National Service Framework NSF sets out 12 standards covering the following areasNSF sets out 12...

National Service FrameworkNational Service Framework

• NSF sets out 12 standards covering the following NSF sets out 12 standards covering the following areasareas– Reducing heart disease in the populationReducing heart disease in the population

– Preventing CHD in high-risk patientsPreventing CHD in high-risk patients

– Acute coronary syndromesAcute coronary syndromes

– Stable anginaStable angina

– RevascularisationRevascularisation

– Heart failureHeart failure

– Cardic rehabilitationCardic rehabilitation


• Standard 1 Standard 1 – NHS and partner agencies should develop, NHS and partner agencies should develop,

implement and monitor policies that reduce the implement and monitor policies that reduce the prevalence of coronary risk factors in the prevalence of coronary risk factors in the population, and reduce inequalities in risks of population, and reduce inequalities in risks of developing heart diseasedeveloping heart disease

• Standard 2Standard 2– NHS and partner agencies should contribute to NHS and partner agencies should contribute to

a reduction in smoking in the local population a reduction in smoking in the local population


• Health Improvement Programme (HiMP)Health Improvement Programme (HiMP)– Reduce smoking, promote healthy eating, Reduce smoking, promote healthy eating,

increase physical activity, reduce overweightincrease physical activity, reduce overweight– Co-ordinated by HACo-ordinated by HA– Clear lines of action and accountabilityClear lines of action and accountability– Structure, process and outcome measures by Structure, process and outcome measures by

which local delivery judged to be specifiedwhich local delivery judged to be specified


• Standard 3Standard 3– GPs and primary care teams should identify all people GPs and primary care teams should identify all people

with established cardiovascular disease and offer them with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to comprehensive advice and appropriate treatment to reduce their risksreduce their risks

• Standard 4Standard 4– GPs and primary care teams should and primary care GPs and primary care teams should and primary care

teams should identify all people at significant risk of teams should identify all people at significant risk of cardiovascular disease but have not yet developed cardiovascular disease but have not yet developed symptoms and offer them appropriate advice and symptoms and offer them appropriate advice and treatment to reduce their riskstreatment to reduce their risks


• If established vascular diseaseIf established vascular disease– Smoking advice including nicotine replacementSmoking advice including nicotine replacement– Other risk factor advice (exercise, diet, alcohol, weight)Other risk factor advice (exercise, diet, alcohol, weight)– BP below 145/85BP below 145/85– Aspirin 75mgAspirin 75mg– Statins to get chol<5 or 30% reductionStatins to get chol<5 or 30% reduction– ACEI if LV dysfunctionACEI if LV dysfunction– Beta-blockers if previous MIBeta-blockers if previous MI– Warfarin or aspirin if A fib and over 60Warfarin or aspirin if A fib and over 60– Tight glucose and BP control in diabeticsTight glucose and BP control in diabetics


• Without vascular disease but CHD risk Without vascular disease but CHD risk greater than 30% over 10 yearsgreater than 30% over 10 years– Smoking advice including nicotine replacementSmoking advice including nicotine replacement– Other risk factor advice (exercise, diet, alcohol, Other risk factor advice (exercise, diet, alcohol,

weight)weight)– BP below 145/85BP below 145/85– Statins to get chol<5 or 30% reductionStatins to get chol<5 or 30% reduction– Tight glucose and BP control in diabeticsTight glucose and BP control in diabetics


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


• Standard 5Standard 5– People with symptoms of possible MI should receive People with symptoms of possible MI should receive

help from appropriately trained person with a help from appropriately trained person with a defibrillator within 8 minutesdefibrillator within 8 minutes

• Standard 6Standard 6– Possible MI patients should be assessed professionally Possible MI patients should be assessed professionally

and, if indicated, receive aspirin and thrombolysis within and, if indicated, receive aspirin and thrombolysis within 60 minutes of the call for help60 minutes of the call for help

• Standard 7Standard 7– NHS Trusts should have protocols so MI patients receive NHS Trusts should have protocols so MI patients receive

proven cost-effective treatmentsproven cost-effective treatments


• Aspirin 300mg followed by 75mg odAspirin 300mg followed by 75mg od• Beta-blockers for at least 1 yearBeta-blockers for at least 1 year• ACEI reviewed after 4-6 weeksACEI reviewed after 4-6 weeks• Keep BP < 140/85Keep BP < 140/85• Statins to get chol<5 or 30% reductionStatins to get chol<5 or 30% reduction• Tight glucose and BP control in diabeticsTight glucose and BP control in diabetics• Risk factor adviceRisk factor advice• Arrange rehabilitationArrange rehabilitation• Assess potential benefit from revascularisationAssess potential benefit from revascularisation


