Dr Seaton's letter in full

Dr. Douglas Seaton was an eminent consultant at Ipswich Hospital for nearly 30 years. Today, he calls into question controversial plans to remove care of heart attack patients from the hospital and move treatment to Norwich, Cambridge, or Basildon.

Dr. Douglas Seaton was an eminent consultant at Ipswich Hospital for nearly 30 years. Today, he calls into question controversial plans to remove care of heart attack patients from the hospital and move treatment to Norwich, Cambridge, or Basildon.

THE heart is a muscle and like other muscles it needs its own blood supply. This blood supply is carried through the coronary arteries which keep the heart muscle (myocardium) alive by supplying it with oxygen.

If one of the coronary arteries is suddenly blocked for long enough, by the formation of a clot (thrombus), part of the myocardium is starved of oxygen and is damaged or may die. This is a heart attack (myocardial infarction or MI for short) and the usual symptom is a persistent tight constricting pain across the centre of the chest that is unrelieved by rest.

The diagnosis of an MI is confirmed with an electrocardiogram (ECG). This is a routine test that records the electrical activity of the heart on a paper trace. Typically a part of the trace known as the 'ST segment' is seen to be displaced upwards on the paper making a diagnosis of 'ST segment elevation myocardial infarction' or 'STEMI' for short.

Once a STEMI has been diagnosed by trained staff, either in the ambulance or in the accident and emergency department, treatment should be started rapidly as prompt treatment can reduce the chance of heart muscle damage and save the patient's life.

Delay has the opposite effects. There are two main ways of treating patients with STEMIs. One is with clot-busting medication given through a drip and is called thrombolysis. The other involves threading a thin tube (balloon catheter) from an artery in the groin or at the wrist into the blocked coronary artery that is outlined with dye using x-ray equipment.

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The balloon is then inflated to stretch open the artery (angioplasty) that is then held open by the placement of a small tubular metal mesh (stent). Angioplasty and stenting for STEMIs is known as primary per-cutaneous coronary intervention or PPCI for short. Both thrombolysis and PPCI are emergency procedures and both have to be carried out as quickly as possible.

The rapidity of the medical team response can be measured by 'call to needle time' in the case of thrombolysis or 'call to balloon time' in the case of PPCI. Of the two treatments, research has shown that PPCI achieves better patient outcomes than thrombolysis, provided that it is carried out without delay and by an experienced team.

The Strategic Health Authority (SHA) for the east of England has its headquarters outside Cambridge and is responsible for ensuring that the people of Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk receive good health care. Its website states that:

“Our tripartite mission is to:

Deliver a better patient experience

Improve people's health

Reduce unfairness in health”

These aspirations may have a hollow ring about them for many Suffolk residents in view of the SHA's recent proposals to alter the management of heart attack sufferers in Suffolk and the draconian way in which its message was delivered. It was proposed that all such Suffolk patients should be transported by ambulance directly to cardiac centres in Papworth, Norwich or Basildon rather than to the Ipswich Hospital. Let us examine the SHA's three mission statements in this context, one by one.

Will the patient's experience be better if he or she has to undergo a long ambulance trip to Papworth Hospital (66 miles from central Ipswich), the Norfolk and Norwich Hospital (45 miles) or Basildon Hospital in Essex (57 miles)? Google estimates for these journey times from an IP1 post code is 79, 73 and 77 minutes respectively. An ambulance might manage the journey faster but it first has to reach the caller who may well be in a rural district and traffic conditions are often uncertain. The initial part of the patient experience would certainly be no better.

Will people's health be improved by transfer to one of these three centres? The question that needs answering is whether the delayed PPCI resulting from transport time added to the receiving hospital's door to balloon time will still offer real benefits when compared with rapid thrombolysis given locally. I'm not convinced that this question has been answered yet for Suffolk people, particularly those in the east of our county. We know that thrombolysis is currently administered very rapidly in the catchment area of Ipswich Hospital, often in the ambulance by experienced paramedics. There is also the issue of the possible consequences if the STEMI patient's condition deteriorates seriously en route to one of the out-of-county centres. The paramedics are highly trained but the facilities in an ambulance are obviously limited.

Will the new scheme reduce unfairness in health? Not if delayed treatment causes people living in East Suffolk to experience more heart muscle damage from STEMIs than those living nearer the proposed PPCI centres in Cambridgeshire, Norfolk and Essex. Thrombolysis carried out in the ambulance to these centres won't do, as research has shown that combining thrombolysis and PCI (so-called 'facilitated PCI') tends to result in episodes of bleeding without improving clinical outcomes.

In short it is by no means clear that the SHA's 'tripartite mission' will be achieved and there will be no point in replacing an excellent Ipswich based thrombolysis service with short call to needle times unless we can be sure that the proposed out-of-county PPCI service for many heart attack victims in Suffolk would not be sub-optimal as a result of delayed call to balloon times.

Ipswich has a large hospital with over 600 beds. Historically it has prided itself on providing high quality emergency treatment to a population in East Suffolk of over 300,000 people. It has carried out thrombolysis very well but now PPCI has been shown to be more effective provided it is carried out without delay. The SHA should be looking to expand cardiology services in Suffolk by planning for the future provision of PPCI in Ipswich Hospital. Firm plans to set up and expand such a dedicated cardiology catheter facility would no doubt attract the additional expertly trained cardiologists that would need to be recruited in order to run such a unit 24 hours a day. It might in the meantime be possible for some consultant cardiologists from Papworth to assist the local team with daytime sessional PPCI work in Ipswich. Such sessional visits used to serve our patients well a number of years ago when I worked as a consultant in Ipswich. There will of course be significant cost implications in setting up a dedicated centre at Ipswich Hospital but these should not detract from positive forward planning. Morale sapping cut backs in health care do nobody any good.

This is a matter that local people feel very strongly about and all our politicians had better take note. In the meantime perhaps the pressure might be kept up by a local appeal for funding in much the same way as happened in the 1980s when the Suffolk Scanner Appeal raised money for our first CT scanner.

Dr Douglas Seaton

Consultant Physician, Ipswich Hospital 1979-2006.


Glossary of terms

Myocardium: the heart muscle

Coronary arteries: arteries supplying the heart muscle with oxygen

Thrombus: a blood clot

Myocardial infarction (MI): a heart attack with damage to the heart muscle

Electrocardiogram (ECG): an electrical trace of the heart muscle's activity

ST segment: a part of the ECG trace

STEMI: ST segment elevation myocardial infarction (a heart attack in which the ECG shows ST segment elevation)

Angioplasty: the stretching open of an artery with a balloon catheter

Thrombolysis: the removal of clot using clot-busting medication given via a drip.

Stent: a tubular metal mesh designed to hold open a coronary artery once it has been stretched by angioplasty.

PCI: per-cutaneous coronary intervention, usually meaning angioplasty followed by stent placement under local anaesthetic.

PPCI: primary PCI meaning PCI carried out as the initial procedure (rather than thrombolysis) for a STEMI.

Call to needle time: the length of time between the patient requesting help and being given thrombolysis for a STEMI.

Call to balloon time: the length of time between the patient requesting help and receiving PPCI for a STEMI.

SHA: Strategic Health Authority, based near Cambridge for East of England