Cardiovascular Diseases in Europe


  Euro Heart Survey and National Registries of Cardiovascular
              Diseases a...
The designations employed and the presentation of the material in this
publication do not imply the expression of any opin...
Contents



Introduction ....................................................................................................
ESC Brochure demo left


Introduction




      Cardiovascular disease is the major cause of                              ...
ESC Brochure demo right


                                                                                                ...
ESC Brochure demo left


Euro Heart Survey Programme




                                                                 ...
ESC Brochure demo right


                                                                         Cardiovascular Mortalit...
Acute Coronary Syndromes
                                                                                                 ...
Acute Coronary Syndromes
    ESC Brochure demo right


                                                                   ...
Acute Coronary Syndromes
                                                                                                 ...
Acute Coronary Syndromes
    ESC Brochure demo right


                                                                   ...
Acute Coronary Syndromes
                                                                                                 ...
Acute Coronary Syndromes
    ESC Brochure demo right


                                                                   ...
ESC Brochure demo left


Euro Heart Survey
Stable Angina Pectoris



                                                     ...
ESC Brochure demo right


                                                                                                ...
Coronary Revascularisation
                                                                                               ...
Coronary Revascularisation
    ESC Brochure demo right


                                                                 ...
Coronary Revascularisation
                                                                                               ...
Coronary Revascularisation
    ESC Brochure demo right


                                                                 ...
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
Cardiovascular Diseases in Europe - Euro Heart Survey
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Transcript of "Cardiovascular Diseases in Europe - Euro Heart Survey"

  1. 1. Cardiovascular Diseases in Europe Euro Heart Survey and National Registries of Cardiovascular Diseases and Patient Management Edited by Wilma Scholte op Reimer, Anselm Gitt, Eric Boersma, Maarten Simoons With contributions from Fernando Áros, Alex Battler, Shlomo Behar, Héctor Bueno, John Cleland, Harry Crijns, Hugo Ector, Kim Fox, Lucas Kappenberger, Michel Komajda, Barbara Mulder, Lars Ryden, Jochen Senges, Alec Vahanian, Lars Wallentin, William Wijns, on behalf of the investigators Sophia Antipolis, France 2004
  2. 2. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Society of Cardiology concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or borders. The names of countries used in this publication are those obtained at the time the original language edition of the book was prepared. Material from this publication may be used with reference to this source: Scholte op Reimer WJM, Gitt AK, Boersma E, Simoons ML (eds.). Cardiovascular Diseases in Europe. Euro Heart Survey and National Registries of Cardiovascular Diseases and Patient Management – 2004. Sophia Antipolis; European Society of Cardiology; 2004. © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  3. 3. Contents Introduction .................................................................................................................................................. 2 Euro Heart Survey Programme .................................................................................................................... 4 Cardiovascular Mortality in Europe............................................................................................................... 5 Euro Heart Survey on Acute Coronary Syndromes ...................................................................................... 6 German Registries of Myocardial Infarction ................................................................................................. 9 Spanish Registries of Acute Coronary Syndromes .................................................................................... 10 Swedish Registry for Cardiac Intensive Care ............................................................................................. 11 Euro Heart Survey on Stable Angina Pectoris............................................................................................ 12 Euro Heart Survey on Diabetes and the Heart ........................................................................................... 13 Euro Heart Survey on Coronary Revascularisation .................................................................................... 14 Coronary Revascularisation in Europe ....................................................................................................... 16 SHAKESPEARE – International PCI Registry ............................................................................................ 17 Euro Heart Survey on Heart Failure ........................................................................................................... 18 Euro Heart Survey on Valvular Heart Disease ........................................................................................... 20 Euro Heart Survey on Adult Congenital Heart Disease.............................................................................. 22 Pacemakers and Implantable Cardioverter Defibrillators ........................................................................... 23 Euro Heart Survey on Atrial Fibrillation ...................................................................................................... 24 Trends in Management and Outcome of AMI Patients in Israel 1992-2002 ............................................... 26 Concluding Remarks .................................................................................................................................. 28 Contributors to the Euro Heart Survey Programme.................................................................................... 30 Contributors to other European Surveys and Registries of ........................................................................ 33 Euro Heart Survey Sponsors...................................................................................................................... 34
