Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Patients only recieve rehab if they survive their MI!
- Raj Thakkar (2 March 2003)
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Comprehensive Cardiac Care in Angus
- Alan G Begg, Karen Fletcher CHD Coordinator (6 March 2003)
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What is secondary prevention?
- Dominic C Horne (12 March 2003)
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Re: Achieving NSF standards for cardiac rehabilitation and secondary prevention
- Robert R West (26 March 2003)
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Raj Thakkar, GP Registrar Buckinghamshire, HP10 OEE
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Dear Editor Ischaemic artery disease (IHD) remains the number one killer in the United Kingdom. Great efforts are in place aimed and reducing risk factors for IHD: smoking, hypertension, hypercholesterolaemia and so on. Agreed cardiac rehab is essential but morbidity and mortality would surely be reduced if we treated myocardial infarction (MI) patients at the earliest opportunity. National Service Framework (NSF) guidelines aim to reduce thrombolysis times to 20 minutes in 75% of eligible patients. Efficacy of thrombolysis falls the longer the delay between onset of chest pain and treatment. Hospitals have been targeted to reduce “door to needle” times yet there does not appear to be a huge effort to educate people to seek advice early with chest pain. I looked at the case notes of all patients seen in the local hospital in a month with a complaint of “chest pain” (using the Accident and Emergency computerized database). Information on delay between onset of chest pain and coming to hospital and past history of IHD were taken from the casualty notes. The patient group was looked at as a whole and also divided into those who had a positive past history of IHD and those that did not. The time delay between these two groups was compared. 145 patients attended the Accident and Emergency department with a complaint of chest pain over the sample period. 68 of these patients were admitted. 33 of those admitted had a previous history of IHD. The mean delay between onset of chest pain and coming to hospital was 9.8 hours. The mean delay in those who has a past history of IHD was 11.4 hours. One patient who had a previous MI in the past waited 4 days before coming to hospital with chest pain caused by another MI. In those who had no IHD in the past, the mean delay was 7.6 hours. There was no statistical difference between these two groups. Myocardial infarction can present with a spectrum of guises including chest pain, which can be mild to severe. It can be asymptomatic or present with arrhythmia or sudden death. All patients that were reviewed could potentially have had a coronary syndrome. It has been demonstrated that patients may be waiting too long to come to hospital and therefore run the risk of not benefiting from potential treatment. This appears to be the rate-limiting step in pain to treatment times. We must emphasize, particularly to those who are at risk of a coronary event, that they should not delay coming to hospital with chest pain. Patient education appears to be as important, of not more so than door to treatment times in treating people with potential MI. If we are to do this, however, hospitals must be able to receive a greater number of chest pain patients. Competing interests: None declared |
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Alan G Begg, CHD Lead Angus Local Health Care Cooperative Townhead, Montrose, DD10 8LE, Karen Fletcher CHD Coordinator
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Hasnain Dalal and his colleagues need to be congratulated on their success in managing patients who survive a myocardial infarction. In Angus a similar approach has been adopted which provides comprehensive cardiac care through the four phases of cardiac rehabilitation and in line with the recently published SIGN Guideline (1). In addition to a locality based Heart Manual programme and practice led structured long term follow up, suitable patients also attend a phase 3 education and exercise programme. Patients with stable coronary disease are encouraged to continue regular exercise organised by a partnership involving Angus Cardiac Patients Group and both the Health and Local Authorities. Patient identification after a myocardial infarction should however flow from routine hospital care and not require a search through laboratory data printouts. Appropriate Information Management and Technology is essential if this information is to flow seamlessly across organisational boundaries. The Electronic Health Record can provide this solution (2), with all the necessary information, using agreed data sets being available to all professionals involved at the point of patient care. Improved quality outcomes can then be both assured and easily demonstrated. (1) BEGG A, GRIFFITH JM The Electronic Health Record and the Management of Cardiovascular Disease British Journal of Cardiology 2002; 9(10) 630-633. (2) Scottish Intercollegiate Guidelines Network (SIGN) Cardiac Rehabilitation Edinburgh SIGN 2002 No.57. Competing interests: None declared |
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Dominic C Horne, GP Principal Huntly Health Centre, Aberdeenshire, AB54 8EX
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When I was a lad, Secondary Prevention in the context of ischaemic heart disease (as it then was) meant treating someone after they had had a myocardial infarction (MI). Increasingly these days it is being used to refer to patients with established coronary heart disease (CHD), as well as those with other forms of vascular disease such as Type 2 Diabetics, who have yet to suffer an MI. It was interesting to note that the paper on achieving National Service Framework (NSF) standards in CHD (1) used the term in its narrower sense, ie. for those post MI (as in the NSF itself). It seems to me that there is both a logical and practical need to distinguish between these groups, as their risk of MI, and thus their potential to benefit from "preventative" therapy, differ significantly. I would therefore like to propose that the term Secondary Prevention be reserved for those with established vascular disease who have not yet had an event, and 'Tertiary Prevention' be introduced for those who have. Any feedback would be greatly valued. (1) Dalal H, Evans P. Achieving national service framework standards for cardiac rehabilitation and secondary prevention. BMJ 2003; 326: 481-4. Competing interests: None declared |
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Robert R West, Reader in Epidemiology University of Wales College of Medicine
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We read the article by Hasnain Dalal and Philip Evans with interest, as many national audits find offers of cardiac rehabilitation falling short of the recommended 85%. We wonder whether the report shows effect of a reconfigured service or ‘natural history’ of post-discharge care? The study is based on records of 106 myocardial infarction patients successfully followed up for 12 months. Thus, the principal findings effectively summarize a ‘natural history’ of patient progress, for example proportion of patients with cholesterol <5 mmol/l at discharge and at 12 month follow-up. A higher proportion of surviving patients with cholesterol <5 mmol/l at follow-up may be anticipated. However presenting the findings as ‘effects of change’ raises the question ‘change of what?’ It is not a ‘before and after’ study, comparing the effect of introducing a new system of health care delivery with the old. The most ‘significant’ finding reported was a difference in the proportion of patients on statins between discharge and follow-up. Again this could be ‘natural history’ of after-care, statin prescription following assessment of cholesterol levels, or this could reflect an (international) time trend of increasing use of statins since the 4S trial (comparison with EUROASPIRE II cited). But further problems rest with the detail; 77/106 on statins at discharge compared with 80/91 at follow up. Is 80 significantly more than 77? Since the sample of 106 patients was drawn from those with 12 month follow-up, this finding tells us that 15 patients had missing information on statins at 12 months, possibly missing because contra-indicated. We wonder also how the rehabilitation community will view the implication that self-completion of the ‘heart manual’ log constitutes adherence to cardiac rehabilitation. Is it possible that smoking-, body weight- and cholesterol-control were better in the cardiac rehabilitation group than in the ‘heart manual group’?. Again to detail 82 (of 106) accepted an offer of cardiac rehabilitation or ‘heart manual’ and 58 complied. This may have been 55% of those offered but, as we have no information about patients not followed-up, it could have been lower. We agree that the NSF targets of 50% non-smoker, BMI <30 and exercising regularly are ‘soft targets’, possibly misprints for half of former smokers to become non-smokers etc. Competing interests: None declared |
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