Stent for Life Initiative

Zuzana KaifoszovaPetr Widimsky

Symposium Stent for Life Casa del Corazón,Madrid

June 10, 2010

Recommendations Class LOE• PPCI for STEMI (within 2 hours)

• Rescue PCI for failed fibrinolysis (within 12 hours)

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

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

• Urgent PCI for hemodynamically unstable NSTE-ACS (within 2 hours)

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

I

IIa

I

IIa

I

I

A

A

B

A

C

A

ESC Guidelines: PCI for acute CAD

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 InitiativePhase I

Situation Mapping & Data Collection

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

020406080

100120140160

STEMITR PL DE IT GR PT AT ES HU FIN LIT NO SRBHR IL SK CZ SE BE BG LAT SLO FR RO UK

82 / 100 000 inhabitants / year(190 / 100 000 / year for all AMIs)

9286 81 81

75 75 72 70 66 64 5949 45 45

35 33 30 30 28 24 23 19 199 8 5

10 7 2 12

53

15

8 1031

1515

40

3528

2635

30

55

2544

3341

2945

714 12 17 13

20 2515

26 26

10

36 40

15

3039 44

3542

21

52

3748 50

6350

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

Reperfusion Therapies Differ in Countries

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

≥600 p-PCI / million / year400-599 p-PCI / million / year200-399 p-PCI / million / year<200 p-PCI / million / yearData not known

Annual Incidence of Primary PCIs

PCI’s (all) / million / year

0500

100015002000250030003500400045005000

PCI / million / year

CH DE IL LAT NO A IT NL CZ SE BE PL FR DKHU GR FIN SLO ES UK LIT SK TR PT HR SRB BG RO

1871

Primary PCI’s / million / year

0100200300400500600700800900

1000

PCI / million / year

CH DE PL CZ SE HU NO SLO DK IL A LIT IT SKBE HR FR LAT PT ES SRB FIN UK BG GR TR RO

378

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

05

10152025303540

p-PCILIT PL SK CZ HU SLO SE DK HR NO DE CH PT SRBAT BG IT IL BE FR ES UK FIN TR RO LAT GR

20% of all PCIs are p-PCIs for STEMI

Mean population per one PCI center

0200 000400 000600 000800 000

1 000 0001 200 0001 400 0001 600 0001 800 0002 000 000

IT GR CH AT BE FR SE IL ES SLO PLBG TR CZ UK HU DK SRB RO

518 698

Population per one primary PCI (24/7) center

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

FR BE IT IL CZ PL AT SE HU ES BGSLO DK LIT TR GR UK

917 614

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

0

20

40

60

80

100

CZ FR BE HU HR PL NO CH ILDE AT DK IT SK BG LIT PT SEES SLO GR UK TR LAT SRB FIN RO

55%

Number of PCIs does not correlate to Countries’ GDP

Number of primary PCIs does not correlate to Countries’ GDP

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

0102030405060708090

% STEM I arriving via EM S

UKSwedenAustriaCzech Rep.IzraelSerbiaSpainSlovakiaItalyTurkeyG reece

STEMI Mortality per Treatment

9,18,3

4,7

0123456789

10

All STEMI

ThrombolysisPrimary PCI

Nationwide „thrombolytic strategy“ for STEMI results in 46% untreated patients

20

46

05

101520253035404550

No reperfusion used

Countries with p-PCIdominance

Countries withthrombolysisdominance

% from all STEMI

Reperfusion Strategy Paradox

• Most people think, that thrombolysis is a kind of treatment widely available for patients everywhere, while p-PCI is limited in its availability.

• 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 IntiativePhase 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 30-60 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 IntiativePhase 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 InitiativeSpain

SFL National LeaderDr. Manel Sabate