BCS recommendations on acute cardiac care

The development of coronary care units (CCUs) in the mid 20^th century was a major advance in cardiology practice as it allowed the concentration of patients with ST elevation myocardial infarction (STEMI) in an area with specialist monitoring, nursing and medical care. This became particularly important as the medical management of STEMI became more aggressive and specialised. The development of primary angioplasty (PPCI) programs for STEMI following Roger Boyle’s report ‘Mending hearts and brains’¹ in 2006 has led to a further shift in the role of the CCU. Some units no longer admit STEMI patients, while in PPCI centres the concentrated influx of patients previously treated across a network has placed CCU beds and staff under considerable pressure.

However, the workload of CCUs has been changing for many years and the development of PPCI cannot be considered in isolation. For example, it is well recognised that there is an increasing proportion of elderly patients presenting acutely with complex problems, particularly related to heart disease. The incidence and detection of non-ST elevation MI is rising with the use of high sensitivity troponin and there is good evidence that aggressive management impacts on outcomes. Hospital Episode Statistics² suggest that acute coronary syndromes represent only a relatively small proportion of the acute cardiology intake, with heart failure and arrhythmias (particularly atrial fibrillation (AF)) much more common. The availability of new procedures for previously untreatable conditions (e.g. TAVI for aortic stenosis in the elderly population with co-morbidities), has also had an impact.

More importantly there is now data to suggest that patients presenting with acute cardiac conditions fare better under the care of specialist cardiology teams. Data from MINAP demonstrate quite clearly that management within a CCU environment leads to shorter length of stay, more evidence based medication (aspirin, statins, beta blockers, ACE inhibitors etc.), more coronary angiography and lower mortality. Yet currently, less than half the patients presenting with NSTEMI are managed within a CCU.

The National Heart Failure Audit³ supports similar conclusions for heart failure, showing that the mortality is halved from 12% to 6% for patients managed within cardiology by trained specialists (data adjusted for confounding variables). These patients also have better access to disease modifying treatment and specialist nurse follow-up. Similar data (though not from the UK) exists for the management of AF.

The net result of these changes is that CCUs remain busy but that the nature of the workload is changing with admission of older, sicker and more complex patients. In practical terms, units are no longer CCUs but are better described as Acute Cardiac Care Units.

British Cardiovascular Society Working Group on acute cardiac care

Over the last year, a working group of the BCS has been considering the organisation and provision of care for all acute cardiac conditions, including staffing, location, diagnostic requirements and the role of specialist nurses and cardiac physiologists.  The final report, published in October 2011, is available on the website⁴ and was developed with input from all the affiliated groups of the BCS, together with representatives from commissioning, NHS improvement and the British Heart Foundation.

There have been some controversial areas – for example should all acute hospitals be able to provide temporary pacing or pericardiocentesis on site at all times? Although relatively infrequently required, these patients often present as an emergency and a formal local/network arrangement must be in place in advance to ensure appropriately skilled staff are available. Currently the numbers of consultant cardiologists remain too low to provide access to senior cardiology care 24/7 in all hospitals, but this must surely be our aim.

The main conclusions of the report are:

• Patients presenting with cardiac conditions managed in specialised cardiac wards have demonstrably better outcomes;
• A significant proportion of these patients are not currently managed within a cardiac service leading to increased morbidity and mortality, and cost to the NHS;
• Patients presenting with acute cardiac conditions should be managed by a specialist, multidisciplinary cardiac team and have access to key cardiac investigations, and interventions at all times;
• All hospitals admitting unselected acute medical patients should have an “acute cardiac care unit” (ACCU) where high-risk patients with a primary cardiac diagnosis should be managed;
• All high-risk cardiac patients must have access to an ACCU, and access should not be restricted to patients with ACS

Dr David Walker
Consultant Cardiologist
(David.walker@esht.nhs.uk)

Conquest Hospital, The Ridge, St Leonards-on-Sea, East Sussex, TN37 7RD

References

1 Mending hearts and brains – clinical case for change: Report by Professor Roger Boyle, National Director for heart disease and stroke. Professor Roger Boyle. Department of Health 2006.  Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063282

2 Hospital Episode Statistics online – www.hesonline.nhs.uk

3 National Heart Failure Audit 2010. The NHS Information Centre 2010. Available from: http://www.bsh.org.uk/Default.aspx?tabid=142

4 The full report is available at: http://www.bcs.com/pages/news_full.asp?NewsID=19792012

Working Group members

D Walker Chair, BCS
N West Deputy Chair, BCS
S Ray VP Clinical Standards, BCS
S Bridge, CEO Papworth Hospital
S Furniss, Heart Rhythm UK
J Keenan, British Association for Nursing in Cardiovascular Care
M Knapton, British Heart Foundation
C Knight, British Cardiovascular Intervention Society
G Lloyd, British Society for Echocardiography
C Marley, NHS Improvement: Heart
T McDonagh, British Society for Heart Failure
T Quinn, MINAP
D Ritchley, Society for Cardiological Science and Technology
K Timmis, Heart Care Partnership
K Wilmer, Royal College of Physicians