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Coronary Heart Disease
Standards Development
Scoping Report
June 2008
© NHS Quality Improvement Scotland 2008
First published June 2008
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Content
Background ....................................................................................................4
Patient concerns ............................................................................................5
The evidence base for diagnosis, treatment and management of
coronary heart disease..................................................................................6
Development of CHD standards ...................................................................7
Cardiac conditions not covered by the proposed programme of work ....8
Bibliography...................................................................................................9
Arrhythmia/palpitations .........................................................................9
Cardiac rehabilitation ...........................................................................10
Chest pain (stable angina and acute coronary syndromes) .............11
Chronic heart failure.............................................................................12
Background
Coronary heart disease (CHD) is the leading cause of death in the UK. It is
responsible for approximately one in five deaths in men and one in six deaths
in women resulting in over 101,000 deaths every year.
Although death rates from CHD have been falling since the late 1970s, the
rate in the UK is still amongst the highest in Western Europe and higher still in
Scotland compared to the south of England. Mortality rates also vary across
Scotland and the highest rates are found in the west of Scotland.
CHD is the leading cause of premature death in the UK (death under the age
of 75) accounting for 1 in 5 premature deaths in men and 1 in 10 in women.
In Scotland, CHD has remained a national priority since the mid-1990s.
In 2000, the then Clinical Standards Board for Scotland published the
standards for Secondary Prevention Following Acute Myocardial Infarction.
The delivery of these standards was supported by the introduction of the
national strategy for Coronary Heart Disease and Stroke by the Scottish
Executive in 2002. Subsequent revision of this strategy took place in 2004.
There have also been other strategic initiatives such as the establishment of a
National Advisory Committee, the development of managed clinical networks
(MCNs) and the recent ban on smoking in enclosed public spaces.
In 2005, the Scottish Intercollegiate Guideline Network (SIGN) undertook a
major review of the management of CHD related guidelines. This resulted in
the publication of a comprehensive set of guidelines covering primary
prevention of cardiovascular disease, stable angina, acute coronary
syndromes, chronic heart failure and cardiac arrhythmias.
These guidelines, and the cardiac rehabilitation guideline from 2002, provide
a framework around which NHS Quality Improvement Scotland aims to
develop modern standards of care for CHD, supported by a parallel
programme of national audits and the development of clinical indicators in
relation to coronary heart disease.
Patient concerns
The following issues will be highlighted to members of the pathway project
groups throughout the process of standards development to ensure that,
wherever possible, these are embedded within the standards throughout the
journey of care.
•
Patients feel it is important to receive early diagnosis and treatment.
•
Patients identified a need for open communication from doctors,
particularly in response to questions from patients and their families.
Patients should receive a full explanation of the results of the
assessment and any investigations undertaken. They should not
hesitate to ask any further questions that they may wish answered.
•
Patients feel there is a need for doctors to give appropriate information
on medication (including side effects) and provide patients with a clear
explanation on why they have been given these drugs. They also feel it
is important that prescribed drugs are frequently reviewed.
•
Patients want to be given information to help them understand and
manage their condition. This information could be made available as
books, leaflets, video tapes and the internet. Patients who are having
coronary artery bypass surgery want their healthcare team to give them
information before and afterwards to improve their care; management
of risk factors; psychological distress (such as anxiety) and physical
functioning (ability to carry out everyday activities).
•
Patients want to receive cardiac rehabilitation (a structure exercise
programme) after coronary revascularisation.
•
Patients feel it is important for doctors to discuss the psychological
aspects of cardiac rehabilitation and help patients appreciate the value
of it. This is important for recovery of confidence, psychological and
physical well being.
•
Patients feel it may be helpful for people with cardiovascular disease
(CVD) risk to attend self help groups. Some of these groups meet for
regular exercise while others offer support to patients and their carers.
A list of support groups should be available at your local health centre.
(From the SIGN guidelines for patients
http://www.sign.ac.uk/patients/network.html)
The evidence base for diagnosis, treatment and management of
coronary heart disease
The following aspects of CHD, addressed in detail within the SIGN guidelines
for CHD (SIGN 57, 93-97) will from the basis for the evidence used to develop
the standards for CHD within Scotland.
