Introduction

This quality standard covers the diagnosis and management of acute coronary syndromes (including myocardial infarction) in adults aged 18 years and over.

It does not cover the secondary prevention of myocardial infarction, including rehabilitation; this will be covered by a separate quality standard.

For more information see the topic overview.

Why this quality standard is needed

The term 'acute coronary syndromes' encompasses a range of conditions including unstable angina, non-ST-segment-elevation myocardial infarction (NSTEMI) and ST-segment-elevation myocardial infarction (STEMI). All are due to a sudden reduction of blood flow to the heart, usually caused by the rupture of an atherosclerotic plaque within the wall of a coronary artery, and may cause the formation of a blood clot.

The most common symptom of acute coronary syndromes is severe pain in the chest and/or in other areas (for example, the arms, back or jaw), which can last for several hours. Other symptoms include sweating, nausea and vomiting, breathlessness and feeling faint.

People with acute coronary syndromes may have a poor prognosis without prompt and accurate diagnosis. Treatments are available to help ease the pain, improve the blood flow and to prevent any future complications.

The highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible using drug treatment and/or revascularisation. This applies to all people with STEMI, including those who have been resuscitated after cardiac arrest. The time taken to restore coronary blood flow is very important because heart muscle starts to be lost as soon as the coronary artery is blocked.

In people with NSTEMI and unstable angina, the aim of treatment is to alleviate pain and anxiety and prevent recurrence of ischaemia. For people with unstable angina, treatment also aims to prevent or limit progression to acute myocardial infarction. The type of treatment is determined by the person's individual risk of future adverse cardiovascular events (heart attack and stroke, repeat treatment or death).

The quality standard is expected to contribute to improvements in the following outcomes:

  • deaths from cardiovascular diseases

  • length of hospital stay

  • adverse effects of interventions (for example, bleeding and stroke)

  • incidence of further heart attacks.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014–15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

Improvement areas

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Aligning across the health and care system

* Indicator shared with public health outcomes framework

Table 2 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable

4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)*

Alignment across the health and care system

* Indicator shared with the NHS Outcomes Framework

Coordinated services

The quality standard for acute coronary syndromes (including myocardial infarction) specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole acute coronary syndromes (including myocardial infarction) care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to adults with acute coronary syndromes (including myocardial infarction).

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality acute coronary syndromes service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with acute coronary syndromes (including myocardial infarction) should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with acute coronary syndromes (including myocardial infarction). If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.