A national services framework (NSF) on coronary heart disease (CHD) for England was launched on March 6 by the Secretary of State for Health (Mr Alan Milburn).
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NSF for coronary heart diseaseThe NSF is a blueprint for tackling coronary heart disease written by clinicians, heart specialists and patient representatives. It sets national standards for preventing and treating CHD, defines service models for preventing and treating CHD, establishes immediate priorities, goals and performance indicators against which progress will be measured (within agreed time scales), and identifies practical tools to support implementation.
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Two of the new standards relate to prevention of CHD in high risk patients - those with diagnosed CHD or other occlusive arterial disease and those who are at a greater than 30 per cent risk of CHD over 10 years. One of the recommended interventions for these groups of patients is to use statins and dietary advice to reduce cholesterol levels to less than 5mmol/L.
Other recommendations for patients who have or are at high risk of CHD include advice and treatment to maintain blood pressure below 140/85mmHg, advice about stopping smoking (including advice about nicotine replacement therapy) and information about lifestyle factors such as physical activity, diet, alcohol consumption, weight and diabetes. People with diabetes should undergo meticulous control of blood pressure and glucose levels, the NSF says.
An immediate priority set out by the NSF is to increase the use of effective medication after heart attack so that by April, 2002, 90 per cent of patients discharged from hospital will be prescribed aspirin, 80 per cent statins and 80 per cent beta-blockers or ACE inhibitors.
On resources, the report says that hypertension is an area where there is potential for greater efficiency in prescribing. While it recommends the use of ACE inhibitors in people with left ventricular dysfunction, the NSF notes that they have only "marginal benefits" in initial treatment of hypertension and that thiazide diuretics and beta-blockers are cheaper and as effective.
Asked about the additional prescribing cost to GPs, Mr Milburn responded that it was "fine" for drug bills to increase so long as the treatment was both cost and clinically effective. The NSF demonstrated that the use of statins (as described above) was a "cost effective treatment which saves lives," he said.
Another standard of the NSF is that people thought to be suffering from a heart attack should be assessed and, if indicated, receive aspirin. After a heart attack, thrombolysis should be given within 60 minutes of calling for professional help. A long term goal of the NSF is that 75 per cent of patients will receive thrombolysis within 30 minutes of hospital arrival by April, 2002, and within 20 minutes by April, 2003.
Waiting times were too long, Mr Milburn said. In order to reduce them, capacity would need to be built up in the NHS by training more staff and by holding on to them.
Long-term aims of the NSF include a maximum of three months' wait for angiography and a three-month wait for coronary artery bypass grafting in high-risk patients (12 months for those not considered high risk). An NSF goal is that the total number of revascularisation procedures will increase by 3,000 by April, 2002.
Other measures include the introduction of rapid-access chest pain clinics to ensure a maximum of two weeks' wait for specialist assessment following the development of chest pain. By April, 2001, there should be 50 such clinics and a further 50 by April, 2002. Specialist smoking cessation clinics should also be introduced, aiming to help 150,000 people by April, 2001.
Mr Milburn said that death rates from CHD were much higher among unskilled men than among professional men. "Worse still, those areas in the country with the highest level of CHD often have the poorest provision of services." This view was supported by Sir George Alberti (president of the Royal College of Physicians and co-chairman of the NSF) who said that both access to, and performance of, services needed to be improved in the worst places.
Mr Milburn announced at the launch of the NSF that £50m would be given to "kick-start the crusade against heart disease". He said that while implementing the guidelines would take time, some changes could happen quickly.
The National Service Framework for coronary heart disease is available on the Department of Health's website (www.doh.gov.uk/nsf/coronary.htm).
In Scotland, guidelines for secondary prevention of CHD after a heart attack have been released by the Scottish Intercollegiate Guidelines Network (SIGN). The guidelines give recommendations for cardiac assessment, drug therapy, lifestyle modification and risk factor management. Guidelines for cardiac rehabilitation are in development.
Like the NSF, the SIGN guidelines set a desired total cholesterol of below 5.0mmol/L. According to SIGN, lipid lowering drug therapy should be given if total cholesterol is above 6.0mmol/L and should be considered if lifestyle advice fails in patients with cholesterol levels between 5.0 and 6.0mmol/L. Discussing lipid lowering drugs, the SIGN guidelines say that pravastatin and simvastatin are the drugs of choice in patients post-myocardial infarction (MI). This is because they have the greatest body of evidence, mostly from clinical trials, for the prevention of CHD.
Drug therapy that should be given following MI are aspirin, beta-blockers and ACE inhibitors, the SIGN guidelines say. Daily aspirin should be given routinely and continued for life in patients with coronary heart disease but clopidogrel would be a suitable alternative if aspirin was contraindicated. Antiplatelet agents (usually aspirin) are also recommended over warfarin for long-term prophylaxis post-MI.
The guidelines are available at www.sign.ac.uk under clinical guidelines/published guidelines/document 41.
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