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

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40%50%

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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: J.Martin@ucl.ac.ukWilliam Wijns: William.Wijns@olvz-aalst.be