An initiative by the HSE’s Acute Coronary Syndrome (ACS) Clinical Programme has led in a short space of time to earlier and better intervention nationally for patients suffering from ST segment myocardial infarctions (STEMI), the potentially most fatal form of myocardial infarctions.

The ACS programme, set up in 2010, has put the management of STEMI as a priority for the initial phase of its work. The consultant clinical lead of the programme, Prof Kieran Daly, has stressed that the progress achieved in STEMI management must be maintained through adequate resourcing.

Outlining the success of the programme to date, Prof Daly says: “When we started the STEMI programme, the cardiology community was aware that these patients required very early intervention, be it drug therapy, or being brought directly to a cath lab and administering PCI. There were various programmes within different hospitals that were trying to do that, but there was no co-ordinated national programme, there was no standardised national protocol to deal with these cases.

“So the whole aim of the ACS programme initially has been to standardise STEMI management; to develop a national protocol that everyone would be aware of and would adhere to, and to involve the public, the ambulance service, regional hospitals, major centres and have them all working to the same protocol and working more efficiently through intervening as early as possible.”

The STEMI programme was put in place nationally between October 2012 and January 2013. Prof Daly said before the service was reorganised and enhanced, it was accepted that the best and most efficient way to deal with STEMI was to get the patient into a cardiac cath lab early, within 120 minutes maximum from the time of diagnosis to performing primary PCI (PPCI) and opening up the blocked artery and if necessary inserting a stent.

“If you go back to 2011, approximately 45% of patients with STEMIs were getting thrombolysis, and following that in the next few days they would be transferred to a centre where there was a cardiac cath lab with the ability to do angioplasty, and then the procedure would carry on from there, but only 55% of patients were getting PPCI back in 2011.”

Research has shown that quickly-administered PPCI is generally superior to thrombolysis in STEMI, and results in lower risk of reinfarction and stroke.

Prof Daly says an audit of the new programme has shown that by the end of 2013, only 8% of STEMI cases in Ireland were getting thrombolysis and 92% were getting angioplasty. 

“So we have gone from almost 50/50 to a predominance of primary angioplasty in quite a short time.

“We achieved this because first of all we had very lengthy discussions with all the hospitals involved, both those who were going to do the primary angioplasty and those where these patients might come into their EDs. We set up very good links with the ambulance service across the country, so that they became aware of the protocol and what was happening. We had discussions with primary care so that they understood what was going on.”

Prof Daly said the simple message with the protocol was that from the time an ECG is done and the diagnosis is made, if you can get that patient to one of the designated primary PCI centres within 90 minutes travel time the outcomes are much better.

The reorganisation of PCI services in recent years into designated centres meant that ambulances now bypass hospitals and go directly on to a centre performing PPCI, thereby delaying optimal treatment and outcomes.

“We had to designate where the primary PCI centres would be, which hospitals were to do this work, and they had to put in place teams to provide this service, ideally on a 24/7 basis. All of this was necessary before the protocol was introduced.”

Asked what the average waiting time for PCI treatment of STEMI was before the service reorganisation, Prof Daly said:

“You can’t really put a figure on what the average wait was before the protocol was introduced because too many of the patients concerned were getting thrombolysis. Any patient that came into a regional hospital was being brought into the ED, and the vast majority of EDs weren’t set up to deal with these cases; they didn’t have a cath lab and even if they did they might not have had 24/7 angioplasty. The only people that were getting primary angioplasty were largely those who were brought directly into these centres anyway.

Now, a common scenario is that ambulance will transport a patient directly to a designated centre.

“Where a patient walks or is driven in by car to an ED in a regional non-PCI centre, the ED doctors will do the ECG, make the decision and if they can get that patient transported to a primary PCI centre within 90 minutes that’s what happens.”

Prof Daly said the improvements happened within a relatively short space of time, although it took three years of preparation to put it all in place. Now he wants to ensure that the success of this service improvement is continued and consolidated.

“We want to ensure first that the STEMI programme remains in place and is supported properly. The 24/7 rota for staff is onerous. A lot was achieved on the basis of enthusiasm, dedication, etc. but not necessarily with the ideal level of resource support that is necessary.

