The National Institute of Health and Care Excellence’s (NICE) guideline made recommendations about treatment that should be given immediately after a person has had ST-segment-elevation myocardial infarction (STEMI).
The death rate for patients who experience STEMI has, according to a NICE press release, fallen from around one in five in the early 1980s to nearer one in 20 currently. However, as stated in the release, patients with STEMI still account for around 35,000 hospital admissions in England and Wales each year.
In recent years, primary percutaneous coronary intervention (PPCI) has replaced fibrinolysis the use of as the best way quickly to unblock the coronary artery and restore adequate coronary reperfusion for people with STEMI. It is estimated that around 95% of the population in England and Wales now have access to a PPCI treatment, however some people, particularly those living in more rural areas, will still receive fibrinolysis if PPCI cannot be given within a specified timeframe, according to the release.
The timeliness of PPCI is a crucial factor in improving outcomes for patients with a STEMI and it therefore forms a key part of this guideline. As its starting point, the guideline recommends that all people with STEMI are immediately assessed for their eligibility for coronary reperfusion. The guideline also covers the use of antiplatelet and antithrombin drugs, and improving outcomes for the minority of people still receiving fibrinolysis.
Key recommendations for clinicians in the guideline included:
- Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if:
– presentation is within 12 hours of onset of symptoms and
– primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
- Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiography (with follow-on PPCI if indicated).
- Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.
- When commissioning PPCI services for people with acute STEMI, be aware that outcomes are strongly related to how quickly PPCI is delivered, and that they can be influenced by the number of procedures carried out by the PPCI centre.
Mark Baker, director of the Centre for Clinical Practice at NICE, said: “The guideline development group has carefully weighed all the current evidence and have come up with a set of recommendations that have at their core the need to ensure that wherever they live there should be a single reperfusion strategy for people with STEMI, that should work consistently and be reproducible for all people, 24 hours a day, seven days a week. A great deal has been done to improve outcomes for people who have had an acute STEMI heart attack; this guideline identifies how outcomes can be improved even further.”
Huon Gray, consultant cardiologist and national clinical director for Heart Disease, NHS England, who chaired of the independent group that produced the guideline added: “There is evidence that as many as 30% of people who have had a STEMI heart attack do not receive reperfusion treatment to remove the blockage in the coronary artery to restore blood flow. This is usually for good clinical reasons but the expert group felt some of these people may be eligible for this treatment, but this needs further investigation. Every minute counts and this guideline emphasises the importance of immediate assessment of a person’s suitability for reperfusion treatment and then its delivery as quickly as possible.”
Rob Henderson, consultant cardiologist, Nottingham University Hospitals and Deputy Chair of the guideline development group, said:“There have been substantial developments in the management of STEMI over recent years and a NICE review of what works and what is cost-effective is therefore timely. The guideline highlights the need to deliver reperfusion therapy to eligible patients with STEMI as quickly as possible and confirms that PPCI is the preferred reperfusion strategy, provided that it can be delivered within the recommended timeframes. The guideline also provides up-to-date guidance on other important aspects of STEMI management, including the treatment of patients who remain unconscious after cardiac arrest, the use of radial artery access for PPCI, and the use of fibrinolysis for the small proportion of patients with STEMI who will still be eligible for this reperfusion therapy. The guideline should be of great interest to anyone involved in the management of patients with acute STEMI.”