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, FMedSciChairman, European Critical Care FoundationProfessor of Cardiovascular Medicine, University College LondonAdjunctProfessor of Medicine, Yale University


Overview
Overview to treat acute heart attack patients

  • The science

    • MyocardialInfarction – introduction

    • Best treatment – whatisprimaryangioplasty?

    • Savingheart muscle – the importance of timing

    • Emergency transport and borders

  • Stent for Life Initative Guidelines Implementation Model

    • Inequalitiesacross 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 primaryangioplasty

  • Discussion and Q&A


  • Primary angioplasty explained
    Primary to treat acute heart attack patientsangioplastyexplained

    Arrival

    After balloon

    Balloon

    Open artery

    Closed

    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 to treat acute heart attack patients

    Primary PCI vs. Thrombolysis in ST-Elevation Myocardial Infarction:

    Meta-analysis (23 Randomised controlled trials, N=7,739)

    Short-term Outcomes (4-6 weeks)

    P<.0001

    P<.0001

    PPCI

    Frequency (%)

    Thrombolytictherapy

    P=.0002

    P<.0001

    Death

    Nonfatal

    MI

    Recurrent

    Ischemia

    Death, Nonfatal, Reinfarction,

    or Stroke

    Based on Keeley EC, et al. Lancet. 2003;361:13-20.


    Death at 3 years presentation delay
    Death at 3 years – presentation delay to treat acute heart attack patients

    Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)


    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.

    Roughly 1% every 3 minutes

    Y=2.86 (± 1.45) + 0.0045X1 + 0.000043X2P<.001

    De Luca G, et al. Circulation. 2004;109:1223-1225.


    The ambulance arrives
    The ambulance arrives Mortality—Primary PCI

    • Acute electrocardiogram

    ST-segment Elevation


    Call Mortality—Primary PCI

    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.

    Ambulance


    Borders and access to ppci
    Borders and access to pPCI Mortality—Primary PCI

    Country A Country B


    Stent for Life Initiative Mortality—Primary PCIGuidelines Implementation ModelWilliam Wijns, MD, PhD, FESC, FAHACo-Founder, Stent for Life InitiativeCo-Director, Cardiovascular Centre, O.L.V.Z. Aalst, Belgium


    Reperfusion therapies differ between countries
    Reperfusion therapies differ between countries Mortality—Primary PCI

    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
    Stent for Life Initiative Objectives Mortality—Primary PCI

    • Define regions/countries with an unmet medical need in the optimal treatment of ACS.

    • 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
    SFL Impact on Access to PPCI Mortality—Primary PCI


    Stent for life initiative esc stemi guidelines implementation in countries key learning points
    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
    Stent for Life Initiative Implementation in Countries - Key Learning PointsLeading 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 Implementation in Countries - Key Learning PointsCampaign 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 Implementation in Countries - Key Learning Pointsregions and access to primaryangioplastyJohn Martin, MD, FRCP, FESC, FMedSciChairman, European Critical Care FoundationProfessor of Cardiovascular Medicine, University College LondonAdjunctProfessor of Medicine, Yale University


    Borders and access to ppci1
    Borders and access to pPCI Implementation in Countries - Key Learning Points

    Country A Country B


    Urban areas near border regions
    Urban areas near border regions Implementation in Countries - Key Learning Points

    Badajoz, Spain/Portugal

    Daugavpils, Latvia/Lithuania

    Londonderry, N Ireland/Ireland

    Enschede, Netherlands/Germany

    Flensburg, Denmark/Germany

    Kemi, Finland/Sweden

    Komotini, Greece/Bulgaria

    Lille, France/Belgium

    Salzburg, Austria/Germany

    Strasbourg, France/Germany

    Szczecin, Poland/Germany

    Trieste, Italy/Slovenia


    Example badajoz
    Example:Badajoz Implementation in Countries - Key Learning Points


    Urban areas near border regions1
    Urban areas near border regions Implementation in Countries - Key Learning Points

    • ECCF 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
    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! access to primary angioplasty

    John Martin: [email protected]

    William Wijns: [email protected]


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