  4. 4. ESC Brochure demo left Introduction Cardiovascular disease is the major cause of European, national and local education death and disability in the Western world. programmes have been developed to in- The European Society of Cardiology (ESC) is form physicians about guidelines for patient dedicated to improve health in Europe by re- management. Such education programmes ducing the impact of diseases of the heart are a crucial part of continuing medical edu- and blood vessels. Therefore the ESC sup- cation (CME). ports research in this area. Additionally, the Surveys and registries of clinical prac- ESC has developed a series of guidelines and tice such as the Euro Heart Survey pro- education programmes to improve quality of gramme close the circle. The Euro Heart Sur- care, including prevention, diagnosis and pa- vey programme has been launched by the tient management. The ESC has launched ESC in order to evaluate: the Euro Heart Survey Programme to monitor to which extent clinical practice corre- routine clinical practice. These efforts can be sponds with existing guidelines summarised as a cycle of quality improve- the applicability of evidence based medi- ment. cine the outcome of different strategies for pa- tient management. Research Currently, participation in surveys and registries is largely voluntary, but we envis- Guidelines age that systematic surveys and registries will evolve to become a mandatory part of quality assurance programmes, which may Surveys be requested by national health authorities in Education the near or more distant future. The conduct of national and international registries and surveys would be greatly facili- tated by systematic data collection in clinical practice. Therefore the ESC, in cooperation with the European Union, initiated develop- Guidelines for the practice of cardiology ment of Cardiology Audit and Registration and cardiovascular medicine are established Data Standards (CARDS). Data standards by European experts appointed by the ESC, have been developed for three priority areas: often in collaboration with other international acute coronary care, interventional cardiol- professional organisations. Most guidelines ogy and clinical electrophysiology. Other top- are developed at the European level, and ics will be addressed in the coming years. subsequently adopted by the National Socie- This third ESC report on Cardiovascular ties of Cardiology and related organisations Diseases in Europe, presents some highlights throughout Europe. Guidelines are regularly from the Euro Heart Surveys, as well as updated, to include new findings from clinical other European cardiovascular surveys and studies and basic research. registries over the last five years. 2 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  5. 5. ESC Brochure demo right Introduction Salient findings in this report are: There is still a significant variation in the burden of cardiovascular diseases across the ESC member countries, with low mor- tality in Southern and Western Europe, and high mortality in Eastern Europe. Clinical practice varies significantly among hospitals in Europe, both with regard to patient characteristics and the application of diagnostic and therapeutic measures. A significant and appropriate increase in the use of medication, percutaneous coro- nary procedures, pacemakers, and Im- plantable Cardioverter Defibrillator sys- tems (ICD) was observed. In contrast, the total volume of cardiac surgery procedures stabilised, and the duration of hospitalisa- tion was gradually reduced. The adherence to guidelines for prevention and management of cardiovascular dis- ease did improve, and was associated with improved patient outcome. Yet, in many hospitals these guidelines have only partly been implemented and the adherence to guidelines should be further improved. Quality assurance in medicine is a con- tinuous process and involves many different components. The ESC will continue to pro- mote research, guideline development, edu- cation and a critical review of the practice of cardiology and cardiovascular medicine through surveys and registries. This report is an illustration of this ongoing process. Maarten L. Simoons, MD, FESC Chairman Euro Heart Survey Jean Pierre Bassand, MD, FESC President ESC 2002-2004 Michal Tendera, MD, FESC President ESC 2004-2006 3 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  6. 6. ESC Brochure demo left Euro Heart Survey Programme The European Society of Cardiology launched the Euro Heart Survey programme in 1998. Since then a series of surveys have been completed: 1999 Secondary prevention of coronary ar- tery disease 2000 Heart failure Acute coronary syndromes 2001 Valvular heart disease 2002 Coronary revascularisation EURO HEART S URV EY 2003 Stable angina pectoris PARTI CIPATI NG COUNT RIES Diabetes and the heart 2004 Adult congenital heart disease Atrial fibrillation A second survey on acute coronary syn- dromes is ongoing, while surveys are being planned on acute heart failure, cardiac ar- Patients < 100 rhythmias and indications for the application 100 to 200 200 to 300 of internal cardioverter defibrillator therapy. 300 to 400 400 to 500 Most ESC member countries are currently > 500 participating in the survey programme. In No data fact, the participation in the programme evolved from 47 hospitals and 15 countries participating in 1999 to 182 hospitals and 35 SECO NDARY P REVENTIO N 1999 NUM BER OF PATI ENTS ENROLL ED countries participating in the 2004 survey on atrial fibrillation. In order to achieve a better representa- tion of the practice of cardiology throughout Europe, the number of sites has been in- creased, while the number of patients en- rolled at each site has decreased. In the Patients < 100 coming years participation of additional hos- 100 to 200 200 to 300 pitals and countries will be further facilitated 300 to 400 400 to 500 with online (web based) data entry and stan- > 500 dardised patient record forms. Thus the Euro No data Heart Survey Programme will offer a bench- marking service for quality assurance for all the participating hospitals. AT RIAL FIBRILL ATION 2004 NUM BER OF PATI ENTS ENROLL ED 4 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  7. 7. ESC Brochure demo right Cardiovascular Mortality in Europe Cardiovascular disease is the main cause of Age and gender standardised mortality death in most countries in Europe. Unfortu- nately, major differences remain in cardio- vascular mortality rates between different Nu mb er/tho usand countries with high mortality figures in East- <3 3 to 4 ern Europe, and relatively low mortality fig- 4 to 5 5 to 6 ures in Northern, Western and Southern 6 to 7 7 to 8 Europe. Central and Eastern European coun- >8 No data tries have a cardiovascular mortality rate ranging from 5 per 1,000 inhabitants (Poland) to 9 per 1,000 inhabitants (Bulgaria CARDIOVAS CULAR and Ukraine). This represents a two to three MORT ALIT Y ~ 2001 fold increased risk compared with France, Iceland, Italy, Spain, and The Netherlands, countries with the lowest mortality rates due to cardiovascular diseases (< 3 per 1,000 Age and gender standardised cardiovascular mortality per 1,000 inhabitants inhabitants). 10 Ukraine Trends of age and gender standardised Bulgaria 9 cardiovascular mortality during the 1980- Romania Hungary 8 2002 period show a similar pattern to all Czech Republic 7 Poland cause mortality: down sloping curves in the Greece 6 Germany Nordic, Western and Southern region (except Finland 5 United Kingdom Greece), but stable, or up sloping curves in Sweden 4 Italy Central and Eastern European countries Netherlands 3 Spain (e.g., Bulgaria, Romania, Ukraine). France 2 It should be noted, however, that while 1980 1985 1990 1995 2000 standardised mortality rates continue to de- cline, the crude, non-standardised mortality rates remain approximately stable (e.g., It- Crude cardiovascular mortality aly, Spain, The Netherlands) or even in- per 1,000 inhabitants % crease (e.g., Bulgaria, Greece, Romania, 10 Ukraine Ukraine). Hence, the total burden of cardio- 9 Bulgaria Romania vascular disease remains high, due to the 8 Hungary Czech Republic ageing of the population. 7 Greece Sweden 6 Germany Poland Data Source: 5 Finland Italy WHO mortality database 4 United Kingdom Netherlands 3 Spain France 2 1980 1985 1990 1995 2000 5 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  8. 8. Acute Coronary Syndromes ESC Brochure demo left Euro Heart Survey Acute Coronary Syndromes The Euro Heart Survey on Acute Coronary Syndromes (ACS) was designed to delineate the characteristics, treatments and outcome of ACS patients in Europe, and to compare Patients < 100 adherence to current guidelines. During 100 to 200 200 to 300 2000-2001, 10,484 consecutive patients with 300 to 400 400 to 500 a discharge diagnosis of ACS were enrolled > 500 No data in 103 hospitals from 25 countries. Although guidelines strongly recommend reperfusion therapy in all patients with ST- ACUT E CORONARY SYNDROM ES: elevated myocardial infarction, 44% of pa- NUM BER OF PATI ENTS ENROLL ED tients did not receive this therapy. The most important reason for not providing reperfu- sion therapy was late arrival at the hospital. The majority of patients receiving reperfu- sion therapy were treated with fibrinolytic therapy (65%), while 35% received primary percutaneous coronary intervention (PCI). Perc entage < 40 A large variation in application of 40 to 50 50 to 60 reperfusion therapy was observed between 60 to 70 70 to 80 hospitals and countries, ranging from 8% > 80 No data to 89%. Also the percentage of primary PCI among patients with acute myocardial infarction that received reperfusion ther- PERCENT AG E REP ERFUSIO N T HERAP Y apy varied across hospitals and countries, IN MYO CARDIAL INFARCTIO N with a range from 0% to 84%. In the majority of patients who received reperfusion therapy, the time interval be- tween symptom onset and reperfusion ther- apy exceeded the recommended 30 minutes. In about half of patients, it took more than Perc entage <5 30 minutes after hospital arrival before 5 to 10 10 to 15 thrombolytic therapy was started, while in 15 to 20 about 60% of those referred for primary PCI 20 to 25 No data the treatment delay in hospital was more than the recommended 90 minutes. Mean time from emergency room to start of fibri- nolytic therapy varied among hospitals from PERCENT AG E PRIM ARY PCI AM ONG PATIENTS RECEIVING REP ERF USION T HERAP Y 25 to 90 minutes. 6 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  9. 9. Acute Coronary Syndromes ESC Brochure demo right Euro Heart Survey Acute Coronary Syndromes According to the guidelines, antiplatelet ther- T ime from emergency room to start of apy was prescribed in the large majority of fibrinolytic therapy minutes ACS patients. Although recommended by 300 300 guidelines, beta-blocker therapy was pre- 240 240 scribed less often and varied from 43% to 91% of ACS patients. Similarly, ACE- 180 180 inhibitors were prescribed in only 24% up to 120 82% of patients, while most patients with 120 coronary artery disease do benefit from such 60 60 therapy. 0 In addition, lipid-lowering therapy was 0 1 2 3 4 5 6 7 8 Coun try 12 13 14 15 16 17 18 19 20 9 10 11 being prescribed in 60% on average, ranging from less than 20% to 70% of patients with an acute coronary syndrome (page 8). Mortality rates in ACS patients varied, Antiplatelet therapy at hospital discharge in both for ACS patients with and without ST Acute Coronary Syndromes % elevation. Part of this variation may be re- 100 lated to patient selection in participating hos- 80 pitals. For example, some hospitals may not have included all consecutive patients in the 60 survey. Yet, similar findings were reported 40 by the Swedish registry (page 11). Thirty- day mortality was highest in patients with an 20 undetermined ECG at admission (13%), and in patients with Q-wave myocardial infarction 0 Coun try as discharge diagnosis (11%). These mortal- ity figures are considerably higher than those in recent clinical trials in similar patient populations. Patients in clinical trials in fact Beta-blocker therapy at hospital discharge often represent a low risk subset of the total in Acute Coronary Syndromes % population of patients. 100 80 The Euro Heart Survey on Acute Coronary 60 Syndromes II is currently ongoing. 40 20 0 Coun try 7 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  10. 10. Acute Coronary Syndromes ESC Brochure demo left Euro Heart Survey Acute Coronary Syndromes Publications: Lipid lowering therapy at hospital discharge in Acute Coronary Syndromes Hasdai D, Behar S, Wallentin L, Danchin N, Gitt % AK, Boersma E, Fioretti PM, Simoons ML, Battler A. A 100 prospective survey of the characteristics, treatments and outcomes of patients with Acute Coronary Syndro- 80 mes in Europe and the Mediterranean basin: The Euro 60 Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23:1190-1201. 40 Hasdai D, Lev EI, Behar S, Boyko V, Danchin N, Vahanian A, Battler A. Acute coronary syndromes in 20 patients with pre-existing to severe valvular disease of the heart: lessons form the Euro Heart Survey of Acute 0 Coun try Coronary Syndromes. Eur Heart J 2003;24:623-629. Lev EI, Battler A, Behar S, Porter A, Haim M, Boyko V, Hasdai D. Frequency, characteristics and out- come of acute coronary syndromes—The Euro Heart Survey of Acute Coronary Syndromes experience. A J 30-day mortality in myocardial infarction Cardiol 2003;91;224-227. admitted with ST -elevation Hasdai D, Behar S, Boyko V, Danchin N, Bassand % 50 JP, Battler A. Cardiac biomarkers and acute coronary syndromes – The Euro Heart Survey Acute Coronary 40 Syndromes Experience. Eur Heart J 2003;24:1189- 1194. 30 Hasdai D, Haim M, Behar S, Boyko V, Battler A. Acute Coronary Syndromes in patients with prior cere- 20 brovascular events: lessons from the Euro Heart Survey 10 on Acute Coronary Syndromes. Am Heart J 2003;24:832-838. 0 Hasdai D, Porter A, Rosengren A, Behar S, Boyko Coun try V, Battler A. Effect of gender on outcome of acute co- ronary syndromes. Am J Cardiol 2003;91:1466-1469. Hasdai D, Behar S, Boyko V, Battler A. Treatment modalities of diabetes mellitus and outcomes of acute coronary syndromes. Coronary Artery Disease 30-day mortality in Acute Coronary 2004;15:129-135. Syndromes admitted without ST -elevation % Haim M, Battler A, Behar S, Boyko V, Fioretti PM, 50 Hasdai D. Acute coronary syndromes complicated by 40 symptomatic and asymptomatic heart failure. Does cur- rent treatment comply with guidelines? Am Heart J 30 2004;147:859-864. Rosengren A, Wallentin L, Gitt AK, Behar S, Batt- 20 ler A, Hasdai D. Sex, age and clinical presentation of acute coronary syndromes. Eur Heart J 2004;25:663- 10 670. 0 Coun try 8 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  11. 