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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

  • 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


After balloon


Open artery


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)

Short-term Outcomes (4-6 weeks)




Frequency (%)









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

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
  • Acute electrocardiogram

ST-segment Elevation



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
Borders and access to pPCI

Country A Country B


Stent for Life InitiativeGuidelines 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

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
  • 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.
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 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
  • 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 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

Country A Country B

urban areas near border regions
Urban areas near border regions

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

urban areas near border regions1
Urban areas near border regions
  • 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!

John Martin:

William Wijns: