomarker and other research based measures in relation to MINAP ‘phenotypes’ is made possible by linkages with investigator led (i.e. bespoke data collection) cohort studies (e.g. 200,000 women in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) 2011. Discussion is underway for a linkage of MINAP with UK Biobank, with over 500,000 consented participants one of the largest, best characterised cohorts in the world.

CALIBER (Cardiovascular disease research using Linked Bespoke studies and Electronic Records) is a collaborative programme of such research using linked MINAP data funded by the Wellcome Trust (under the electronic health records initiative) and an NIHR programme grant. Further details can be obtained from [email protected].

4. Management of hyperglycaemia in acute coronary syndromes

Dr Clive Weston, University of Swansea

In addition to its primary purpose, as an audit of actual care received against ideal care, the MINAP database lends itself to a variety of subsidiary uses of potential clinical value in the form of observational studies. One such area of work has been the confirmation of an association between blood glucose in ACS and outcome. Those patients who on arrival at hospital have high blood glucose concentrations – hyperglycaemia – have a greater risk of dying than those with normal concentrations (Figure 22).

76 MINAP How the NHS manages patients with heart attack



From the Figure 22 it can be seen that the association between blood glucose and mortality occurs both in diabetic patients and those without a prior diagnosis of diabetes. In fact the increase in risk is greater in the latter group. So, while at normal levels of admission glucose diabetic patients have a higher death rate than non-diabetics, this difference is reversed in the presence of hyperglycaemia (from approximately 11 mmol/L and greater).

The possible reasons for the association: the link to previously undiagnosed diabetes, to ‘stress hyperglycaemia associated with larger heart attacks, and to potential direct adverse effects of glucose during ACS, has been detailed elsewhere29.

Further observations from the database show that the use of insulin infusions to treat hyperglycaemia in non-diabetic patients with ACS is associated with a reduction in risk of death by about a third30. Despite this, the use of insulin in this high risk group is the exception rather than the rule and lags behind the use of insulin in the (relatively) lower-risk diabetic group. In 2008/9, for those arriving at hospital with blood glucose >10.0 mmol/L, infused (intravenous) insulin was given to, 14.6% of non-diabetics, 39.8% of diabetics who normally took tablet treatment and 47.4% of diabetic patients who normally took subcutaneous insulin.

So observational data analysis suggests that: high levels of blood glucose are a marker of increased risk, treatment that reduces blood glucose is associated with a reduction of risk, but only a minority of patients who are eligible for treatment actually receive it. Is this a cause for concern?

Here, such observational analysis reaches its limit, but can at least expose a gap in knowledge. Some clinicians will interpret the available data to support the use of insulin in all patients with ACS presenting with hyperglycaemia. Others will look on the evidence as circumstantial and will be unpersuaded. What is required is a large randomised trial of insulin treatment given in the early stage of ACS (particularly in the non-diabetic group) to rapidly and reliably normalise blood glucose. Only then will it become clear whether untreated patients presenting with ACS and hyperglycaemia presently are being denied an effective life-saving treatment.

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Figure 23 Survival to 180 days after admission to hospital with STEMI, in patients not known to be diabetic with an admission blood glucose >11.0 mmol/L, with respect to normal treatment or an insulin infusion

29. Anantharaman R, Heatley M, Weston CFM. Hyperglycaemia in acute coronary syndromes: risk marker or therapeutic target? Heart 2009;95:697-703.

30. Weston CFM, Walker L, Birkhead JS. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007;93:1542-6.

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Figure 22 Death rates at 30 days after admission to hospital with ACS for those with and those without prior diagnosis of diabetes, with respect to admission blood glucose (mmol/L) – patients with blood glucose <6mmol/L excluded for clarity.



Appendix 1: MINAP Steering Group

Chairman Dr Clive Weston Clinical Director MINAP

Dr John Birkhead Previous Clinical Director MINAP

Department of Health Professor Sir Roger Boyle CBE National Director for Heart Disease and Stroke (to Aug 2011)

Ms Sue Dodd Emergency and Acute Care Manager, Vascular Programme (to July 2011)

NICOR Dr David Cunningham Senior Strategist for National Cardiac Audits

Royal College of Dr Jonathan Potter Physicians Director, Clinical Effectiveness and Evaluation Unit (to May 2011)

British Heart Foundation Professor Peter Weissberg Medical Director

Ambulance Services Dr Steven Rawstone Medical Director, Great Western Ambulance Service

