The management of heart disease in the UK – Current Profile
- The risk of dying from heart attacks is reducing due to improvements in acute care. However, the rate of heart attacks in the population continues to increase. Both these factors increase the burden on the healthcare budget.
- Missed diagnosis. It has been shown that as many as 11.8% of patients who have had an AMI are sent home from an Accident and Emergency Department, although a figure of 6% is more usual. Medical litigation arising from missed diagnosis is increasing at the rate of 20%.
- Inappropriate admission. 13.8% of patients occupying Coronary Care Unit beds have a final diagnosis of Non-Ischaemic Chest Pain (NICP), meaning there was no involvement of the heart in their condition. Each CCU bed costs over £500 a day.
- Funding NHS laboratories for new biochemical tests can be haphazard, and results in 'post-code' variability in their availability to clinicians.
When a patient tells his GP he has been suffering from chest pains or is rushed to the local A&E hospital the speed and accuracy of diagnosis is of critical importance to their survival. Uppermost in the doctors mind is has this patient suffered a heart attack and/or sustained myocardial injury.
Established tests such as an E.C.G. and measurement of creatine kinase (CK) and its MB isoenzyme (CK-MB) are used to confirm or not whether the individual has had an Acute Myocardial Infarction (AMI) or not. However the diagnostic sensitivity of an ECG is only 55 – 75% for Acute Myocardial Infarction.
Moreover as consultant chemical pathologist Dr Paul O Collinson said in his study undertaken at the Mayday University Hospital, Surrey:
"The problem is not simply one of ruling in or out AMI. The problem is that of management of the patient with unstable angina. In the absence of a reliable biochemical protocol to identify myocardial damage, patients that are at short term risk of death or major infarction, are sent home from the emergency room. Recent publications have established that the biochemical Troponin group of tests are significantly more specific and sensitive than CK-MB."
The troponin group of in vitro diagnostic tests have been available from a number of companies for some time now and bedside versions are also available. However, the way in which hospital laboratories are generally funded as trust overheads mean they have great difficulty in getting the additional money to pay for these new tests.
But as Dr Collinson highlighted in his study:
"The new biochemical markers have a major role to play in cost effective management of patients with chest pain. When applied as part of an integrated decision making strategy they can be used to efficiently identify both high risk and low risk patients in a cost effective manner.
To-date the take up of troponins and building them into their CHD decision-making strategy by hospitals has been patchy.
What are missing are national guidelines on the use of troponin tests. Without them we will no doubt see an increase in postal variations in CHD treatment success rates. With them we should expect fewer missed diagnoses and more productive Critical Care Units."