•
Risk assessment and risk stratification of cardiovascular disease
•
Presentation, assessment and diagnosis
•
Management of CHD in the emergency and long term settings
•
Drug therapies for CHD in the emergency and long term settings
•
Device therapies e.g. pacemakers, internal cardiac defibrillators
•
Coronary revascularisation e.g. coronary artery by-pass surgery,
percutaneous coronary intervention
•
Patient support and information needs
•
Cardiac rehabilitation
•
Psychological support and interventions including screening for
depression in patients with CHD
•
Lifestyle modifications
•
Alcohol consumption
•
Smoking cessation
•
Physical activity
•
Dietary advice
•
Palliative care
Development of CHD standards
Programme steering group
The overall strategy for the CHD standards programme will be designed,
developed and delivered by a steering group consisting of the NHS QIS CHD
advisor, three chairs of the standards pathway project groups, representation
from ISD, Chair of the CHD National Advisory Committee, voluntary
organisations, the Scottish patient safety alliance and patient representation.
The steering group will be patient focused and will, wherever possible,
address issues concerning all services for people affected by CHD.
Pathway project groups (PPG)
Standards will be developed within the context of the patient journey
described by 3 pathways of care:
1. Chest pain/angina - encompassing risk assessment of patients at risk
of cardiovascular disease, patients with stable angina presenting to
community-based healthcare teams for scheduled care, unscheduled
care with acute coronary syndromes presenting via the Scottish
Ambulance service to hospital and their subsequent journey through
the hospital setting of coronary care, tertiary referral to a cardiac
catheter laboratory, cardiac surgery, cardiac rehabilitation and
discharge into the community setting.
2. Chronic heart failure – ranging from presentation in the community
setting, through hospital based scheduled and unscheduled care to
discharge, multidisciplinary follow up and management within the
community. Palliative care aspects of care will also be addressed by
this project group.
3. Arrhythmias/palpitations – this project group will consider a wide range
of aspects of the patient pathway covering presentation, diagnosis and
management of atrial and ventricular arrhythmias in the community
setting and as unscheduled care presenting to emergency services in
secondary and tertiary care.
The standards for each pathway will be developed by three pathway project
groups (PPG) chaired by a senior clinician with a background and experience
appropriate to the development of clinical standards for their pathway. The
PPG will comprise of patients, representatives from voluntary and charitable
organisations linked to CHD and a broad range of NHS staff nominated by the
CHD managed clinical networks around Scotland.
Cardiac conditions not covered by the proposed programme of
work
There are a number of other aspects of heart disease that will not be
addressed directly within the current proposed work program for NHSQIS.
These include inherited cardiac conditions (e.g. inherited cardiomyopathies
and arrhythmias), adult congenital heart disease, paediatric heart disease,
adult valvular heart disease, pericardial disease, infective endocarditis and
diseases of the thoracic aorta.
Inherited cardiac conditions will be addressed as part of the development of a
recently established Familial Arrhythmia Network which will be further
complemented by a Familial Cardiomyopathy Network.
Bibliography
In addition to the SIGN guidelines, there are a number of other sources of
information and evidence that will be used to inform the process of standards
development. These include National Service Framework for Coronary Heart Disease (England & Wales)
Department of Health, 2000
Service Framework for cardiovascular health and wellbeing, Northern Ireland
2008
Arrhythmia/palpitations
Blue Cross Blue Shield Association and Kaiser Parmanente. (2006)
Pulmonary vein isolation for treatment of atrial fibrillation. Assessment
Program 21[1]Technology Evaluation Centre, Illinois, Blue Cross Blue
Shield Association and Kaiser Parmanente.
Bryant J, Brodin H, Loveman E, Payne E and Clegg A. (2005) The clinical and
cost effectiveness of impantable cardiverter defibrillators: a systematic
review. Health technology assessment 9[36]London, NCCHTA.
Cameron AC, Jenkins SM, Dunn FG. The burden of atrial fibrillation in
unselected acute medical admissions. Scott Med J. 2008 May;53(2):42-7.
European Society of Cardiology. (2006) ACC/AHA/ESC guidelines for
management of patients with ventricular arrhythmias and the
prevention of sudden cardiac death. European Heart Journal ,
European Society of Cardiology.
European Society of Cardiology. (2006) ACC/AHA/ESC guidelines for the
management of patients with arterial fibrillation. European Heart
Journal , European Society of Cardiology.
