Optimal Reperfusion / New Service

New Service for Heart Attack Patients

From October 2008, beginning with Greater Glasgow, a new regional West of Scotland service will be provided to patients suffering certain types of heart attack.

The Optimal Reperfusion service will be based in the West of Scotland Heart and Lung Centre at the Golden Jubilee National Hospital in Clydebank.

As has always been the case, a large proportion of heart attack patients will be taken to the nearest Accident and Emergency Department before admission to an inpatient ward – this will not change. However, not all heart attacks are the same – some patients suffer an attack because of a blocked artery and this new service is purpose-designed for them.

Paramedics have the training and equipment that allows them to determine if a patient has a blocked artery. They can also confirm the diagnosis by phone with specialist coronary experts. When such a patient is identified, paramedics will immediately take the patient by ambulance direct to the Golden Jubilee National Hospital where they can receive the immediate attention of experts in dealing with these types of conditions.

The aim is to ensure that patients will reach specialist care within 90 minutes of suffering a heart attack – where this is not possible, paramedics will administer clot-busting drugs and keep the patient stable until the service is reached.

There is irrefutable clinical evidence that this approach means better long-term results and fewer complications for patients, particularly those who are at high-risk:

  •  Improved survival
  •  Fewer strokes
  •  Reduced chance of further heart attacks
  •  Less chance of angina

Optimal Reperfusion

The Partnership Behind the New service

Frequently Asked Questions

Glossary

News Release

West of Scotland Heart and Lung Centre

Golden Jubilee National Hospital

Optimal Reperfusion

Also known as Enhanced Reperfusion and Primary Percutaneous Coronary Intervention, it is a technique where blood flow is restored to an organ or tissue that has had its blood supply cut off, as after a heart attack. Early reperfusion minimises the extent of heart muscle damage and preserves the pumping function of the heart.

Using a clot buster (also called thrombolysis) is effective with about two-thirds of patients who have suffered a heart attack (also called a myocardial infarction), Reperfusion using primary angioplasty and stenting provides better long-term results with less complications, especially in high-risk patients. [back to top]

]The Partnership Behind the New service

The new regional West of Scotland Optimal Reperfusion Service is funded to the tune of over £2 million a year by the following organisations:

NHS Ayrshire and Arran

NHS Dumfries and Galloway

NHS Forth Valley

NHS Greater Glasgow and Clyde

NHS Lanarkshire

NHS Scotland National Golden Jubilee Hospital

Scottish Ambulance Service [back to top]

Frequently Asked Questions

 

Questions

Answers provided by Consultant Interventionalist Cardiologist

1.

Are all heart attacks the same?

No, there are several different types of heart attack. The area of the heart that’s affected has important implications for what sort of complications there may be, how well the patient will recover and the treatment they should be given. A "cardiac arrest" may be considered a heart attack.

2.

How do you know if you are having a serious heart attack?

An electrocardiograph (ECG) will be carried out on patients with chest pain. This will be done by the Ambulance paramedic or where a patient self presents at hospital, by the A&E doctors. The ECG identifies what is happening with the heart and will enable a decision to be made by the paramedic and Primary PCI centre on whether the patient should go to the local hospital coronary care unit or taken straight to the PCI centre for Primary PCI.

3.

What is the difference between angiography and angioplasty?

Angiography is taking the x-ray pictures but is not a treatment. Angioplasty is using a balloon catheter after the angiogram to improve the blood supply in narrowed coronary arteries. Most patients receive a stent if angioplasty is undertaken.

4.

What is Primary PCI/Primary Angioplasty?

An angioplasty procedure is a method used to widen or re-open a narrowed or block blood vessel. A balloon is inserted and then inflated to clear the obstruction. Primary Angioplasty or Primary Percutaneous Coronary Intervention (Primary PCI) is where a patient receives the angioplasty treatment of a specific type of heart attack known as ST segment elevation myocardial infarction (STEMI).

5.

What is Enhanced Reperfusion?

Reperfusion is where the blood flow is restored to an organ or tissue that has had its blood supply cut off, as after a heart attack. After a heart attack an immediate goal is to quickly open blocked arteries and reperfuse the heart muscles. Early reperfusion minimises the extent of heart muscle damage and preserves the pumping function of the heart. Using a clot buster (thrombolysis) is effective in about two thirds of patients with an acute myocardial infarction (heart attack). Reperfusion using primary angioplasty and stenting provides better long-term results with fewer complications especially in high-risk patients. Primary PCI must be carried out in a specialised centre.