Welsh Assembly Dr Phillip Thomas Government Lead Cardiac Clinician

British Cardiovascular Professor Keith Fox Society President

Royal College of Nursing Professor Tom Quinn University of Surrey

MINAP Patient/Carer Group Mr Iain Thomas South West London Cardiac and Stroke Network Patient Carer Group

MINAP Patient/Carer Group Mr David Geldard MBE Past President, Heart Care Partnership (UK)

MINAP Hospital User Ms Fiona Dudley Lead Nurse for Cardiology, Mid Yorkshire Hospitals NHS Trust

MINAP Academic Group Professor Adam Timmis Chairman

NHS Improvement Dr Mark Dancy National Clinical Chair

British Cardiovascular Dr Mark de Belder Intervention Society President

Cardiac Networks Mr Mark Walsh Network Director, Black Country Cardiovascular Network

part five: appendices



Appendix 2: Glossary

ACE inhibitors A class of drug with powerful dilating effects on arteries. Used – in the context of heart attack - for the treatment and prevention of heart failure. Also used widely for treatment of high blood pressure. Angiotensin receptor blockers (ARBs) have broadly similar effects.

Acute coronary syndrome This term covers all cardiac episodes that result from sudden and spontaneous blockage or near blockage of a coronary artery; often resulting in some degree of heart muscle damage. The usual underlying cause is rupture of the fine lining of a heart artery, which allows blood to come in contact with the tissues of the wall of the artery, promoting the development of a blood clot (thrombus). The degree of damage, and the type of syndrome (heart attack), that results from the blockage depends on the size of the artery, where in the course of the artery the blockage occurs, the amount of clot that develops and how long it persists within the artery. Not all acute coronary syndromes are suitable for treatment with primary angioplasty or thrombolytic drugs, and the decision is mainly guided by the appearances of the ECG when such treatments are being considered.

Angina Symptoms of chest discomfort that occur when narrowing of the coronary arteries prevent enough oxygen-containing blood reaching the heart muscle when its demands are high, such as during exercise.

Angiogram An X-ray investigation, performed under a local anaesthetic, which produces images of the flow of blood within an artery (in this case the coronary artery). Narrowings and complete blockages within the arteries can be identified during the angiogram and this allows decisions to be made regarding treatment. Often an angiogram is an immediate precursor to an angioplasty and stent implantation or to later coronary artery bypass grafting.

Anti-platelet drugs Drugs, including aspirin, clopidogrel, prasugrel and ticagrelor, which prevent blood clotting. These drugs act by reducing the ‘stickiness’ of the small blood cells (platelets) that can clump together to form a clot.

Aspirin An anti-platelet drug used to help prevent blood clots forming.

Beta-blockers Beta-blockers are drugs that block the actions of the hormone adrenaline (that makes the heart beat faster and more vigorously). They are used to help prevent attacks of angina, to lower blood pressure, to help control abnormal heart rhythms

and to reduce the risk of further heart attack in people who have already had one. They may also be used in small doses in heart failure.

Call-to-balloon (CTB) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the performance of primary angioplasty.

Call-to-needle (CTN) time The interval between the patient alerting the health services that they have symptoms of a heart attack and the administration of thrombolytic therapy.

Cholesterol A fatty substance that plays a vital role in the functioning of every cell wall throughout the body and in the production of various hormones. However, too much cholesterol in the blood increases the risk of coronary heart disease and heart attacks.

Clopidogrel An anti-platelet drug that has been shown to produce added benefit when given with aspirin during an acute coronary syndrome.

Clot-dissolving drugs Drugs used to dissolve the clot (or thrombus) within a heart artery which is the underlying cause of heart attack, see ‘thrombolytic treatment’.

Contraindication The presence of a reason why a treatment is unsuitable in a particular patient.

Door-to-balloon (DTB) time The interval between the ambulance arriving at a hospital and the performance of primary angioplasty.

Door-to-needle (DTN) time The interval between the ambulance arriving at a hospital and the administration of thrombolytic therapy.

Electrocardiogram Also known as ‘ECG’. A test to record the rhythm and electrical activity of the heart. The ECG can often show if a person has had a heart attack, either recently or some time ago. It can also tell if reperfusion therapy is appropriate and if it has been effective.

Heart attack The term applied to the symptoms, usually, but not always, including chest pain, which develop when a clot (thrombus) develops within a heart artery as a result of spontaneous damage to the inner lining of the artery (plaque rupture). The heart muscle supplied by the blocked artery suffers permanent damage if the blood supply is not restored quickly. The damage to heart muscle carries a risk of sudden death, and heart failure in people who survive.