European Society of Cardiology. (2007) Guidelines for cardiac pacing and
cardiac resynchronization therapy. Europace 9, 959-998
National heart rhythm management device task force. (2007) Heart rhythm
management devices: guidance for commissioners. NHS Heart
Improvement Programme.
New Zealand Guidelines Group. (2005) The management of people with atrial
fibrillation and flutter. New Zealand, New Zealand Guidelines Group.
NICE. (2006) Atrial fibrillation: the management of atrial fibrillation. NICE
clinical guideline 36 London, NICE.
NICE. (2005) Cryoablation for atrial fibrillation in association with other cardiac
surgery. Interventional procedure guidance 123 London, NICE.
NICE. (2006) High intensity focused ultrasound for atrial fibrillation in
association with other cardiac surgery . Interventional procedure 184
London, NICE.
NICE. (2006) Implantable cardioverter defibrillators for arrythmias.
Technology appraisal 11London, NICE.
NICE. (2005) Microwave ablation for atrial fibrillation in association with other
cardiac surgery. Interventional procedure guidance 122 London, NICE.
NICE. (2006) Percutaneous radiofrequency ablation for atrial fibrillation.
Interventional procedure guidance 168 London, NICE.
NICE. (2005) Radiofrequency ablation for atrial fibrillation in association with
other cardiac surgery. Interventional procedure guidance 121 London,
NICE.
Ontario Ministry of Health and Long-Term Care. (2006) Ablation for atrial
fibrillation: health technology policy assessment. Toronto
Royal College of Physicians of London. (2006) Atrial fibrillation: national
clinical guideline for management in primary and secondary care.
London, Royal College of Physicians of London.
Cardiac rehabilitation
CREST. (2006) Guidelines for cardiac rehabilitation in Northern Ireland.
CREST.
Jolly K, Taylor R, Lip GYH, Greenfield S, Raftery J, Lane D, Mant J, Jones M,
Lee KW and Stevens A. (2007) The Birmingham rehabilitation uptake
maximisation study (BRUM). Home-based compared with hospital-based
cardiac rehabilitation in a multi-ethnic population: cost effectiveness and
patient adherence. Health technology assessment 11[35]London,
NCCHTA.
NICE. (2007) MI: secondary prevention. NICE clinical guideline 48 London,
NICE.
Chest pain (stable angina and acute coronary syndromes)
Blue Cross Blue Shield Association and Kaiser Parmanente. (2006) Contrastenhanced cardiac computed tomographic angiography in the diagnosis
of coronary artery stenosis or for evaluation of acute chest pain.
Assessment Program 21[5]Technology Evaluation Centre, Illinois, Blue
Cross Blue Shield Association and Kaiser Parmanente.
Blue Cross Blue Shield Association and Kaiser Parmanente. (2005) External
counterpulsation for treatment of chronic stable angina pectoris and
chronic heart failure. Assessment Program 20[12]Technology
Evaluation Centre, Illinois, Blue Cross Blue Shield Association and
Kaiser Parmanente.
Bryant J, Brodin H, Loveman E, Payne E and Clegg A. (2005) The clinical and
cost effectiveness of impantable cardiverter defibrillators: a systematic
review. Health technology assessment 9[36]London, NCCHTA.
European Society of Cardiology. (2006) Guidelines on the management of
stable angina pectoris. European Heart Journal , European Society of
Cardiology.
Hayes Inc. (2006) Electrical spinal chord stimulation for the treatment of
intractable angina pectoris. United States, Hayes Inc.
NCCHTA. (2009) Enhanced external counterpulsation (EECP) for stable
angina or heart failure.
NCCHTA. (2009) The effectiveness and cost effectiveness of biomarkers for
the prioritisation of patients awaiting coronary revascularisation: a
systematic review and decision model.
NICE. (2009) Investigation, assessment and management of acute chest pain
of suscpected cardiac origin.
NICE. (2010) The management of stable angina.
Robinson M, Palmer S, Sculpher M, Philips Z, Ginnelly L, Bowens A, Golder
S, Alfakih K, Bakhai A, Packham C, Cooper N, Abrams K, Eastwood A,
Pearman A, Flather M, Gray D and Hall A. (2005) Cost effectiveness of
alternative strategies for the initial medical management of non-ST
elevation acure coronary syndrome: systematic revies and decisionanalytical modelling. Health technology assessment 9[27]London,
NCCHTA.