6.

Will local coronary care units remain once Primary PCI is introduced?

Yes, all heart attack patients, other than those with the STEMI type, will be taken to their local hospital for treatment.

7.

What is the timeframe to get a primary PCI to be given from the onset of chest pain?

In general, the timeframe is calculated from the point of diagnosis (through the ECG) to receiving the Primary PCI treatment. Clinical evidence currently states that this should be within 90 minutes from diagnosis. Within the 90 minute period, 40 minutes is allocated as the travel time.

8.

If you cannot get to hospital within the timeframe for Primary angioplasty what happens then?

Where the travel time for transfer exceeds 40 minutes then thrombolysis (clot buster) is preferred to Primary PCI. The patient would still be taken to the PCI centre as PCI could be undertaken if the ECG post-thrombolysis suggests that the clot buster has not worked.

9.

Where are the Primary Angioplasty centres going to be?

There are two specialist centres in the West of Scotland that will provide this service, the Golden Jubilee National Hospital in Clydebank and Hairmyres Hospital in East Kilbride.

10.

How long is it after a heart attack that you can no longer receive a clot buster (thrombolysis)?

A clot buster should generally be given within six hours of onset of symptoms.

11.

If you already have Coronary Heart Disease(CHD)/angina how long should you wait with pain before calling for an ambulance?

If angina pain lasts more than 20 minutes despite using GTN (the medication provided for such instances) you should phone 999 for an ambulance.

12.

Can a stent fail?

A combination of blood thinning drugs are given to reduce the risk of the stent clotting. Over a longer period of time the artery can re-narrow and this is called re-stenosis. This can often be treated with a drug-eluting stent if this occurs.

13.

How long have drug eluting stents been available and are they widely available across Scotland?

There are guidelines on when to consider using a drug eluting stent over a bare-metal stent. Both stents are available throughout Scotland.

14.

Do patients still need to carry evidence of having received streptokinase?

Yes, but streptokinase has now been replaced with a new clot-buster called TNK. Unlike streptokinase, TNK can be given more than once if required and therefore does not need a card to be carried.

15.

Why has the number of heart attacks reduced?

The rate of serious heart attack where there is complete blockage of a coronary artery has been falling and is now around 700 patients per million of population. GPs have been very good at treating cholesterol levels and blood pressure and other risk factors. GPs should take most of the credit. While early days yet, the smoking ban in public places may be helping too.

16.

What is the success rate of treatment?

Clot busters work in two thirds of patients. With primary angioplasty more than 19 out of 20 patients will have their blocked artery reopened

17.

Why would you be given an angiogram but then treated with medication rather than being given a stent?

If a clot-buster has removed the clot in the coronary artery and there is a good blood flow then treatment with blood thinners such as aspirin and/or clopidogrel is advised. A stent is used to open blocked or significantly narrowed arteries.

18.

What is narrowing of the arteries?

This is where the diameter of the artery is reduced, usually due to cholesterol deposits in the artery. This reduces or restricts the maximum blood flow down the artery to the heart muscle.

19.

Can you use stents for narrowing valves

Not routinely. Some work is ongoing in Canada and in some European centres but this is still very much at the development stage.

20.

Is it true that parts of your heart muscle die after a heart attack even if the thrombolysis is successful? And even with a mild heart attack?

Yes, a heart attack will leave a scar on the heart muscle, the size of which depends on the severity of the heart attack.

21.

Do heart attacks, especially mild ones, always have symptoms?

Some older patients and some diabetic patients can have a mild heart attack with few symptoms. This may be picked up on via an electrocardiograph (ECG) or Echocardiogram (ultrasound) months or years later.

22.

Is it possible to keep clot busting drugs in peoples’ homes if they have a heart condition?

No, you cannot use a clot buster without having an Electrocardiograph (ECG) and someone who can understand the ECG.

23.

If you have had a heart bypass procedure, what is the possibility of getting a stent if there is future damage or further deterioration?

The main message here is that you should look after your bypass with a healthy lifestyle. In some patients it is possible to improve the blood supply if new narrowing forms even after a bypass.

24.

How often are primary angioplasty procedures successful?

More than 19 out of 20 patients will have their blocked artery reopened.

25.

Does the paramedic make the final decision as to whether to give you the clot buster drug (thrombolysis) or to take you direct to the primary angioplasty centre?