Heart failure Heart failure occurs when a damaged heart becomes less efficient at pumping blood round the body. This may result from damage to the heart muscle caused by a heart attack – either at the time of the attack or many months or even years afterwards. There are typically symptoms of breathlessness during exertion and, later, swelling (oedema) of ankles.

Hyperglycaemia A high concentration of glucose (sugar) in the blood

Meta-analysis A statistical technique for combining the findings from independent studies.

Median The number falling in the middle of a ranked series of numbers.

IQR Interquartile range; the value at 25% and 75% of an ordered set of values.

Myocardial infarction A heart attack in which heart muscle damage is confirmed by blood testing.

Non ST elevation myocardial infarction (nSTEMI) A heart attack that occurs in the absence of ST segment elevation on the ECG. In these patients urgent admission to hospital is mandated but immediate reperfusion therapy is not required.

PCI Percutaneous coronary intervention (see Primary angioplasty)

Pre-hospital thrombolysis Thrombolytic treatment given before arrival in hospital, usually in the ambulance by paramedics. This saves time in providing treatment and is used where journey times to hospital are prolonged.

Primary angioplasty A technique to re-open the blocked coronary artery responsible for the heart attack. A fine catheter (tube) is passed, under local anaesthetic, from an artery in the leg or arm into the blocked heart artery. A small inflatable balloon is then passed through the catheter and across the blockage, allowing the artery to be re-opened by temporary inflation of the balloon. This technique is called angioplasty and when used as the initial treatment for heart attack it is referred to as ‘primary angioplasty’. Following opening of the artery, this is normally kept open by a small expandable metal tube (stent) which is passed into the artery with the angioplasty balloon. The umbrella term that encompasses both balloon dilatation (angioplasty) and stent insertion (stenting) is ‘percutaneous coronary intervention’ (PCI) and primary PCI is increasingly used to describe what in this report we refer to simply as primary angioplasty.

Primary PCI Primary percutaneous coronary intervention – see Primary angioplasty

Re-infarction The development of evidence of re-occlusion (further blockage) of, or development of blood clot within, the coronary artery that was responsible for the original heart attack. This would normally occur after the original blockage had been successfully treated.

Reperfusion treatment The term used to cover both techniques, thrombolytic treatment and primary angioplasty, for urgently reopening a coronary artery. These treatments are suitable only for certain types of heart attack characterised by typical electrocardiographic appearances described as ST segment elevation.

Secondary prevention treatment Medication that reduces the risk of further heart attack, or the risk of complications such as heart failure. See aspirin, beta blockers, ACE inhibitors and ARBs, clopidogrel and statins. These medications are usually initially prescribed to all patients who can tolerate them.

Statins Drugs used to reduce cholesterol levels in the blood. These have been shown to reduce the risk of further heart attacks when taken regularly after a first heart attack

ST elevation myocardial infarction A heart attack characterized by a specific abnormal appearance on the ECG (ST segment elevation) thought to be indicative of complete occlusion of a coronary artery. Reperfusion therapy with thrombolysis or angioplasty has been shown to do more good than harm in these cases.

Thienopyridine inhibitors Antiplatelet agents, of which clopidogrel and prasugrel are presently licensed for use.

Thrombolytic treatment The outcome for certain types of heart attack can be improved by using clot-dissolving (thrombolytic) drugs. Thrombolytic treatment is effective up to about 12 hours after the onset of symptoms but is most effective when given very early after the symptoms started. Thrombolytic drugs are not given unless there are typical changes on the electrocardiogram (ECG). Patients at significant risk of bleeding may not be given this treatment where the risk of bleeding is greater than any potential benefit. Where this risk exists primary angioplasty may be an effective alternative.

Thrombus A blood clot, the development of which is known a thrombosis.



Appendix 3: MINAP publications

1999

Rickards A, Cunningham D. From quantity to quality: the central cardiac audit database project. Heart 1999;82: 1118-1122.

Birkhead JS, Norris RM, Quinn T et al. Acute myocardial infarction: a core dataset. Royal College of Physicians 1999.

2000

Birkhead JS. Responding to the requirements of the National Service Framework for coronary heart disease: a core dataset for myocardial infarction. Heart 2000; 84: 116-7.

2001

Birkhead JS, Pearson M, Norris RM et al. Measurement of Clinical Performance: Practical approaches in acute myocardial infarction. Eds Robert West and Robin Norris. Royal College of Physicians 2001.