• For UNSAFor UNSA– Aspirin, heparinAspirin, heparin– Beta-blockers, nitrates, calcium antagonistsBeta-blockers, nitrates, calcium antagonists– Interventions as for MIInterventions as for MI


By April 2001By April 2001– Ambulance response time of under 8 minutes Ambulance response time of under 8 minutes

for at least 75% of category A callsfor at least 75% of category A calls– At least 75% of A+E departments able to At least 75% of A+E departments able to

provide thrombolysisprovide thrombolysis

National Service FrameworkNational Service FrameworkBy April 2002By April 2002– Door to needle time of under 30 minutes in Door to needle time of under 30 minutes in

75% of eligible cases75% of eligible cases

By April 2003By April 2003– Door to needle time of under 20 minutes in Door to needle time of under 20 minutes in

75% of eligible cases75% of eligible casesTime-Benefit Curve

(GISSI-1)

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• Standard 8Standard 8– People with syndromes of angina should People with syndromes of angina should

receive appropriate investigation and treatment receive appropriate investigation and treatment to relieve their pain and reduce their risk of to relieve their pain and reduce their risk of coronary eventscoronary events


• InvestigationsInvestigations– Hb, glucose, cholesterolHb, glucose, cholesterol– Assess myocardial ischaemiaAssess myocardial ischaemia

• TreatmentTreatment– S/L nitrates, Beta-blockers, Oral nitrates, Ca S/L nitrates, Beta-blockers, Oral nitrates, Ca

antagonists, Aspirinantagonists, Aspirin– Risk factor advice and treatmentRisk factor advice and treatment

• EducationEducation– What to do about possible MIWhat to do about possible MI

• Assess benefits of revascularisationAssess benefits of revascularisation


• By April 2001By April 2001– 50 rapid-access chest pain clinics nationally50 rapid-access chest pain clinics nationally– Agreed hospital protocol for investigation and Agreed hospital protocol for investigation and

management of suspected anginamanagement of suspected angina

• By April 2002By April 2002– 100 rapid-access chest pain clinics nationally100 rapid-access chest pain clinics nationally



• Standard 9Standard 9– People with angina that is increasing in People with angina that is increasing in

frequency or severity should be referred to a frequency or severity should be referred to a cardiologist urgentlycardiologist urgently

• Standard 10Standard 10– NHS Trusts should have a care system so NHS Trusts should have a care system so

patients with confirmed CAD receive timely patients with confirmed CAD receive timely and appropriate investigation and treatment to and appropriate investigation and treatment to relieve symptoms and improve prognosisrelieve symptoms and improve prognosis

• AngiographyAngiography– Extensive ischaemia on non-invasive testingExtensive ischaemia on non-invasive testing– Persisting angina in spite of medical PxPersisting angina in spite of medical Px

• Quantitative assessment of priorityQuantitative assessment of priority– System for stratification System for stratification

(immediate/urgent/soon)(immediate/urgent/soon)

• CABG or PTCACABG or PTCA

• Secondary preventionSecondary prevention

• and rehabilitationand rehabilitation



• Increase number of revascularisations by 3000 by Increase number of revascularisations by 3000 by April 2002April 2002

• Aim for at least 750 PTCAs per million population Aim for at least 750 PTCAs per million population and 750 CABGs per millionand 750 CABGs per million

• Maximum waiting timesMaximum waiting times– GP to specialist for new onset CP (2 weeks)GP to specialist for new onset CP (2 weeks)

– GP to consultant for routineGP to consultant for routine• First stage 13 weeksFirst stage 13 weeks

• Second stage 4 weeksSecond stage 4 weeks


• Maximum waiting timesMaximum waiting times– Decision to investigate to angiographyDecision to investigate to angiography

• First stage 6 monthsFirst stage 6 months• Second stage 3 monthsSecond stage 3 months

– Decision to operate to PTCADecision to operate to PTCA• First stage 12 monthsFirst stage 12 months• Second stage 3 monthsSecond stage 3 months

– Decision to operate to CABGDecision to operate to CABG• First stage (urgent inpatient, high risk 3 months, others 12 First stage (urgent inpatient, high risk 3 months, others 12

months)months)• Second stage (urgent inpatient, high risk 3 months, others 6 Second stage (urgent inpatient, high risk 3 months, others 6

months)months)


• Standard 11Standard 11– Suspected heart failure patients should be offered Suspected heart failure patients should be offered

appropriate investigations (ECG, ECHO) to appropriate investigations (ECG, ECHO) to confirm/refute diagnosis. In confirmed cases confirm/refute diagnosis. In confirmed cases treatments most likely to relieve symptoms and treatments most likely to relieve symptoms and reduce mortality should be offeredreduce mortality should be offered


