Fatality outside hospital from acute coronary events in three British health districts, 1994-5. United Kingdom Heart Attack Study Collaborative Group

Abstract

Objectives: To provide a contemporary account of the treatment and outcomes of acute coronary attacks in England and Wales and to identify strategies that might improve the outcome.

Design: Two year community and hospital based study in three British health districts.

Setting: Health districts of Brighton (population 282,000), South Glamorgan (408,000), and York (264,000).

Subjects: 3523 men and women under 75 years of age who died outside hospital from acute coronary causes, who were admitted to hospital with acute myocardial infarction, or who developed acute infarction or died unexpectedly from acute coronary causes while they were already in hospital.

Interventions: Attempted resuscitation in people having a cardiac arrest outside hospital.

Main outcome measures: Total case fatality, case fatality outside and inside hospital, and the effect of resuscitation on case fatality outside hospital.

Results: 1589 patients died within 30 days of the acute event. Case fatality was 45% (95% confidence interval 43% to 47%), rising from 27% (160/595) (23% to 31%) at age < 55 years to 53% (1019/1916) (51% to 55%) at 65-74 years. Overall, 74% (1172/1589) (72% to 76%) of fatal events happened outside hospital, and there was a negative age gradient (P < 0.001) such that 91% (145/160) (87% to 95%) of fatalities occurred outside hospital at age < 55 compared with 70% (710/1019) (67% to 73%) at 65-74 years. Without successful resuscitation of 55 patients outside hospital, total case fatality at 30 days would have risen from 45% to 46.7%.

Conclusion: Opportunities for reducing fatality from acute coronary attacks lie mainly outside hospital. These results and others imply that survival from cardiac arrest outside hospital might be trebled by improved ambulance and patient response. Proper application of secondary preventive measures for patients with coronary disease could have an even larger impact.

Figure 1

Case fatality and proportion of fatal events occurring outside hospital in the three centres. Circles indicate mean values and bars 95% confidence intervals

Figure 2

Flow diagram showing numbers of survivors and deaths at each stage

Figure 3

Total case fatality and case fatality outside hospital by age group