Reducing readmission rates for ACS patients

Acute coronary syndromes (ACS) are characterised by sudden blockage of a coronary artery which provides vital blood supply to the heart. ACS includes myocardial infarction (MI) and unstable angina, and are important causes of premature mortality, morbidity and hospital admissions in the UK. Currently, over 90 people die from an MI every day.1 Standards have been raised for the detection, treatment and management of all heart disease and improvements have been delivered in most areas of cardiac services since the publication in March 2000 of the National Services Framework for Coronary Heart Disease (NSF)2 which set out a strategy to modernise coronary heart disease services over the following 10 years. Despite this, concludes a new report, a renewed focus on the management and treatment of patients suffering a heart attack or episode of unstable angina each year is vital to reduce the levels of mortality in line with other European countries. The new report, The Big Question: The Future of Acute Coronary Syndromes Patient Outcomes, was developed by HEART UK, together with the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) and AntiCoagulation Europe, together with AstraZeneca, to highlight the achievements made since 2000 and also to point out areas when more work is needed. In light of the current economic constraints being imposed across all areas of the NHS the recommendations and evidence within the report have focused on identifying how existing NHS services, designed to rehabilitate patients after a heart attack, could be better utilised to reduce the current burden of cardiac events, both on the healthcare and welfare systems. One of the goals of the NSF was for 85% of patients discharged from hospital after a heart attack or revascularastion procedure to be offered cardiac rehabilitation.2 However, the latest National Audit of Cardiac Rehabiliation (2010) showed that in 2008/2009, although progress had been made, only 43% of patients in the target groups of MI, bypass surgery and angioplasty took part in cardiac rehabilitation.3

Rehabilitation is key

The report highlights the importance of cardiac rehabilitation for ACS patients, and this should be tailored to meet individual needs and the availability of resources. However, it is widely accepted that patients with ACS do need high standards of early care as this has a major impact on both short and long-term prognosis.4 Research has demonstrated that European countries with higher healthcare expenditure on ACS tend to have lower case-fatality rates.5 Although health service spending is protected, the NHS is facing the need to use its resources as effectively as possible and the announcement that the Department of Health (DH) is moving to “value-based pricing” will put an even greater emphasis on the use of the most effective therapies going forward. The utilisation of evolving invasive procedures such as coronary angioplasty and revascularisation, are becoming more common in an attempt to treat the underlying lesions that may cause ongoing ischemia and trigger future events.6 In England and Wales, in the third quarter of 2008, 58% of patients who received any reperfusion treatment were treated with thrombolysis and 42% were treated with primary percutaneous coronary intervention (pPCI).7 By the end of the first quarter of 2010, the proportion treated with pPCI had risen to 73% and the proportion treated with thrombolysis had fallen to 27%. This has meant length of stay in hospital has fallen and so aftercare following discharge, assumes even greater importance. There is good evidence that cardiac rehabilitation improves survival and quality of life after an ACS event and may also help to reduce the chances of readmission8 and promote an earlier return to work. Physical activity was, traditionally, the principal component of cardiac rehabilitation but it is now recognised that an effective programme should also include education and behaviour change strategies to promote smoking cessation, healthy food choices and psychological health.8 It should also include the proactive management of medical risk factors such as blood pressure and lipid control to national targets and also maximise adherence to secondary prevention drug regimens.9 Commenting on the importance of rehabilitation for ACS patients, Professor Patrick Doherty, national clinical lead for cardiac rehabilitation, said: “There is no doubt that saving life is key, but repeatedly saving the same life is not best practice. Cardiac rehabilitation is a proven clinical and cost-effective addition to care that leads to a reduction in premature cardiac death by actively promoting and supporting change towards sustained health-related behaviours.”