Birkhead JS, Georgiou A, Knight L et al. (eds) A baseline survey of facilities for the management of acute myocardial infarction in England 2000. London: Royal College of Physicians 2001.

2002

Birkhead JS. The National Audit of Myocardial Infarction: A new development in the audit process. Journal of Clinical Excellence 2002; 4: 379-85.

2004

Norris RM, Lowe D, Birkhead JS. Can successful treatment of cardiac arrest be a performance indicator for hospitals? Resuscitation. 2004; 60: 263-269.

Birkhead J, Walker L. MINAP, a project in evolution. Hospital medicine 2004; 452-53.

Birkhead J, Walker L, Pearson M, at al. Improving care for patients with acute coronary syndromes; initial results from the National Audit of Myocardial Infarction (MINAP). Heart 2004; 90: 1004-9.

2005

Quinn T, Weston C, Birkhead J, et al on behalf of Steering Group. Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003- 2005. Quarterly Journal of Medicine 2005; 98 (11): 797-802.

2006

Birkhead, J, Weston, C, Lowe, D on behalf of the National Audit of Myocardial Infarction project (MINAP) Steering Group. 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. BMJ 2006; 332:1306-1311.

Gale CP, Roberts AP, Batin PD, Hall AS. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34.

2007

Weston C, Walker L, and Birkhead J. Early impact of insulin treatment on mortality for hyperglycaemic patients without known diabetes who present with an acute coronary syndrome. Heart 2007; 93: 542-1546.

Birkhead J, Pearson J, Walker L on behalf of the MINAP Steering Group. Management of acute coronary syndromes in England and Wales: a survey of facilities in 2006. Royal College of Physicians, London 2007. ISBN 978-1-86016-314-2.

2008

Weston C. Performance indicators in acute myocardial infarction: a proposal for future assessment of good quality care. Heart 2008; 94:139-1401.

Gale CP, Manda SO, Batin PD, et al. Predictors of in-hospital mortality for patients admitted with ST-elevation myocardial infarction: a real-world study using the Myocardial Infarction National Audit Project (MINAP) database. 2008 Nov;94(11):1407-12.

Ben-Shlomo Y, Naqvi H, Baker I. Ethnic differences in healthcare-seeking behaviour and management for acute chest pain: secondary analysis of the MINAP dataset 2002–2003. Heart 2008; 94: 354 - 359.

Gale CP, Manda SO, Weston CF, et al. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database. 2009 Mar;95(3):221-7.

2009

Bhaskaran K, Hajat S, Haines A, et al. Effects of air pollution on the incidence of myocardial infarction. Heart, 2009; 95, 1746-59.

Horne S, Weston C, Quinn T, et al. The impact of pre-hospital thrombolytic treatment on re-infarction rates: analysis of the Myocardial Infarction National Audit Project (MINAP). Heart 2009; 95: 559-563.



2009 cont.

Birkhead J, Weston C, Chen R. Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Heart 2009; 95:1593-9.

2010

Herrett E, Smeeth L, Walker L, Weston C; on behalf of the MINAP Academic Group. The Myocardial Ischaemia National Audit Project (MINAP). Heart 2010;96:1264-1267.

Bhaskaran K, Hajat S, Haines AP, et al. The short term effects of temperature on the risk of myocardial infarction in England and Wales – a multicity daily time series study using the Myocardial Ischaemia National Audit Project (MINAP) database. BMJ 2010;341: c3823.

Bhaskaran K, Hajat S, Haines AP, et al. Effects of ambient temperature on the incidence of myocardial infarction. Heart 2009, 95, 1760-9.

Gale CP, Roberts AP, Batin PD, et al. Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004. BMC Cardiovasc Disord. 2006 Aug 2;6:34.

West RM, Cattle BA, Bouyssie M, et al. Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales. Eur Heart J. 2010.

McNamara RL. Cardiovascular registry research comes of age. Heart 2010; 96:908-10.

Brophy S, Cooksey R, Gravenor MB, et al. Population based absolute and relative survival to 1 year of people with diabetes following a myocardial infarction: a cohort study using hospital admissions data. BMC Public Health 2010;10:338.

Widimsky P, Wijns W, Fajadet J, et al. European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J 2010; 31:943-57.

2011

Gale CP, Cattle BA, Moore J, et al. Impact of missing data on standardised mortality ratios for acute myocardial infarction: evidence from the Myocardial Ischaemia National Audit Project (MINAP) 2004-7. Heart 2011.

