inequalities across europe in access to primary angioplasty to treat acute heart attack patients...
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Inequalities across Europe in access to primary angioplasty to treat acute heart attack patients
-the cross-border dimension-
John Martin, MD, FRCP, FESC, FMedSci
Chairman, European Critical Care FoundationProfessor of Cardiovascular Medicine, University College London
Adjunct Professor of Medicine, Yale University
Overview
• 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
Closed Open artery
Arrival After balloon
Balloon
Primary angioplasty explained
• Coronary arteries: balloon angioplasty
• 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)
Death Nonfatal
MI
Short-term Outcomes (4-6 weeks)
Fre
qu
en
cy (
%)
P<.0001
P<.0001
P=.0002
P<.0001
PPCI
Thrombolytictherapy
Recurrent
Ischemia
Death, Nonfatal, Reinfarction,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)
6
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.
De Luca G, et al. Circulation. 2004;109:1223-1225.
Y=2.86 (± 1.45) + 0.0045X1 + 0.000043X2
P<.001
Roughly 1% every 3 minutes
The ambulance arrives
• Acute electrocardiogram
ST-segment Elevation
CallAmbulance
1) Transmission of electrocardiogram from ambulance to STEMI centre (hospital) 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 InitiativeGuidelines Implementation Model
William Wijns, MD, PhD, FESC, FAHA
Co-Founder, Stent for Life InitiativeCo-Director, Cardiovascular Centre, O.L.V.Z. Aalst, Belgium
Reperfusion therapies differ between countries
9286
81 8175 75 72 70 66 64
5949 45 45
35 33 30 30 28 24 23 19 199 8 5
1
0 72 12
53
15
8 1031
1515
40
35
2826
3530
55
25
44
33
41
2945
714 12
17 1320
2515
26 26
10
36 40
15
3039
4435
42
21
52
37
48 50
63
50
0%
10%
20%
30%
40%50%
60%
70%
80%
90%
100%
CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO
P-PCI Thrombolysis 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
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 CountriesBulgaria, Cyprus, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain, Turkey, Ukraine, Bosnia and Herzegovina
SFL Affiliate Countries and Organizations-Siberian Association of Interventional Cardiologists -STEMI INDIA -Emirates Cardiac Society-Saudi Heart Association
SFL Alliances-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 FoundationProfessor 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 regions1. Badajoz, Spain/Portugal2. Daugavpils, Latvia/Lithuania3. Londonderry, N Ireland/Ireland4. Enschede, Netherlands/Germany5. Flensburg, Denmark/Germany6. Kemi, Finland/Sweden7. Komotini, Greece/Bulgaria8. Lille, France/Belgium9. Salzburg, Austria/Germany10. Strasbourg, France/Germany11. Szczecin, Poland/Germany12. Trieste, Italy/Slovenia
Example:Badajoz
Urban areas near border regionsECCF briefing paper, preliminary areas identified
•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•Endorse and support the principle of pPCI networks across Europe•Encourage use of a unified, EU-wide 112 emergency response number•Support coordinated action to raise standards to the level of the best performing Member States
Thank you for your attention!
John Martin: [email protected] Wijns: [email protected]