This is part of the engagement process involved in developing and implementing the enhanced reperfusion service. We have an existing system where the paramedic transmits the ECG to the Coronary Care Unit (CCU) located next to the specialist facility where the angioplasty takes place. This is manned 24/7 by experienced CCU staff who can advise the paramedic about the best option for a particular patient.

26.

Does an ECG still give you a proper reading even if you are moving in an ambulance?

Yes, ECGs can be transmitted from a moving ambulance.

27.

Are you trying to stop giving the clot buster drug (thrombolysis)? Is the clot buster still a good treatment?

The clot buster is a good treatment but some patients would be better treated with Primary PCI, particularly if they can be transferred to the PCI centre within a 40 minute travel time.

28.

Are clot busters still being developed?

There are no ongoing trials of clot busting drug. Previous trials on more potent clot busting drugs had been associated with side effects such as bleeding into the brain.

29.

a.

What about aftercare?

Do patients stay at primary angioplasty hospital or are they transferred to their local hospital?

The proposal is that patients would be transferred back to the coronary care unit in their local hospital the next day. Patients that are too unwell to transfer would remain in the PCI Centre until stable.

The exceptions would be patients from Lanarkshire in Hairmyres where their expected discharge is three days or less. These patients would remain at Hairmyres. We are keen to hear patient views on this

b.

If patients are discharged from primary angioplasty hospital how will they get followed-up in community?

We need to establish good links between the Primary PCI centre and community rehabilitation. This is a good point and we need to ensure it happens.

c.

What cardiac rehabilitation class will patients attend?

Cardiac rehabilitation would be done through the patient’s local hospital.

d.

Where will all the hospital cardiac rehabilitation be done if you are discharged earlier e.g. 3 days?

We need to establish good links between the Primary PCI centre and community rehabilitation in local hospitals. This is a good point and we need to ensure it happens

e.

Were patients asked for their views on discharge arrangements?

The unanimous view was that if discharge was three days or less then it was appropriate to discharge from Primary PCI centre. If more than three days then the patient should be transferred back to their local hospital provided support was in place within the Cardiac/CCU wards.

30.

Can another stent be inserted if the artery re-narrows after a stent has been put in place

If re-narrowing (re-stenosis) occurs then a drug eluting stent may be considered.

31

How long do stents last?

Depending on the type of stent used, a new lining will grow in the artery to cover the stent within 4 weeks to 12 months. The stent is no longer required once the artery has healed.

32.

How do they clear out the clot?

Some of the clot is pushed between the stent and artery. Some of the clot is broken up and swept down the opened artery to dissolve in the circulation. Increasingly we are using soft suction catheters to remove the clot before the stent is inserted.

33.

Most common worry nowadays is hospital infections, are they a risk with this procedure?

The groin area or wrist is cleaned with an antibacterial solution before the catheter is inserted. The drapes, staff gowns and catheters come in sterile packs and are used only once. The risk of infection associated with PCI is very low.

34.

What are the risks associated with having an angiogram?

This depends on the co-morbidity of the patient. Young patients with minor fatty deposits are at a lower risk of complications than an older patient who may have severe disease.

35.

What about patients who are too sick to travel in the back of an ambulance?

It is often the sickest people who would benefit most from early treatment with Primary PCI. Protocols will be in place to advise Ambulance paramedics on the appropriate treatment of patients.

36.

What sort of tests should you get at the Cardiology clinic?

The follow-up clinic is mainly to make sure that risk factors for further problems are being addressed, including smoking, cholesterol, diet, exercise, blood pressure control.

37.

What sort of test should you get at your GP’s annual CHD clinic?

If you are well then the cardiologist will often discharge you to the care of your GP. GPs can monitor risk factors, adjust treatment and give advice.

38.

What new treatments are available for patients with Heart Failure?

New innovative treatments are always being developed. Currently cardiac resynchronisation pacemakers are available but these are not suitable for everyone. They are restricted to patients with specific symptoms and very particular ECG patterns and have limited success in terms of the numbers of patients who feel better after the procedure.

39.

What can be done for memory loss following cardiac surgery?

There are no active treatments available. If it doesn’t improve in the first few months then it may not improve long term.

40.

When will Primary PCI be available?

We are working towards a phased implementation process across the West of Scotland with the service commencing in Greater Glasgow in October 2008 and rolled out throughout the West of Scotland in early 2009.