Gale C, West RM, Cattle BA et al. Impact of hospital proportion and volume on primary PCI performance in England and Wales European Heart Journal (in press)

Huynh T, Birkhead J, Huber K, et al. Pre-hospital Fibrinolysis in Europe and North America. JACC: Cardiovascular Interventions (in press).

Cattle BA, Greenwood DC, Gale CP, et al. Multiple Imputation of a Large Clinical Audit Dataset. Statistics in Medicine (in press).

Appendix 4: Contacts for information on heart conditions

American Heart Association http://www.americanheart.org/hearthub/index.htm

Blood Pressure Association http://www.bpassoc.org.uk/Home

British Cardiac Patients Association http://www.bcpa.co.uk/

British Cardiovascular Society http://www.bcs.com/pages/default.asp

British Heart Foundation http://www.bhf.org.uk/

NB: The British Heart Foundation runs a heart information line that

provides information about heart conditions and their management.

It cannot respond to questions about services in individual hospitals.

Tel: 08450 70 80 70

Diabetes UK http://www.diabetes.org.uk/

Department of Health website http://www.dh.gov.uk/en/Home

HEART UK http://www.heartuk.org.uk/

NHS Evidence – cardiovascular http://www.library.nhs.uk/cardiovascular/

NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

NHS Direct Tel: 0845 4647


heart attacks recorded in minap in 2010/11This report is written for the public to show the performance of hospitals, ambulance services and Cardiac networks in England and Wales against national standards for the care of patients with heart attack in 2010/11.

Report prepared by: Lucia Gavalova, Project co-ordinator MINAP

With assistance from:Dr Clive Weston, MINAP Clinical Director Dr John Birkhead, MINAP Clinical Director Ronald van Leeven, MINAP Project co-ordinatorLynne Walker, MINAP Programme managerProfessor Tom Quinn, MINAP Steering Group memberProfessor Adam Timmis, Chairman MINAP Academic GroupMrs Sirkka Thomas, MINAP Patient/carer representativeMr David Geldard, MINAP Patient representative

Electronic copies of this report can be found at: www.ucl.ac.uk/nicor/audits/minap

For further information about this report, contact:

Myocardial Ischaemia National Audit Project National Institute for Cardiovascular Outcomes ResearchInstitute of Cardiovascular ScienceUniversity College London175 Tottenham Court RoadLondon W1T 7NU

Tel: 0203 108 3931 Email: [email protected]

University College London (media enquiries)Media Relations Manager Ruth Howells Tel: 020 3108 3845Email: [email protected]

Acknowledgements

Department of Health Enquiries to the Department should be directed to the Customer Service CentreTel: 0207 210 4850 (line open from 8.30am to 17.00pm Monday to Friday). Textphone for hard of hearing: 0207 210 5025. Or use the web contact form available at; http://www.info.doh.gov.uk/contactus.nsf/memo?openform

In writing to the Minister of State for Health Services at: The Department of Health Richmond House 79 Whitehall London SW1A 2NS

Welsh Assembly Government Ms Cathy WhiteHead of Adult & Children’s HealthMedical DirectorateDepartment for Health, Social Services & ChildrenWelsh GovernmentCathays Park,Cardiff CF10 3NQ

Tel: 029 20826108Email: [email protected]

Hospital or ambulance service data If you require further information on the performance of your local hospital or ambulance service, please contact the relevant hospital or ambulance service, details of which are available at NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

The MINAP team would like to thank all the hospitals and ambulance services that have collected data.

This report was completed in close collaboration with the Central Cardiac Audit Database (CCAD) team who are now part of National Institute for Cardiovascular Outcomes Research (NICOR), and performed the data management and analysis. Sue Manuel has again been especially involved.

The MINAP Steering Group is proud that one of its members, Professor Roger Boyle was recently awarded a knighthood for services to Medicine.

MINAP is commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP). For more information, please visit www.hqip.org.uk.

This report may not be published or used commercially without permission.

Designed and published by:

| www.padcreative.co.uk


How

the NH

S cares for patients with heart attack

MIN

AP Tenth P

ublic Report 2011



myocardial ischaemia national audit project [minap]

How the NHS cares for patients with heart attack

Tenth Public Report 2011 Prepared on behalf of the MINAP Steering Group

NICOR: NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH


myocardial ischaemia national audit project minap · the myocardial ischaemia national audit...

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