11. Acute Coronary Syndromes ESC Brochure demo right German Registries of Myocardial Infarction Since 1994 several prospective multicenter Acute Reperfusion of STEMI registries on acute myocardial infarction Development 1994-2002 % (MITRA 1+2, MIR 1+2, ACOS) have been 100 n=36523 conducted in Germany to document patient p<0.001 for trend characteristics, acute treatment as well as 80 hospital and long-term outcome in clinical 60 practice. 40 To close the circle between existing guidelines and clinical practice all registries 20 used regular benchmarking reports to give 0 feedback to the participating centers for 1994-95 1996-97 1998-99 2000-02 M ITRA, ACOS, M IR 1 quality control. The patient characteristics of the consecutive patients with myocardial in- farction did not change between 1994 and 2002. However, the administration of acute Adjunctive Tx for STEM I reperfusion therapy for ST-elevation myocar- - Acute Phase - dial infarction improved from 49% to 72% of Combination Therapy (Number of Drug s) % all consecutive patients. In addition, the Antiplatelet / BB / ACE-I / Statin n=36523 60 acute adjunctive therapy with antiplatelet p<0.001 for trend drugs, beta-blockers, ACE-inhibitors and 40 statins significantly improved within the years. 20 Associated with the improvement of acute treatment of ST-elevation myocardial infarc- 0 tion in clinical practice according to existing 1994-95 1996-97 1998-99 2000-02 guidelines, a significant reduction of hospital No of Drug s 0 1 2 3 4 M ITRA, ACOS, M IR 1 mortality from initially 16.2% in 1994 to 9.9% in 2002 was observed. Hospital Mortality of STEM I Data Source: Development 1994-2002 % MITRA-Plus; MI Research Institute Ludwig- 20 shafen, Germany p<0.001 for trend 15 n=36523 10 5 0 1994-95 1996-97 1998-99 2000-02 M ITRA, ACOS, M IR 1 9 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  12. 12. Acute Coronary Syndromes ESC Brochure demo left Spanish Registries of Acute Coronary Syndromes Variability in use of diagnostic studies The data presented are from two Spanish in Non ST Elevation Acute Coronary Syndromes registries: DESCARTES and PRIAMHO II. 100 % DESCARTES (Descripción del Estado de los 90 Average use Síndromes Coronarios Agudos en un Registro 80 Temporal Español) is a nation-wide prospec- 70 60 tive register of 2,017 consecutive non ST- 50 elevated ACS patients, enrolled during 2002 40 in 55 randomly selected hospitals. PRIAMHO 30 20 II (The Proyecto de Registro de IAM Hospita- 10 larios) includes 6,221 consecutive patients 0 Troponins Lipid Echo Non- Early PCI CABG from 58 hospitals with a Coronary Care Unit profile invas ive Cath test D ESC AR TE S in 2000. Both studies show a significant variation in diagnostic and therapeutic procedures Variability in treatment among participating hospitals. A typical ex- in Non ST Elevation Acute Coronary Syndromes ample is the application of cardiac troponin % 100 measurements. Cardiac troponin measure- 90 ments are the gold standard for the detec- 80 tion of myocardial necrosis (evidence of 70 60 myocardial infarction), and these measures 50 were applied in 85% of patients on average. 40 However, there were hospitals in which car- 30 20 diac troponin was measured in only 10% of Average use 10 patients, whereas other hospitals applied the 0 ASA He parin Clopi- GP B- ACE-I* Statin* measurement in all patients. Another exam- dogre l IIb/IIIa blocker * In patients with indication Inh. D ESC AR TE S ple is the application of percutaneous coro- nary intervention (PCI) in ACS patients with- out ST elevation, which varied from 5% to Variability in treatment 55%. In patients with ST segment elevation in ST Elevation Myocardial Infarction myocardial infarction, the application of fibri- % 100 Average use nolytic therapy ranged from 10% to 60%, 90 80 while primary PCI was performed in 0% to 70 30% of patients. 60 50 40 Publications: 30 20 Arós F, Cuñat J, Loma-Osorio A, Torrado E, Bosch X, 10 Rodríguez J, Bescós L, Ancillo P, Pabón P, Heras M, Mar- 0 rugat J, on behalf of the investigators of the PRIAMHO II Fibrino- Prim ary ASA B-blockers ACE-I Lipid-lowering lys is pe rfus ion C ICU Discharge C ICU D ischarge CICU D ischarg eCICU D ischarg e study. Management of Myocardial Infarction in Spain in PR IAMH O II the Year 2000. The PRIAMHO II Study. Rev Esp Cardiol 2003;56:1165-1173. 10 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  13. 