Fatality outside hospital from acute coronary events in three British health districts, 1994-5

BMJ 1998;316:1065-1070 ( 4 April )

General Practice

Fatality outside hospital from acute coronary events in three British health districts, 1994-5

Editorial by Evans

R M Norris on behalf of the United Kingdom Heart Attack Study Collaborative Group.

^a Cardiac Department, Royal Sussex County Hospital, Brighton BN2 5BE, ^b Collaborators and participating centres are listed at the end of the report

Objectives: To provide a contemporary account of the treatment and outcomes of acute coronary attacks in England andWales and to identify strategies that might improve the outcome.
Design: Two year community and hospital based study in three British health districts.
Setting: Health districts of Brighton (population 282 000), South Glamorgan (408 000), and York (264 000).
Subjects: 3523 men and women under 75 years of age who died outside hospital from acute coronary causes, who were admittedto hospital with acute myocardial infarction, or who developedacute infarction or died unexpectedly from acute coronary causeswhile they were already in hospital.
Interventions: Attempted resuscitation in people having a cardiac arrest outside hospital.
Main outcome measures: Total case fatality, case fatality outside and inside hospital, and the effect of resuscitationon case fatality outside hospital.
Results: 1589 patients died within 30 days of the acute event. Case fatality was 45% (95% confidence interval 43% to47%), rising from 27% (160/595) (23% to 31%) at age <55 yearsto 53% (1019/1916) (51% to 55%) at 65-74 years. Overall, 74% (1172/1589)(72% to 76%) of fatal events happened outside hospital, and therewas a negative age gradient (P<0.001) such that 91% (145/160)(87% to 95%) of fatalities occurred outside hospital at age <55compared with 70% (710/1019) (67% to 73%) at 65-74 years. Withoutsuccessful resuscitation of 55 patients outside hospital, totalcase fatality at 30 days would have risen from 45% to 46.7%.
Conclusion: Opportunities for reducing fatality from acute coronary attacks lie mainly outside hospital. These resultsand others imply that survival from cardiac arrest outside hospitalmight be trebled by improved ambulance and patient response. Properapplication of secondary preventive measures for patients withcoronary disease could have an even larger impact.

Key messages

In three health districts during 1994-5 total case fatality for people under 75 years of age was 45% and 74% of fatal events happened outside hospital
The likelihood of a fatal event occurring outside hospital was greater for people under 55 years of age (91%) than for those aged 65-74 years (70%)
Total fatality was reduced appreciably (by 1.7%) by resuscitation outside hospital, but this proportion might possibly be trebled by further upgrading of ambulance services
Because 46% of people who died were already known to have coronary heart disease, improved secondary prevention may have a major part in further reducing mortality

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