Stent for Life Initiative

Stent for Life Initiative

Zuzana Kaifoszova Petr Widimsky Symposium Stent for Life Casa del Coraz贸n,Madrid June 10, 2010

ESC Guidelines: PCI for acute CAD Recommendations • PPCI for STEMI (within 2 hours)

Class LOE I

A

• Rescue PCI for failed fibrinolysis (within 12 hours)

IIa

A

• PCI for STEMI with shock and contraindications to fibrinolytic therapy irrespective of time delay

I

B

• Angiography and PCI after successful fibrinolysis (within 24 hours)

IIa

A

• Urgent PCI for hemodynamically unstable NSTEACS (within 2 hours)

I

C

• Early PCI for high-risk NSTE-ACS (within 72 hours)

I

A

Stent for Life Initiative European Executive Board

• • • • • • • •

Petr Widimsky/ SFL project co-chairman Jean Fajadet /SFL project co-chairman Nicolas Danchin (WG Acute Cardiac Care) Carlo Di Mario (EAPCI President) William Wijns (EAPCI Past President) Steen Kristensen (ESC) Marielle de la Torre (EAPCI Executive Officer) Zuzana Kaifoszova (SFL Project Manager, Europe)

Stent for Life Initiative Phase I Situation Mapping & Data Collection

Annual incidence of hospital admissions for STEMI Ref. P.Widimsky, European Heart Journal, doi:10.1093/eurheartj/ehp492

160

∅82 / 100 000 inhabitants / year

140

∅(190 / 100 000 / year for all AMIs)

120 100 80 60 40 20 0 TR HR

STEMI PL IL

DE SK

IT CZ

GR SE

PT BE

AT BG

ES LAT

HU SLO

FIN FR

LIT RO

NO UK

SRB

Reperfusion Therapies Differ in 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

3

15

86

40

39

31 8

10

81

75

75

72

70

66

64

35

37

42

48

52

50

15

35

55

35 26

30

44 25

33

59

41 49

45

45 33

30

30

28

24

23

19

19 9

SLO

DE

CH

NO

DK

PL

HR

P-PCI

SE

HU

BE

IL

IT

FIN

Thrombolysis

45 29

35

CZ

50 63

28 81

44

40 15

92

21 30

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

Annual Incidence of Primary PCIs

â&#x2030;Ľ600 p-PCI / million / year 400-599 p-PCI / million / year 200-399 p-PCI / million / year <200 p-PCI / million / year Data not known

5000

PCI’s (all) / million / year

4500 4000 3500 3000

∅ 1871

2500 2000 1500 1000 500 0

PCI / million / year CH HU

DE GR

IL FIN

LAT SLO

NO ES

A UK

IT LIT

NL SK

CZ TR

SE PT

BE HR

PL SRB

FR BG

DK RO

Primary PCI’s / million / year

1000 900 800 700 600

∅ 378

500 400 300 200 100 0

PCI / million / year CH BE

DE HR

PL FR

CZ LAT

SE PT

HU ES

NO SRB

SLO FIN

DK UK

IL BG

A GR

LIT TR

IT RO

SK

% of primary PCIs among all PCIs (measure of cathlab effectivity ??)

40

∅ 20% of all PCIs are p-PCIs for STEMI

35 30 25 20 15 10 5 0 LIT AT

p-PCI PL BG

SK IT

CZ IL

HU BE

SLO FR

SE ES

DK UK

HR FIN

NO TR

DE RO

CH LAT

PT GR

SRB

Mean population per one PCI center 2 000 000 1 800 000 1 600 000 1 400 000 1 200 000 1 000 000 800 000 600 000 400 000 200 000 0 IT BG

∅ 518 698

GR TR

CH CZ

AT UK

BE HU

FR DK

SE SRB

IL RO

ES

SLO

PL

Population per one primary PCI (24/7) center 3 000 000 2 500 000 2 000 000 1 500 000

