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