Heart attack audit points to systemic flaws

The recently published NOCA audit on ST elevation myocardial infarction highlights concerning downturns in performance. Paul Mulholland reports

During RCSI’s Charter Week earlier this month, the National Office of Clinical Audit (NOCA) published its Irish Heart Attack Audit National Report 2024.

The report presented data on 1,615 patients who experienced an ST elevation myocardial infarction (STEMI) during the year.

It outlines a number of concerning findings in relation to the area, notably the falling rate of primary percutaneous coronary intervention (PCI).

PCI is the internationally preferred therapy for STEMI. However, in 2024, only 77 per cent of patients with a STEMI received primary PCI, compared with 86 per cent in 2017.

While the report notes the proportion receiving thrombolysis has risen modestly, it states this remains suboptimal, and variation in thrombolysis use is evident across hospitals.

“The variation in the delivery of primary PCI, and of thrombolysis when transport for timely primary PCI is not feasible, cannot be explained by simple geographic distance,” according to the report.

“Structural and systemic delays in the diagnosis and transport of patients with a STEMI have led to deviation from the agreed national clinical model of care for STEMI across different hospital networks.”

It explains the decline in primary PCI reflects delayed patient presentation to hospital, and initial presentation to non-PCI-capable hospitals.

Only 55 per cent of patients with a STEMI arrived directly by ambulance to a PCI centre in 2024, with a further 10 per cent self-presenting to a PCI centre.

According to the data, 24 per cent of patients self-presented to non-PCI-capable hospitals. In total, 32 per cent were transferred by ambulance from a non-PCI-capable hospital and only 57 per cent of transferred patients ultimately underwent primary PCI, compared with 87 per cent of those arriving directly to a PCI centre.

“Alarmingly, 11 per cent of patients were contraindicated for reperfusion due to late presentation, most commonly due to patients seeking help more than 12 hours after symptom onset,” the report states.

Symptom recognition

According to the NOCA, patient delay in seeking medical help is a chief contributor to delayed opportunities for timely reperfusion.

In 2024, only 45 per cent of patients who arrived directly by ambulance to a PCI centre called for help within one hour of symptom onset. This is down from 49 per cent in 2023.

“This persistent delay in symptom recognition and ambulance activation underlines the importance of public awareness campaigns around symptom recognition and STEMI treatment pathways,” the report states.

ECG

Across the STEMI care pathway, regardless of whether patients self-present to PCI centres or present initially to non-PCI-capable hospitals, the timeliness of diagnostic ECG remains “inadequate”.

The report shows that in 2024 only 35 per cent of patients who self-presented to a PCI centre received an ECG within the recommended 10 minutes of arrival.

The figure falls to 28 per cent among patients who first presented to non-PCI-capable hospitals.

“These missed targets are particularly important for self-presenting patients, for whom rapid ECG diagnosis is the main determinant of reperfusion timing.”

For this group, the median time from first medical contact to balloon (FMCTB) was 84 minutes in 2024, above the 60-minute target.

Inter-hospital transfer

For patients initially presenting to non-PCI-capable hospitals, the report states that “transfer delays remain the greatest systemic weakness”.

In 2024, just 3 per cent of patients who initially presented to a non-PCI-capable hospital achieved the recommended ‘door-in door-out’ time of 30 minutes. Only 26 per cent met the target of arrival at a PCI centre within 90 minutes of first medical contact.

“These delays significantly undermine equitable access to reperfusion and remain a persistent gap in the STEMI network,” according to the report.

“Improved coordination, governance, communication, National Ambulance Service [NAS] resourcing, and real-time use of audit data are urgently required.”

Thrombolysis

For patients in whom primary PCI cannot be delivered within 90 minutes, guideline-recommended thrombolysis remains both “underutilised and delayed”.

Rates of timely thrombolysis have declined markedly, dropping from 45 per cent in 2017 to just 22 per cent in 2024. This downward trend is particularly concerning given thrombolysis serves as the key alternative to PCI when inter-hospital transfer times are extended.

Reperfusion

Among patients who presented directly to PCI centres in 2024, achievement of timeliness targets remained inconsistent. The 30-minute door-to-balloon target was reached in 55 per cent of cases, with marked variation between centres, from 70 per cent in the best-performing hospital to 35 per cent in the lowest-performing hospital. Outcomes were poorer for self-presenters, with only 30 per cent meeting the 60-minute FMCTB target.

“These findings underscore the need for hospital-level quality improvement initiatives focusing on both emergency department [ED] time to ECG processes, and catheterisation laboratory [cath lab] activation and processes.”

Another concerning trend is the reduced use of ED bypass for patients diagnosed with a STEMI prior to hospital arrival or at referring hospitals.

Other concerns were expressed relating to risk factors, chronic disease management, and public awareness.

Irish Heart Foundation

The report states, overall, 27 per cent of STEMI presentations had a diagnosis of diabetes in 2024. Also, 44 per cent of patients with a STEMI had a previous history of hypercholesterolaemia, and 53 per cent had a previous history of hypertension. Smoking remained a major risk factor: 36 per cent of patients were current smokers, and smokers experienced a STEMI on average 11 years earlier than non-smokers.

“This demonstrates that we have much more to do in helping people quit smoking and in treating the other risk factors such as hypertension and hypercholesterolaemia,” the Medical Director of the Irish Heart Foundation Dr Angie Brown told the Medical Independent (MI).

Dr Brown also pointed out the audit shows the public are not aware enough of the importance of calling an ambulance immediately if they think they are having a heart attack.

“This is putting STEMI patients at risk of a worse outcome,” she said, calling for the roll-out of a national heart attack awareness campaign.

HSE response

The HSE welcomed the findings of the audit. “We acknowledge there are improvements to be made and to that end, the HSE’s National Heart Programme has developed an action plan to address the report’s findings,” said HSE Chief Clinical Officer (CCO) Dr Colm Henry.

“This plan includes a proposal for the setting up of new regional primary PCI groups in each of the six health regions, in addition to the designation of University Hospital Waterford as the country’s seventh 24/7 primary PCI centre, as announced by Minister Carroll MacNeill in April 2025.”

The National Heart Programme will work with the HSE health regions, the Office of the CCO, as well as other key HSE national functions, including the NAS, to implement a number of proposals (see panel).

Next steps

When asked by MI what actions should follow the findings, Prof Ronan Margey, National Clinical Lead for the Irish Heart Attack Audit, said the response needs to be two-fold: A clearer message to the public about lifestyle, recognising symptoms and seeking urgent care, and a renewed focus within the health service on strengthening systems and reducing delays.

Regarding the latter, he said: “What we have really called for is within the regions of the HSE to formalise their audit and quality improvement programmes to focus on heart attack care – to look at each of those areas we outlined, such as recognising chest pain in the emergency room, shortening the time to ECG, shortening the ‘door-in door-out’ time in small model 3 hospitals that don’t perform primary PCI…. And for each of those larger PCI centres to focus on ensuring the patients bypass the emergency room, when they are identified with STEMI, that they are brought directly to the cath lab without delay.”

Prof Margey said “ultimately the big ask” is for the NAS to be resourced to match the demand that will fall on the service if it receives increased calls to assess patients with chest pain.

“But also, more importantly, when they get the call to transfer patients between hospitals, that they can react to that as a priority transfer, and that they are not burdened down with inter-hospital transfers being utilised for perhaps non-emergencies.”