Do heart attack treatments change depending where you live?

An ECG reading

The care that you receive after a heart attack will vary greatly depending on where you live, a 10-year-long study has suggested.

This variation in care was largely due to differences in the delivery of heart attack treatments between hospitals.

The study looked at whether patients with the most common type of heart attack received all the treatments, follow-up care and advice which are recommended by national guidelines. The most frequently missed were dietary advice, advice to help people to stop smoking and the prescription when indicated of anti-platelet drugs such as clopidogrel - all of which could help to reduce avoidable deaths.

Only 13.5 per cent of patients received care that met all the recommendations, and some regions were only providing this in just over 10 per cent of cases, the study funded by the British Heart Foundation (BHF) and the National Institute for Health Research (NIHR) found.

The North East and North Cumbria had the highest percentage of people receiving all appropriate treatments, at 20 per cent. The East Midlands had the lowest percentage of people receiving all appropriate treatments (10.3 per cent), the research, published in the BMJ, found.

This study shows that many people in the UK are not receiving optimal care after a heart attack

The researchers used data from the Myocardial Ischaemia National Audit Project (MINAP) - the national heart attack register - to analyse the 357,228 cases of non-ST elevation myocardial infarction (NSTEMI), the most common type of heart attack, in 232 hospitals in England between January 2003 and January 2013. Heart attack patients with are divided into those with, and those without, ST segment elevation visible on the ECG. No ST-elevation (NSTEMI) usually indicates that the coronary artery is only partly blocked, while STEMI usually means the coronary artery is fully blocked - but although the early risk can be lower, the overall death rates for NSTEMI are high, and worse than for STEMI. 

The most common treatments that they were given was an ECG (94.1 per cent of people were given this), aspirin (89.1 per cent of patients were given this at discharge, 88.7 per cent on diagnosis or by an ambulance person,) and statins on discharge (86.2 per cent).

The BHF view

Professor Peter Weissberg, former Medical Director at the British Heart Foundation, which funded the research, said: “This study shows that many people in the UK are not receiving optimal care after a heart attack.

“The data demonstrate the importance of auditing medical practice, but audit can only benefit patients if health care providers, in this case the admitting hospitals, take note of the results and take steps to improve patient care. The study shows there is much room for improvement. All hospitals should review their guidelines and ensure that they are appropriately applied to all patients.

The hospital bed of a heart attack patient

“Applying clinical guidelines in heart disease costs little and in the long-term saves money and, most importantly, saves lives.”

The strengths and limitations of the research

There were a large number of participants, and the research was carried out over a long time, which makes it more reliable.

Moreover, the study is the first to look at variations in NSTEMI care across a whole healthcare system and included all NHS hospitals in England which provided care for adults with NSTEMI.

If patients were offered a treatment but chose not to have it, or it was not applicable to them, this was taken into account by the researchers.

However, the study does have limitations in that it relies on the accuracy of the UK Heart Attack Register, which depends upon clinicians and healthcare managers recording the care given. It is also possible that standards may have improved since the 2003-2013 period covered by the study.

The fact that patients weren’t given advice on quitting smoking or healthy eating might be partly because this advice is given when patients attend cardiac rehabilitation programmes.

Applying clinical guidelines in heart disease costs little and in the long-term saves lives

Media coverage

The story was covered by the Daily Mail and Express. Both headlines were potentially misleading - the Mail said "Thousands are dying" and the Express said "Lives of thousands of heart attack victims at risk". But this statistic is from a separate study that suggested about 33,000 deaths could have been avoided over a 10-year period if heart attack after-care guidelines were followed at hospitals across England and Wales.

It’s important to also note that the researchers found that the level of care received in a specific region rose and fell over time, meaning that no one region consistently delivered a dependable standard of care. Therefore marking certain areas as good and others as bad may be too simplistic.

The research did, however, show that overall there were substantial improvements in care over time.

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