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Inequalities across Europe in access to primary angioplasty
to treat acute heart attack patients
-the cross-border dimensionJohn Martin, MD, FRCP, FESC, FMedSci
Chairman, European Critical Care Foundation
Professor of Cardiovascular Medicine, University College London
Adjunct Professor of Medicine, Yale University
Overview
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•
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The science
• Myocardial Infarction – introduction
• Best treatment – what is primary angioplasty?
• Saving heart muscle – the importance of timing
• Emergency transport and borders
Stent for Life Initative Guidelines Implementation Model
• Inequalities across Europe in access to best treatment
• Stent for Life Initiative mission & activities
• Key learning points and impact
• ACT NOW. SAVE A LIFE Campaign
Border regions and access to primary angioplasty
Discussion and Q&A
Primary angioplasty explained
• Coronary arteries: balloon angioplasty
Arrival
Closed
After balloon
Balloon
Open artery
• The European Society of Cardiology (ESC) guidelines recommend primary PCI as
the preferred treatment whenever it is available within 90-120 minutes of the
first medical contact
Angioplasty reduces mortality and morbidity
Primary PCI vs. Thrombolysis in ST-Elevation Myocardial Infarction:
Meta-analysis (23 Randomised controlled trials, N=7,739)
Short-term Outcomes (4-6 weeks)
Frequency (%)
P<.000
1
P<.000
1
P=.000
2
Death
P<.000
1
PPCI
Thrombolytic
therapy
Nonfatal Recurrent Death, Nonfatal, Reinfarction,
MI
Ischemia or Stroke
Based on Keeley EC, et al. Lancet. 2003;361:13-20.
Death at 3 years – presentation delay
Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)
Time from symptom onset to treatment predicts 1
Year Mortality—Primary PCI
The relative risk of 1 year mortality increases
by 7.5% for each 30 minute delay.
Roughly 1% every 3 minutes
Y=2.86 (± 1.45) + 0.0045X1 + 0.000043X2
P<.001
6 2004;109:1223-1225.
De Luca G, et al. Circulation.
The ambulance arrives
• Acute electrocardiogram
ST-segment Elevation
1) Transmission of
electrocardiogram from
ambulance to STEMI
centre (hospital)
Ambulance
Call
2) Hospital doctor
makes the STEMI
diagnosis and directs
the ambulance to the
STEMI centre.
Borders and access to pPCI
Country A
Country B
Stent for Life Initiative
Guidelines Implementation Model
William Wijns, MD, PhD, FESC, FAHA
Co-Founder, Stent for Life Initiative
Co-Director, Cardiovascular Centre, O.L.V.Z. Aalst, Belgium
Reperfusion therapies differ between countries
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
7
1
14
0
12
7
17
2
13
12
20
10
15
25
26
15
26
36
5
15
3
21
30
39
40
31
8
35
44
37
42
48
52
50
10
50
63
40
15
15
92
35
55
35
28
86
81
81
26
75
75
72
70
66
64
30
44
25
33
59
41
49
45
45
35
33
30
30
28
24
23
19
19
9
CZ SLO
DE
CH
NO
DK
PL
HR
P-PCI
SE
HU
BE
IL
IT
FIN
Thrombolysis
45
29
AT
FR
SK
ES
LAT
UK
BG
PO SRB GR
8
5
TR
RO
No reperfusion
P.Widimsky et al. November 19, 2009. Reperfusion therapy for ST elevation acute myocardial infarction in
Europe: description of the current situation in 30 countries. Eur. Heart.J.doi:10.1093/eurheartj/ehp492
Stent for Life Initiative Objectives
1. Define regions/countries with an unmet medical need in
the optimal treatment of ACS.
2. Implement an action program to increase patient access
to primary PCI where indicated:
– To increase the use of primary PCI to more than
70% among all ST segment elevation myocardial
infarction patients,
– To offer 24/7 service for primary PCI procedures
at all invasive facilities to cover the country
STEMI population need.
SFL Impact on Access to PPCI
No reperfusion
Percentage of reperfusion therapy utilization in the SFL6 countries,
development from 2008 to 2011
100%
2008 2011
2008 2011
2008 2011
2008 2011
2008 2011
Trombo
2008 2011
3
9
90%
22
34
80%
28
30
39
35
48
50
52
19
14
70%
40
63
9
60%
26
40
50%
35
28
40%
78
25
33
64
30%
57
41
50
44
20%
33
10%
32
23
30
19
9
0%
Bulgaria
29
France
Greece
8
Serbia
Spain
Turkey
PPCI
Stent for Life Initiative: ESC STEMI Guidelines Implementation
in Countries - Key Learning Points
• Integrate SFL into National Cardiology Program
• Engage all stakeholders e.g. physicians, politicians, payers and
patients’ organizations
• Build Regional Network and Infrastructure (EMS)
• Establish National ACS/AMI Registry
• Increase Disease Awareness (Educational campaign to
government, payers and lay public)
Stent for Life Initiative
Leading Example for Other Geographies
SFL Member Countries
Bulgaria, Cyprus, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain, Turkey,
Ukraine, Bosnia and Herzegovina
SFL Affiliate Countries and Organizations
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Siberian Association of Interventional Cardiologists
STEMI INDIA
Emirates Cardiac Society
Saudi Heart Association
SFL Alliances
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European Critical Care Foundation
WIN
ACT NOW.SAVE A LIFE
Campaign Objective
Increase awareness of heart attack symptoms and
the urgency of treatment among Europeans
A key barrier in every country is lack of action to
urgently call an ambulance as soon as heart attack
symptoms are observed
Border regions and access to primary angioplasty
John Martin, MD, FRCP, FESC, FMedSci
Chairman, European Critical Care Foundation
Professor of Cardiovascular Medicine, University College London
Adjunct Professor of Medicine, Yale University
Borders and access to pPCI
Country A
Country B
Urban areas near border regions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Badajoz, Spain/Portugal
Daugavpils, Latvia/Lithuania
Londonderry, N Ireland/Ireland
Enschede, Netherlands/Germany
Flensburg, Denmark/Germany
Kemi, Finland/Sweden
Komotini, Greece/Bulgaria
Lille, France/Belgium
Salzburg, Austria/Germany
Strasbourg, France/Germany
Szczecin, Poland/Germany
Trieste, Italy/Slovenia
Example:Badajoz
Urban areas near border regions
ECCF briefing paper, preliminary areas identified
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Badajoz, Spain/Portugal
Szczecin, Poland/Germany
Strasbourg, France/Germany
Enschede, Netherlands/Germany
Flensburg, Denmark/Germany
Salzburg, Austria/Germany
Kemi, Finland/Sweden
Londonderry, N Ireland/Ireland
Lille, France/Belgium
Trieste, Italy/Slovenia
Daugavpils, Latvia/Lithuania
Komotini, Greece/Bulgaria
Summary - options and ideas for cross border cooperation in
access to primary angioplasty
Specific to cross-border regions
• Generate political will based on saving citizens’ heart muscle
• Establish agreements to minimise delays for patients of border zones
to facilitate more rapid access to 24/7 primary angioplasty centres
• Carry out research and collect additional data to identify border
regions which could benefit from greater cross-border collaboration
• Identify cross-border and regional networks that are already working
well and encourage transfer of best practices to other regions
• Identify and rank criteria necessary for successful cross-border pPCI
networks
Europe-wide
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Endorse and support the principle of pPCI networks across Europe
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Encourage use of a unified, EU-wide 112 emergency response
number
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Support coordinated action to raise standards to the level of the best
performing Member States
Thank you for your attention!
John Martin: [email protected]
William Wijns: [email protected]