The lesser of two heart attacks?

Let’s start with the good news. If you are unlucky enough to suffer a major heart attack, you are more likely than ever to survive it. One of the principle reasons is that the NHS in England now has a network of heart attack centres around the country, close to where you live. There are eight in London alone. Ambulance crews are trained to spot one of these life-threatening events which happen when the blood vessels to the heart become completely blocked. Victims are taken straight to one of these centres instead of the nearest A&E. Cardiologists carry out immediate emergency coronary angioplasty treatment and specialist nurses are on hand to ensure that the patient leaves with the correct drugs, lifestyle advice and onward referrals.

But the bad news is that if you are one of the majority of people who suffer a less severe form of heart attack, known as a non-ST elevation myocardial infarction (NSTEMI), there is no guarantee that you are going to get optimum treatment from the health service and after-care can be pretty patchy. In fact, thousands of heart attack deaths could have been prevented if the NHS had followed its own aftercare guidelines, according to a major study published in the European Heart Journal: Acute Cardiovascular Care.

‘Simple interventions, such as prescribing statins, are being missed and this is resulting in loss of life,’ says Dr Chris Gale, associate professor of cardiovascular health sciences at the Leeds Institute of Cardiovascular and Metabolic Medicine who led the study. A total of 389,057 people were included in the analysis which covered a 10 year period from 2003 to 2013. Researchers found that 86.9 per cent of NSTEMI heart attack patients were not recorded as receiving one or more internationally agreed recommended interventions including angiograms, aspirin and blood pressure medications.

‘Major heart attack patients are looked after extremely well by the NHS and there is a highly efficient standardised protocol. As a result, heart attack death rates are falling,’ explains Professor Peter Weissberg, medical director of the British Heart Foundation.

However, less serious heart attack patients are falling through the cracks. When they get to A&E, they might not be treated by a cardiac specialist and we know that people treated by cardiac specialists do better.

Elderly patients are particularly at risk, says Professor Weissberg because they may have multiple health problems and tend to be seen by generalists. ‘They may end up in a general ward or a geriatric ward and not be seen by a cardiologist at all.’

Professor Martin Cowie,  consultant cardiologist at the Royal Brompton Hospital and Professor of Cardiology at the National Heart and Lung Institute, Imperial College, London, says that it is ‘hugely concerning’ that many patients with less serious heart attacks leave hospital without being prescribed statins that help reduce the level of ‘bad’ LDL cholesterol in the blood. ‘Lots of trials show that statins can help reduce the risk of further heart attacks but this latest research suggests some people are going home without it.’

He says that there needs to be more robust systems in place. ‘There needs to be a continuous process of updating staff and systems so that patients get everything they need to ensure the best possible outcome,’ Patients are also missing out on angiograms, where a special dye is injected into the arteries so that X-rays can show if arteries to the heart are narrowed or partially blocked. ‘Angiograms are normally done to see if someone is at high risk of a future heart attack. It does seem that at smaller hospitals and for elderly patients, these are done less frequently that they should be. In other western countries like Germany and Australia, angiograms are performed far more frequently.

Echocardiograms, or cardiac ultrasound, which sends out high-frequency sounds waves through the chest to scan the heart and blood vessels, are useful ways to see if there has been extensive cardiac damage due to the heart attack. These are recommended as part of European Society of Cardiology guidelines, but are not always done.

Professor Cowie says that the care of NSTEMI heart attack patients needs to much more systematic. ‘There needs to be a continuous process of updating staff and systems so that patients get everything they need to ensure the best possible outcome. And greater access to cardiologists and heart specialists will also improve long-term survival rates.

Cardiovascular disease causes more than a quarter of all deaths in the UK and the vast majority of these are caused by a heart attack. High blood pressure, type 2 diabetes, obesity and smoking are all risk factors for heart disease.