13. Acute Coronary Syndromes ESC Brochure demo right Swedish Registry for Cardiac Intensive Care The purpose of RIKS-HIA, the Register of Reperfu sion treatment Information and Knowledge about Swedish in ST-elevation myocardial infarction. Heart Intensive care Admissions, is to im- Sw edish Registry 2002. prove acute coronary care through continu- ous information about need of care, therapy and results of therapy and changes within a hospital as well as in comparison with other hospitals. In 2002 there were 70 participat- ing hospitals, which covered 95% of all pa- tients admitted to a coronary care unit in Sweden. Data with regard to myocardial infarction show a similar situation as observed in Spain: a large variability exists in baseline characteristics, patient management and outcome between the participating sites. For Median (95% confidence interval) time from emergency room to start of fibrinolytic therapy. example, the interval between patient arrival Swedish Registry 2002. in the hospital and the initiation of fibri- nolytic therapy varied from 20 minutes in some hospitals to more than 1 hour in oth- ers. Again 30-day mortality varied from less than 5% to about 15%. Interestingly, the type of hospital and the number of patients treated seems to be importantly associated with differences in patient management. Outcome was better in larger hospitals, with invasive facilities, treating a high number of patients. The results of the RIKS-HIA registry were 30-day mortality in myocardial infarc tion similar to the Euro Heart Survey (page 6-8). Swedish Registry 2002 For example, under-treatment with reperfu- sion therapy was observed in 40% of pa- tients, and the median delay time between onset of chest pain and start of fibrinolytic therapy was 2-2.5 hours on average, and until start of direct PCI 3.5 hours. Data Source: Stenestrand U, Wallentin L. RIKS-HIA report 2002. 11 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  14. 14. ESC Brochure demo left Euro Heart Survey Stable Angina Pectoris The Euro Heart Survey on Stable Angina Pec- toris (2003) included 3,779 ambulatory pa- tients from 36 countries, presenting to a car- diologist as an outpatient. The population Patients < 100 consisted of patients at new presentation to 100 to 200 200 to 300 a cardiologist in whom a diagnosis was made 300 to 400 400 to 500 of stable angina, caused by myocardial is- > 500 No data chaemia due to coronary disease based on clinical assessment, and who did not have unstable angina. The 197 participating hospi- tals were a mix of hospitals with non- STABL E ANGINA PECT ORIS: NUM BER OF PATI ENTS ENROLL ED invasive diagnostic facilities only (33%), with both non-invasive and invasive cardiology facilities (19%), and hospitals that had, in addition to a catheterization laboratory, car- Medical therapy in patients newly presenting diac surgery facilities on site (31%). with stable angina pectoris % After assessment by a cardiologist, the 100 majority of patients (81%) were taking or 80 were prescribed on an antiplatelet agent. 60 However, percentages of patients treated with antiplatelet drugs ranged from 44% to 40 100% between countries. In all, 48% were 20 on statin treatment, 67% were receiving 0 beta-blockers, 61% were on a nitrate, 27% Antiplatelets Statin B-blockers Nitrates Ca- ACE- I were taking a calcium channel blocker, and blockers 40% were using ACE-inhibitors. Although there remains room for further improve- ment, these figures compare favourably with Anti-anginal drugs per patient the 1999 survey on secondary prevention. in patients with newly presenting stable angina pectoris The majority of patients (59%) were on % by European region 60 two or more anti-anginal drugs after assess- 50 ment by a cardiologist, and 13% on no anti- anginal drug. The number of anti anginal 40 drugs per patient did not differ significantly 30 between males and females, but did increase 20 with age up to 70 years. 10 0 North West Central Mediterranean Overall No of Drugs 0 1 2 >2 12 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  15. 15. ESC Brochure demo right Euro Heart Survey Diabetes and the Heart The Euro Heart Survey on Diabetes and the Heart was carried out in 2003. The survey included 4,961 patients from 110 hospitals in 25 countries. Included patients were referred Patients to a cardiologist due to coronary artery dis- < 100 100 to 200 ease out of whom 2,107 (43%) were admit- 200 to 300 300 to 400 ted on acute basis and 2,854 (57%) had sta- 400 to 500 > 500 ble coronary artery disease. An oral glucose No data tolerance test (OGTT) was recommended by the protocol and gluco-metabolic characteri- zation performed according to present WHO DIABET ES AND T HE HEART : recommendations. NUM BER OF PATI ENTS ENROLL ED The survey revealed that diabetes is known to be present in about a third of pa- tients with coronary artery disease: 29% in Prevalence of abnormal glucose regulation acute patients and 34% in patients with a in patients with a cute coronary arte ry disease stable cardiac condition. In addition, when an oral glucose tolerance test was performed Normal Known diabetes in patients with acute coronary artery dis- ease, another 15% of patients were shown to have diabetes that was not yet recog- nised. In patients with stable coronary artery disease the corresponding proportion was Impaired Newly 10%. Furthermore, in both acute and stable glucose Impaired detected cardiac patients, about