National Service Framework

1
National Service Framework

• NSF sets out 12 standards covering the following
  areas
• Reducing heart disease in the population
• Preventing CHD in high-risk patients
• Acute coronary syndromes
• Stable angina
• Revascularisation
• Heart failure
• Cardic rehabilitation

2
National Service Framework

• Standard 1
• NHS and partner agencies should develop,
  implement and monitor policies that reduce the
  prevalence of coronary risk factors in the
  population, and reduce inequalities in risks of
  developing heart disease
• Standard 2
• NHS and partner agencies should contribute to a
  reduction in smoking in the local population

3
National Service Framework

• Health Improvement Programme (HiMP)
• Reduce smoking, promote healthy eating, increase
  physical activity, reduce overweight
• Co-ordinated by HA
• Clear lines of action and accountability
• Structure, process and outcome measures by which
  local delivery judged to be specified

4
National Service Framework

• Standard 3
• GPs and primary care teams should identify all
  people with established cardiovascular disease
  and offer them comprehensive advice and
  appropriate treatment to reduce their risks
• Standard 4
• GPs and primary care teams should and primary
  care teams should identify all people at
  significant risk of cardiovascular disease but
  have not yet developed symptoms and offer them
  appropriate advice and treatment to reduce their
  risks

5
National Service Framework

• If established vascular disease
• Smoking advice including nicotine replacement
• Other risk factor advice (exercise, diet,
  alcohol, weight)
• BP below 145/85
• Aspirin 75mg
• Statins to get chollt5 or 30 reduction
• ACEI if LV dysfunction
• Beta-blockers if previous MI
• Warfarin or aspirin if A fib and over 60
• Tight glucose and BP control in diabetics

6
National Service Framework

• Without vascular disease but CHD risk greater
  than 30 over 10 years
• Smoking advice including nicotine replacement
• Other risk factor advice (exercise, diet,
  alcohol, weight)
• BP below 145/85
• Statins to get chollt5 or 30 reduction
• Tight glucose and BP control in diabetics

7
National Service Framework

• By April 2002 80-90 of heart attack patients
  should be on proven effective medicines (aspirin,
  beta-blockers, statins)

8
National Service Framework

• Standard 5
• People with symptoms of possible MI should
  receive help from appropriately trained person
  with a defibrillator within 8 minutes
• Standard 6
• Possible MI patients should be assessed
  professionally and, if indicated, receive aspirin
  and thrombolysis within 60 minutes of the call
  for help
• Standard 7
• NHS Trusts should have protocols so MI patients
  receive proven cost-effective treatments

9
National Service Framework

• Aspirin 300mg followed by 75mg od
• Beta-blockers for at least 1 year
• ACEI reviewed after 4-6 weeks
• Keep BP lt 140/85
• Statins to get chollt5 or 30 reduction
• Tight glucose and BP control in diabetics
• Risk factor advice
• Arrange rehabilitation
• Assess potential benefit from revascularisation

10
National Service Framework

• For UNSA
• Aspirin, heparin
• Beta-blockers, nitrates, calcium antagonists
• Interventions as for MI

11
National Service Framework

• By April 2001
• Ambulance response time of under 8 minutes for at
  least 75 of category A calls
• At least 75 of AE departments able to provide
  thrombolysis

12
National Service Framework

• By April 2002
• Door to needle time of under 30 minutes in 75 of
  eligible cases
• By April 2003
• Door to needle time of under 20 minutes in 75 of
  eligible cases

13
National Service Framework

• Standard 8
• People with syndromes of angina should receive
  appropriate investigation and treatment to
  relieve their pain and reduce their risk of
  coronary events

14
National Service Framework

• Investigations
• Hb, glucose, cholesterol
• Assess myocardial ischaemia
• Treatment
• S/L nitrates, Beta-blockers, Oral nitrates, Ca
  antagonists, Aspirin
• Risk factor advice and treatment
• Education
• What to do about possible MI
• Assess benefits of revascularisation

15
National Service Framework

• By April 2001
• 50 rapid-access chest pain clinics nationally
• Agreed hospital protocol for investigation and
  management of suspected angina
• By April 2002
• 100 rapid-access chest pain clinics nationally

16
National Service Framework

• Standard 9
• People with angina that is increasing in
  frequency or severity should be referred to a
  cardiologist urgently
• Standard 10
• NHS Trusts should have a care system so patients
  with confirmed CAD receive timely and appropriate
  investigation and treatment to relieve symptoms
  and improve prognosis

