National Institute for Health and Clinical Excellence (NICE)
Printable version

New standard from NICE to improve diagnosis and treatment of unstable angina and heart attacks

NICE has emphasised the importance of speed in treating heart attack patients and establishing their risk of future heart attacks or strokes. In 6 new quality statements, NICE has set out priorities for the NHS to improve standards of care for adults who have acute coronary syndromes.

The National Institute for Health and Care Excellence has emphasised the importance of speed in treating heart attack patients and establishing their risk of future heart attacks or strokes. In 6 new quality statements, NICE has set out priorities for the NHS to improve standards of care for adults who have acute coronary syndromes.

Adults who have had a type of heart attack called a non-ST-segment-elevation myocardial infarction (NSTEMI), or who have unstable angina, should be assessed for their risk of having further heart attacks or strokes in the future using an established risk scoring system that predicts 6-month mortality to guide treatment.

Acute coronary syndromes cover a range of conditions including unstable angina, NSTEMI and ST-segment-elevation myocardial infarction (STEMI). All are due to a sudden reduction of blood flow to the heart, usually caused by the rupture of an atherosclerotic plaque within the wall of a coronary artery and may cause the formation of a blood clot.

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said: “It’s important that treatments can be tailored according to whether the patient is at high, intermediate or low risk of future cardiovascular events, balancing the benefit of treatment against any risk of associated adverse events, particularly bleeding, in the light of this assessment.”

Building on the NICE clinical guidelines on the assessment and diagnosis of chest pain of recent onset, the early management of unstable angina and NSTEMI, and Myocardial infarction with ST-segment elevation, the quality standard also highlights the importance of preventing damage to the heart muscle by quickly unblocking the coronary artery and restoring adequate blood flow (coronary reperfusion) for people who have had an acute heart attack (STEMI).

It states that adults with a STEMI who present within 12 hours of the onset of symptoms have primary percutaneous coronary intervention (PCIi), as the preferred means to widen the narrowed or blocked artery, as soon as possible but within 120 minutes of the time when fibrinolysisii could have been given.

“Restoring an adequate coronary blood flow as quickly as possible during the acute phase of STEMI is a crucial factor in improving outcomes successfully since  evidence suggests the majority of potentially salvageable heart muscle could be lost within 3 hours of the coronary artery being blocked” continued Professor Leng.

“The more heart muscle that is lost, the poorer the outcome for the patient. Apart from resuscitation if your heart stops, restoring blood flow to the heart as quickly as possible is the most important priority in people having an acute heart attack.” 

The quality standard also highlights the need to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future heart attacks or strokes are offered coronary angiographyiii (with follow-on PCI if indicated) within 72 hours of first admission to hospital. For adults who are clinically unstable, this should be done as soon as possible but within 24 hours of becoming clinically unstable.

The quality standard also states that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated).

The NICE quality standard for acute coronary syndromes (including myocardial infarction) is available on the NICE website

Notes to Editors

References and explanation of terms

i.   Mechanical techniques as a means of widening acutely blocked coronary arteries, thereby restoring coronary flow. They include balloon coronary angioplasty, stent insertion (where a short wire-mesh tube is inserted into an artery to allow blood to flow more freely through it), and thrombus extraction catheters.

ii.   Fibrinolysis is the use of drugs to break down blood clots (also termed thrombolysis).

iii.  Coronary angiography is a type of X-ray used to examine the blood vessels in the heart. The images created during an angiography are called angiograms. Blood vessels don't show up clearly on ordinary X-rays, so a special dye is injected into the area being examined. The dye highlights the blood vessels as it moves through them and appears white on the angiogram.

About acute coronary syndromes (ACS) and heart attacks

1.   People with acute coronary syndromes may have a poor prognosis without prompt and accurate diagnosis. Treatments are available to help ease the pain, improve the blood flow and to prevent any future complications.

2.  The highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible using drug treatment and/or revascularisation. This applies to all people with STEMI, including those who have been resuscitated after cardiac arrest. The time taken to restore coronary blood flow is very important because heart muscle starts to be lost as soon as the coronary artery is blocked.

3.  In people with NSTEMI and unstable angina, the aim of treatment is to alleviate pain and anxiety and prevent recurrence of ischaemia. For people with unstable angina, treatment also aims to prevent or limit progression to acute myocardial infarction. The type of treatment is determined by the person’s individual risk of future cardiovascular events (heart attack and stroke, repeat treatment or death).

4.  The incidence of STEMI has been declining over the past 20 years. It varies between regions and averages around 500 hospitalised episodes per million people each year in the UK.

5.  The London Ambulance Service attended 9657 cardiac arrests in 2011–12 for a population of around 8.2 million people (1177 per million people). Most of these will have been attributed to acute coronary syndromes, so the overall population prevalence of STEMI is likely to be in the region of 750–1250 per million people.

6.  Over the past 30 years, in-hospital mortality after acute coronary syndromes has fallen from around 20% to nearer 5%. This has been attributed to various factors, including improved drug therapy and speed of access to effective treatments.

7.  The diagnosis of NSTEMI is more difficult to establish than STEMI and therefore its prevalence is harder to estimate. The annual incidence of hospital admissions for non-ST elevation ACS is about 3 per 1000

About the quality standard

1.  The NICE quality standard for acute coronary syndromes (including myocardial infarction) is based on the following NICE accredited guideline:

About NICE quality standards

1.  NICE quality standards aim to help commissioners, health care professionals, social care and public health practitioners and service providers improve the quality of care that they deliver.

2.  NICE quality standards are prioritised statements designed to drive measurable quality improvements within a particular area of health or care. There is an average of 6-8 statements in each quality standard.

3.  Quality standards are derived from high quality evidence-based guidance, such as NICE guidance or guidance from NICE accredited sources, and are produced collaboratively with health care professionals, social care and public health practitioners, along with their partner organisations, patients, carers and service users.

4. NICE quality standards are not mandatory but they can be used for a wide range of purposes both locally and nationally. For example, patients and service users can use quality standards to help understand what high-quality care should include. Health care professionals and social care and public health practitioners can use quality standards to help deliver high quality care and treatment.

5.  NICE quality standards are not requirements or targets, but the health and social care system is obliged to have regard to them in planning and delivering services, as part of a general duty to secure continuous improvement in quality.

6.  Quality standard topics are formally referred to NICE by NHS England (an executive non-departmental public body, established in October 2012) for health-related areas, and by the Department of Health and Department for Education for areas such as social care and public health.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website:www.nice.org.uk and follow us on Twitter: @NICEComms.

 

Channel website: https://www.nice.org.uk/

Share this article

Latest News from
National Institute for Health and Clinical Excellence (NICE)

Spotlight on women at Serco – Anita’s story