[back to top]

Glossary

Heart Attack

A heart attack is when low blood flow causes the heart to starve for oxygen. Heart muscle dies or becomes permanently damaged. Your doctor calls this a myocardial infarction. May include "cardiac arrest"

Angiography

Angiography is a test that uses an injection of a liquid dye to make the arteries easily visible on X-rays.

Angioplasty

Angioplasty is the technique of mechanically widening a narrowed or totally obstructed blood vessel to improve the blood supply to the heart A balloon is inserted and then inflated to clear the obstruction. Most patients receive a stent if angioplasty is undertaken.[back]

Primary Percutaneous Coronary Intervention (Primary PCI)/Primary Angioplasty

Primary PCI/Primary angioplasty is where a patient receives immediate angioplasty treatment of a specific type of heart attack known as ST segment elevation myocardial infarction (STEMI).

Clot

Blood clots are the clumps that result from coagulation of the blood (blood hardens from liquid to solid). A blood clot that forms in a blood vessel or within the heart and remains there is called a thrombus.

Thrombolysis (clot buster)

Thrombolysis is the breakdown of blood clots using clot busting medicine.

Streptokinase

A clot busting drug.

Optimal Reperfusion/Enhanced Reperfusion

Reperfusion is where the blood flow is restored to an organ or tissue that has had its blood supply cut off, as after a heart attacked. Early reperfusion minimises the extent of heart muscle damage and preserves the pumping function of the heart.

Using a clot buster (thrombolysis) is effective in about two thirds of patients with an acute myocardial infarction (heart attack). Reperfusion using primary angioplasty and stenting provides better long-term results with fewer complications especially in high-risk patients.

Electrocardiograph (ECG)

An electrocardiograph is a commonly used, non-invasive procedure for recording electrical changes in the heart. The record, which is called an electrocardiogram (ECG), shows the series of waves that relate to the electrical impulses which occur during each beat of the heart. The results are printed on paper or displayed on a monitor.

Stent

Stents are commonly used to keep blood vessels open that have previously become blocked. A stent is a wire metal mesh tube used to prop open an artery during angioplasty. The stent stays in the artery permanently, holds it open, improves blood flow to the heart muscle and relieves symptoms (usually chest pain). [back ]

Drug Eluting Stent

A drug eluting stent is a drug-coated stent which slowly releases a drug which is known to interfere with the process of re-blocking arteries.

Narrowing of the arteries

Narrowing of the arteries is when fatty deposits start to develop in the walls of arteries and they gradually build up to form lumps which extend into the middle of the artery. This reduces the ease of blood flow through the artery.

Re-stenosis

Re-narrowing of arteries.

Coronary Heart Disease (CHD)

Coronary heart disease is the term that describes what happens when the heart's blood supply is blocked, or interrupted, by a build up of fatty substances in the coronary arteries.

Angina

Angina is a specific type of chest discomfort caused by inadequate blood flow through the blood vessels (coronary vessels) of the heart muscle (myocardium).

Cardiac rehabilitation

Cardiac rehabilitation is a multidisciplinary approach to improve short-term recovery from heart disease and promote long-term changes in lifestyle which help to correct adverse risk factors.
Cardiac rehabilitation services address lifestyle issues including diet, exercise training, risk factor modification, education and counselling.

Cardiac/Coronary Care Unit

The Coronary Care Unit (CCU) is an area in hospitals for patients who have heart-related illnesses.  The Unit is designed to be a quiet, calm and restful area in which patients can be further evaluated and closely monitored.  Adult patients who are typically admitted to the CCU suffer from a variety of critical cardiac conditions.

Ambulance paramedic

Paramedics are the senior ambulance service healthcare professionals at an accident or a medical emergency. Working either alone or with an ambulance technician, they assess the patient's condition and then give essential treatment. They use high-tech equipment, such as defibrillators (which restore the heart's rhythm), spinal and traction splints and intravenous drips, and as well as administering oxygen and drugs.

Primary PCI Centre/hospital

The hospital that has the specialist facilities and staff to under Primary PCI/Angioplasty

West of Scotland Boards

The West of Scotland Boards involved in providing the Optimal Reperfusion Service include:

NHS Ayrshire and Arran

NHS Dumfries & Galloway

NHS Forth Valley

NHS Greater Glasgow and Clyde

NHS Lanarkshire (PCI Centre)

NHS Scotland National Golden Jubilee Hospital (PCI Centre)

Scottish Ambulance Service