• ACEIACEI• DiureticsDiuretics• Beta-blockers (advise specialist initiation)Beta-blockers (advise specialist initiation)• Nitrates/hydralazine for ACEI intolerantNitrates/hydralazine for ACEI intolerant• DigoxinDigoxin• Lifestyle/risk factor adviceLifestyle/risk factor advice• Control BPControl BP• Flu vaccineFlu vaccine• Tight BP and glucose control in diabeticsTight BP and glucose control in diabetics


• Outreach follow-up by specialist nursesOutreach follow-up by specialist nurses

• Multidisciplinary community support Multidisciplinary community support including palliative careincluding palliative care

• Heart failure clinics (nurse practitioners or Heart failure clinics (nurse practitioners or doctors, primary or secondary care)doctors, primary or secondary care)

• Clear protocolsClear protocols

• Easy/open access echocardiographyEasy/open access echocardiography


• Standard 12Standard 12– NHS Trusts should put in place agreed NHS Trusts should put in place agreed

protocols so patients admitted suffering from protocols so patients admitted suffering from CHD are invited into secondary prevention CHD are invited into secondary prevention protocols and rehabilitationprotocols and rehabilitation

St Mary’s response to the NSFSt Mary’s response to the NSF

• Standard 7 (proven treatments offered)Standard 7 (proven treatments offered)– Secondary prevention nurseSecondary prevention nurse

• Standards 9 and 10 (revascularisation)Standards 9 and 10 (revascularisation)– Standards largely in placeStandards largely in place

• Standard 11 (heart failure)Standard 11 (heart failure)– Open access echo in placeOpen access echo in place– Heart failure clinicHeart failure clinic

• Standard 12 (rehabilitation)Standard 12 (rehabilitation)– Programme in placeProgramme in place

St Mary’s response to the NSFSt Mary’s response to the NSF

• Standard 6 (thrombolysis)Standard 6 (thrombolysis)– Triage ECG roomTriage ECG room– Chest pain specialist nurseChest pain specialist nurse

• Standards 8 (new onset/stable angina)Standards 8 (new onset/stable angina)– Rapid assessment unitRapid assessment unit– Chest pain specialist nurseChest pain specialist nurse

Chest PainChest Pain Services at St Marys Services at St Marys

• Refer Refer high riskhigh risk patients patients with potential with potential MIMI or or unstable angina to the on-call cardiologist unstable angina to the on-call cardiologist (bleep 1216) for assessment in casualty(bleep 1216) for assessment in casualty

• PPatients atients potentially at moderate riskpotentially at moderate risk– RRecent onset chest pain (within 3 months)ecent onset chest pain (within 3 months)– WWorsening chest pain orsening chest pain ofof possibly ischaemic possibly ischaemic

origin can be referred to the Rapid Assessment origin can be referred to the Rapid Assessment Unit (0171 886 2000)Unit (0171 886 2000)

Rapid assessment unit nurse Rapid assessment unit nurse reviewreview

• SuspectedSuspected myocardial infarction or unstable myocardial infarction or unstable angina angina – Transfer to casualty resuscitationTransfer to casualty resuscitation– ECG immediately in resuscitationECG immediately in resuscitation– Contact cardiologist immediately Contact cardiologist immediately – Insert IV cannulaInsert IV cannula– Give soluble aspirin 300mg po or aspirin Give soluble aspirin 300mg po or aspirin

300mg po chewed300mg po chewed

InvestigationsInvestigations arranged arranged by RAU by RAU staffstaff

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

Cardiologist assessmentCardiologist assessment

• After patient already worked upAfter patient already worked up– AdmissionAdmission– Diagnosis of stable angina with appropriate Diagnosis of stable angina with appropriate

drug treatment and follow updrug treatment and follow up– ReassuranceReassurance

• CommunicationCommunication– Faxed report on the same day of referralFaxed report on the same day of referral

SummarySummary

• Patients with probable MI/UNSA to on-call Patients with probable MI/UNSA to on-call cardiologistcardiologist

• Patients with recent onset/worsening chest Patients with recent onset/worsening chest pain of possible ischaemic origin to RAU pain of possible ischaemic origin to RAU (0171 886 2000)(0171 886 2000)

• If in doubt ring the RAU to discussIf in doubt ring the RAU to discuss

SummarySummary

• Easy accessEasy access

• Same day assessment with full non-invasive Same day assessment with full non-invasive work upwork up

• Same day communication of resultsSame day communication of results

SummarySummary

• Early risk stratificationEarly risk stratification– Prevent potential disaster of missed diagnosis Prevent potential disaster of missed diagnosis

• Targeting of high risk patientsTargeting of high risk patients– Reduce morbidity/mortalityReduce morbidity/mortality

• Some reduction in pressure on A+E and Some reduction in pressure on A+E and routine outpatientsroutine outpatients

National Service Framework NSF sets out 12 standards covering the following areasNSF sets out 12...

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