∅ 917 614

1 000 000 500 000 0 FR SLO

BE DK

IT LIT

IL TR

CZ GR

PL UK

AT

SE

HU

ES

BG

Only 55% of all PCI centers offer non-stop 24/7 p-PCI service 100

∅ 55%

80 60 40 20 0 CZ DE ES

FR AT SLO

BE DK GR

HU IT UK

HR SK TR

PL BG LAT

NO LIT SRB

CH PT FIN

IL SE RO

Number of PCIs does not correlate to Countriesâ&#x20AC;&#x2122; GDP

Number of primary PCIs does not correlate to Countriesâ&#x20AC;&#x2122; GDP

Only 51% STEMI patients arrive to the first hospital by EMS

90 80 70 60 50 40 30 20 10 0 % STEMI arriving via EMS

UK Sweden Austria Czech Rep. Izrael Serbia Spain Slovakia Italy Turkey Greece

STEMI Mortality per Treatment 10 9

9,1 8,3

8 7 6 5 4 3 2 1 0

All STEMI 4,7

Thrombolysis Primary PCI

Nationwide â&#x20AC;&#x17E;thrombolytic strategyâ&#x20AC;&#x153; for STEMI results in 46% untreated patients % from all STEMI 46

50 45 40 35 30 25 20 15 10 5 0

Countries with p-PCI dominance 20

No reperfusion used

Countries with thrombolysis dominance

Reperfusion Strategy Paradox â&#x20AC;˘ Most people think, that thrombolysis is a kind of treatment widely available for patients everywhere, while p-PCI is limited in its availability. â&#x20AC;˘ The opposite is true: far more patients receive reperfusion treatment in countries with low use of thrombolysis and high use of p-PCI

Summary • Most North, West and Central European countries use p-PCI for the majority of their STEMI patients.

• The lack of organised p-PCI networks is associated with fewer patients overall receiving some form of reperfusion therapy.

• Primary PCI rates > 600 per million are needed to provide this treatment for most STEMI patients in Europe.

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 achieve primary PCI rates of more than 600 per one million inhabitants per year,



To offer 24/7 service for primary PCI procedures at all invasive facilities to cover the country STEMI population need.

Stent for Life Intiative Phase II

Learning the experience from the best practice countries

How Can We Improve

Networks and Infrastructure •

Regional network (EMS, non-PCI hospitals and PCI centers) should cover an area with population around 0,5 million (cca 0,3 – 1 million).

•

Respect the right of local hospitals to take care for the patients after primary PCI is completed and the patient is stabilized (tertiary transport to the local hospital nearest to patient’s home).

•

All PCI centers should provide non-stop (24/7) services for primary PCI. PCI hospitals, which are not able to provide non-stop (24/7) primary PCI services, should not be part of the network.

J.Knot:How to set up an effective national primary angioplasty network: lessons learned from five European countries (EuroIntervention, August 2009).

How Can We Improve Emergency Medical Services (EMS) • • • • •

EMS staff training is more important that the EMS staff structure (trained nurses suitable for the triage and transport of AMI patients) EMS ambulances: equipped by resuscitation facilities and by a portable 12-leads ECG. ECG teletransmission (to the PCI center) can be left on the local decision, is not mandatory.

Road transport is prefferred (air transport takes usually more time).

Helicopter transport is generally faster in mountainous, islandic or very scarsely populated regions.

J.Knot:How to set up an effective national primary angioplasty network: lessons learned from five European countries (EuroIntervention, August 2009).

How Can We Improve Transport & Time Delays Primary transport should bypass the nearest non-PCI hospital and the Emergency Room or Intensive Care Unit of the PCI center.

• Immediately diagnostic ECG call to cathlab and start transfer. The ECG – cathlab time <90 minutes can be achieved in vast majority of patients.

•

Admission to Emergency Room (or ICU) in the PCI center delays reperfusion by at least 20-40 minutes.

•

Admission to non-PCI hospital followed by the „secondary transport“ to PCI center delays reperfusion by at least 3060 minutes.

J.Knot:How to set up an effective national primary angioplasty network: lessons learned from five European countries(EuroIntervention, August 2009).

Stent for Life Intiative Phase III

Implementation in Countries

Stent for Life Initiative Declaration was signed at the ESC/EAPCI General Assembly on Aug 31, 2009 •

Turkey (78 p-PCI / mil. / yr.)

•

Greece (95 p-PCI / mil. / yr.)

•

Bulgaria (130 p-PCI / mil. / yr.)

•

Serbia (157 p-PCI / mil. / yr.)

•

Spain (165 p-PCI / mil. / yr.)

•

France (231 p-PCI / mil. / yr.)

Stent for Life Initiative Spain

SFL National Leader Dr. Manel Sabate