SIGN. (2007) Acute coronary syndromes. Edinburgh, SIGN.
SIGN. (2007) Management of stable angina: a national clinical guideline.
Edinburgh, SIGN.
University of Warwick, Joint Royal Colleges Ambulance Liaison Committee.
(2006) Non-traumatic chest pain/discomfort. Joint Royal Colleges
Ambulance Liaison Committee.
Chronic heart failure
Systematic review and individual patient data meta-analysis of diagnosis of
heart failure, with modelling of the implications of different diagnostic
strategies in primary care. (2009)
AHRQ. (2006) Testing for BNP and NT-ProBNP in the diagnosis and
prognosis of heart failure. Evidence report/technology assessment
number 142 Canada, AHRQ.
American College of Emergency Physicians Clinical Policies Subcommittee.
(2007) Clinical policy: critical issues in the evaluation and management
of adult patients presenting to the emergency department with acute
heart failure syndromes. American College of Emergency Physicians.
Belgian Healthcare Knowledge Centre. (2005) Natriuretic peptides in the
diagnostic work-up of patients with suspected heart failure. Belgium,
Belgian Healthcare Knowledge Centre.
Clegg AJ, Scott DA, Loveman E, Colquitt J, Hutchinson J, Royal P and Bryant
J. (2005) The clinical and cost-effectiveness of left ventricular assist
devices for end-stage heart failure: a systematic review and economic
evaluation. 9[5]Southampton, NCCHTA.
Craig J., Bradbury I, Cummins E, Downie S, Foster L and Stout A. (2005)
Health technology report 6: The use of B-type nariuretc peptides (BNP
and NT-ProBNP) in the investigation of patients with suspected heart
failure. HTA report 6 Edinburgh, QIS.
CREST. (2005) Guidelines on the management of chronic heart failure in
Northern Ireland. Northern Ireland, CREST.
European Society of Cardiology. (2007) Guidelines for cardiac pacing and
cardiac resynchronization therapy. Europace 9, 959-998
European Society of Cardiology. (2005) Guidelines for the diagnosis and
treatment of chronic heart failure. European Heart Journal , European
Society of Cardiology.
European Society of Cardiology. (2005) Guidelines on the diagnosis and
treatment of acute heart failure. European Heart Journal , European
Society of Cardiology.
Fox M, Mealing S, Anderson R, Dean J, Stein K, Price A and Taylor RS.
(2007) The clinical effectiveness and cost-effectiveness of cardiac
resynchronisation (biventricular pacing) for heart failure: systematic
review and economic model. 11[47]Southampton
Hayes Inc. (2005) Candestartan cilexetil for heart failure. United States,
Hayes Inc.
Hayes Inc. (2005) Cardiac resynchronization therapy for chronic heart failure.
United States
Hayes Inc. (2006) Extracorporeal membrane oxygenation for heart failure
(children and adults). United States, Hayes.
Heart Failure Society of America. (2006) Comprehensive heart failure practice
guideline. Journal of Cardiac Failure 12[1], e1-e122
Living and dying with chronic heart failure: a palliative care approach. Scottish
Partnership for Palliative Care, March 2008
(http://www.palliativecarescotland.org.uk/publications/HF%20final%20d
ocument.pdf)
Medical Services Advisory Committee. (2005) Cardiac resynchronisation
therapy for severe heart failure. MSAC application 1042 Australia,
Medical Services Advisory Committee.
National Heart Foundation of Australia, Cardiac Society of Australia and New
Zealand. (2006) Guidelines for the prevention, detection and
management of chronic heart failure in Australia. Australia, National
Heart Foundation of Australia.
National heart rhythm management device task force. (2007) Heart rhythm
management devices: guidance for commissioners. NHS Heart
Improvement Programme.
NCCHTA. (2009) Enhanced external counterpulsation (EECP) for stable
angina or heart failure.
NICE. (2007) Cardiac resynchronisation therapy for the treatment of heart
failure. NICE technology appraisal guidance 120 London, NICE.
SIGN. (2007) Management of chronic heart failure. Edinburgh, SIGN.
University of Michigan Health System. (2006) Heart failure - systolic
dysfunction. Michigan, University of Michigan.