17
National Service Framework

• Angiography
• Extensive ischaemia on non-invasive testing
• Persisting angina in spite of medical Px
• Quantitative assessment of priority
• System for stratification (immediate/urgent/soon)
• CABG or PTCA
• Secondary prevention
• and rehabilitation

18
National Service Framework

• Increase number of revascularisations by 3000 by
  April 2002
• Aim for at least 750 PTCAs per million population
  and 750 CABGs per million
• Maximum waiting times
• GP to specialist for new onset CP (2 weeks)
• GP to consultant for routine
• First stage 13 weeks
• Second stage 4 weeks

19
National Service Framework

• Maximum waiting times
• Decision to investigate to angiography
• First stage 6 months
• Second stage 3 months
• Decision to operate to PTCA
• First stage 12 months
• Second stage 3 months
• Decision to operate to CABG
• First stage (urgent inpatient, high risk 3
  months, others 12 months)
• Second stage (urgent inpatient, high risk 3
  months, others 6 months)

20
National Service Framework

• Standard 11
• Suspected heart failure patients should be
  offered appropriate investigations (ECG, ECHO) to
  confirm/refute diagnosis. In confirmed cases
  treatments most likely to relieve symptoms and
  reduce mortality should be offered

21
National Service Framework

• ACEI
• Diuretics
• Beta-blockers (advise specialist initiation)
• Nitrates/hydralazine for ACEI intolerant
• Digoxin
• Lifestyle/risk factor advice
• Control BP
• Flu vaccine
• Tight BP and glucose control in diabetics

22
National Service Framework

• Outreach follow-up by specialist nurses
• Multidisciplinary community support including
  palliative care
• Heart failure clinics (nurse practitioners or
  doctors, primary or secondary care)
• Clear protocols
• Easy/open access echocardiography

23
National Service Framework

• Standard 12
• NHS Trusts should put in place agreed protocols
  so patients admitted suffering from CHD are
  invited into secondary prevention protocols and
  rehabilitation

24
St Marys response to the NSF

• Standard 7 (proven treatments offered)
• Secondary prevention nurse
• Standards 9 and 10 (revascularisation)
• Standards largely in place
• Standard 11 (heart failure)
• Open access echo in place
• Heart failure clinic
• Standard 12 (rehabilitation)
• Programme in place

25
St Marys response to the NSF

• Standard 6 (thrombolysis)
• Triage ECG room
• Chest pain specialist nurse
• Standards 8 (new onset/stable angina)
• Rapid assessment unit
• Chest pain specialist nurse

26
Chest Pain Services at St Marys

• Refer high risk patients with potential MI or
  unstable angina to the on-call cardiologist
  (bleep 1216) for assessment in casualty
• Patients potentially at moderate risk
• Recent onset chest pain (within 3 months)
• Worsening chest pain of possibly ischaemic origin
  can be referred to the Rapid Assessment Unit
  (0171 886 2000)

27
Rapid assessment unit nurse review

• Suspected myocardial infarction or unstable
  angina 
• Transfer to casualty resuscitation
• ECG immediately in resuscitation
• Contact cardiologist immediately
• Insert IV cannula
• Give soluble aspirin 300mg po or aspirin 300mg po
  chewed

28
Investigations arranged by RAU staff

• Cardiovascular observations
• ECG
• Routine bloods
• BMstix if known or suspected diabetic
• CXR
• Exercise treadmill test if possible ischaemic
  pain
• Echo and spirometry if shortness of breath

29
Cardiologist assessment

• After patient already worked up
• Admission
• Diagnosis of stable angina with appropriate drug
  treatment and follow up
• Reassurance
• Communication
• Faxed report on the same day of referral

30
Summary

• Patients with probable MI/UNSA to on-call
  cardiologist
• Patients with recent onset/worsening chest pain
  of possible ischaemic origin to RAU (0171 886
  2000)
• If in doubt ring the RAU to discuss

31
Summary

• Easy access
• Same day assessment with full non-invasive work
  up
• Same day communication of results

32
Summary

• Early risk stratification
• Prevent potential disaster of missed diagnosis
• Targeting of high risk patients
• Reduce morbidity/mortality
• Some reduction in pressure on AE and routine
  outpatients