“And we have to remember that the programme was introduced at a time when there were a lot of cutbacks in the service. We wouldn’t necessarily always have had the ideal staff numbers but we were keen to get ahead with it and support it as we went along. We need to ensure that staff support for the programme is brought to a higher level.”

The ACS programme is now looking at the optimal way to deal with non-STEMI infarctions.

“These would be patients who come in with what you might call ‘stuttering’ heart attacks; they are not necessarily minor, they could be major but not full-blown STEMIs as such. They all will have to be dealt with, of course. You’re talking here about risk stratification in these cases, deciding whether they need to be transferred urgently, or can they be transferred within 24 or 72 hours to a centre that can do angiography and then angioplasty if necessary – that’s what we are working on at the moment.”

The ACS programme’s remit is quite wide, Prof Daly says. “It also includes prevention. We are concerned with why all these cardiac problems are occurring in the first place. We are trying to ensure that primary prevention is taking place.

“The programme also oversees rehabilitation, to try to ensure that when patients come out of hospital they are brought into a rehabilitation programme, and from there you start secondary prevention so that lifestyle changes are put in place and maintained.”

Prof Daly says the ACS programme works with organisations like the Irish Heart Foundation and Croi to try to bolster support for prevention and work with primary care.

“Looking back on our work to date, I think the ACS programme has been very successful in that we can now say that a national programme is in place and our results compare well to those of other European countries.

“We do have ongoing issues with data collection, because an audit is only as good as the data that is being collected. It’s a constant struggle to make sure there is good data collection, and that’s something we have to keep working on.

“We also need to ensure that the communication between primary care, ambulance services and the hospitals is maintained.”

Prof Daly says one of the big success stories that has come out of the programme is the involvement of the helicopter services.

“A significant number of patients, particularly along the west coast, are now transferred to designated treatment centres by helicopter, because they are outside the 90-minute transfer limit if they came by road. At the moment, we are also looking at the possibility of patients in Donegal who would not be able to get to the major centres within the 90-minute timeframe by road, being transferred into Altnagelvin Hospital in Derry to have procedures carried out there.

“The ambulance service has done excellent work in this programme; 12-lead ECG machines were installed in ambulances and personnel were trained in STEMI recognition. There is a learning curve for everyone, and there was a very intensive training programme for ambulance crews, so that they could read ECGs etc and understand what was going on.

“That was a huge step for them in terms of responsibility, making that call. We set in place a dedicated 1800 phoneline that links the ambulance crews directly to the cardiology units in the main centres.”

Prof Daly believes Ireland’s services for managing myocardial infarction now compare very well internationally.

“I think we are doing a very good job, given that we have been working with resources that have not been on a par with other national cardiology services. In terms of staff numbers we would still be well behind units in the UK or mainland Europe. Despite this, our outcomes are as good as in these other countries.”

He says the advances in treating STEMI patients has to be seen as one of the significant improvements in cardiology care in recent decades.

“You can now take a patient with a blocked artery and you can get them into a cath lab, open up the artery, stent it, and hugely limit the amount of muscle damage that’s done. And two hours after this procedure is done the patient could be sitting up in the ward reading the newspaper.

“To me this has been an extraordinary development over the past 10 to 15 years. Beforehand, these patients might have been put in a CCU, given pain medication and you would just have to ride out the heart attack. The problem was you would be doing little to limit the amount of muscle damage occurring. And the mortality levels have reduced. We have at least halved the mortality figures from heart attacks compared to 15-20 years ago.”

The work of the ACS Clinical Programme is only part of the picture in the reorganisation and enhancement of cardiology care.

Says Prof Daly: “This is only the beginning, there is a lot of other work to be done. There’s a clinical programme for heart failure in place. Sudden cardiac death in the young probably requires a national programme as does the electrophysiology service.

“When you look at Ireland in terms of our population we should have national protocols and strategies across a range of services . We should not necessarily have to duplicate all services, but we should decide where our strengths are and work on those; decide which centres should have particular areas of expertise, as has been done with the STEMI initiative.”