a third had abnormal tolerance fasting diabetes glucose fasting glucose or impaired glucose toler- ance. Thus, the majority of patients with acute or chronic coronary disease have an abnormal glucose metabolism. Since several Prevalence of abnormal glucose regulation studies have shown that such patients do in patients with stable coronary artery disease have impaired outcome, systematic screen- ing for abnormal glucose metabolism seems Known diabetes Normal appropriate. Publications: Bartnik M, Rydén L, Ferrari R, Malmberg K, Pyörälä k, Newly detected Simoons M, Standl E, Soler-Soler J, Öhrvik J, on behalf diabetes of the Euro Heart Survey Investigators. The prevalence Impaired Impaired of abnormal glucose regulation in patients with coronary glucose fasting artery disease across Europe (Eur Heart J, in press). tolerance glucose 13 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  16. 16. Coronary Revascularisation ESC Brochure demo left Euro Heart Survey Coronary Revascularisation The Euro Heart Survey on Coronary Revas- cularisation included consecutive patients who presented for coronary angiography and had significant coronary disease (any steno- Patients < 100 sis over 50% in diameter). In 2000-2001, 100 to 200 200 to 300 over 8,000 procedures were screened and 300 to 400 400 to 500 5,767 cases were included from 132 hospi- > 500 No data tals of 31 ESC member countries. Coronary revascularisation is recom- mended for patients with stable and unstable CO RO NARY REV ASCUL ARISATIO N: coronary disease to relieve anginal symp- NUM BER OF PATI ENTS ENROLL ED toms, to retard disease progression, and to prevent death or myocardial infarction. In patients presenting with evolving myocardial infarction, immediate coronary revascularisa- Treatment of patients with stenosis > 50% tion by means of a ‘primary’ percutaneous 100% intervention (PCI) is nowadays considered the best treatment option, as it is more ef- 80% fective and safer than fibrinolysis. In clinical 60% practice, however, indications for revascu- larisation are determined as much by avail- 40% ability as by risk assessment. The percent- 20% age of invasive (PCI and CABG) and non- 0% invasive treatment in patients with a stenose Ho spi tal over 50% varied largely across hospitals. PCI CABG Non-Invasive In patients undergoing PCI for acute coronary syndromes, GP IIb/IIIa receptor blockers are recommended by guidelines. A GP IIb/IIIa inhibitors in PCI patients large variation (from 0% to 100%) between % hospitals was observed in the percentage of 100 PCI patients in which GP IIb/IIIa blockers 80 were prescribed. 60 40 20 0 Ho spi tal 14 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  17. 17. Coronary Revascularisation ESC Brochure demo right Euro Heart Survey Coronary Revascularisation One-year mortality and reported quality of 1-year mortality life of patients varied. Average mortality was in patients with stenosis > 50% % 4.9% and ranged from 0% to 20% between 50 hospitals. 40 Quality of life was assessed with the Eu- roqol 5D, a standardised quality of life meas- 30 ure. An Euroqol score of zero indicates a 20 situation comparable to death from a society perspective, and the best possible score is 1. 10 After 30-days, patients who underwent CABG 0 had the lowest Euroqol score whereas PCI Ho spi tal patients perceived the best quality of life, which is comparable to quality of life levels of their age counterparts in the general population. The lower score after CABG re- Quality of life after 30 days and 1 year flects the prolonged recovery period after Euroqol total score Best possible score major surgery. After one year, a consider- 1 able improvement was observed in the CABG 0.9 group, up to the level of the PCI group. The PCI group remained at a high Euroqol quality 0.8 of life score, while quality of life of patients 0.7 in the non-invasively treated group wors- 0.6 ened. 0.5 Half of all patients, and especially those 30 days 1 year who did not undergo an invasive treatment PCI CABG Non-Invasive (59%), indicated one or more problems with respect to mobility, self-care, activity, dis- comfort/pain, or anxiety/depression. Almost half of the medically treated patients (45%) Quality of life after 1 year Patie nts indicat ing p ro blems per t reatment g roup experienced problems with respect to pain % 50 and discomfort, as compared to 30% in the PCI and CABG group. 40 30 20 10 0 Mobility Selfcare Activity Discomfort Anxiety Pain Depression PCI CABG Non-Invasive 15 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  18. 18. Coronary Revascularisation ESC Brochure demo left Coronary Revascularisation in Europe Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting have been developed to treat symptoms of patients PCI per m illion inhabitants with manifest coronary artery disease. To < 300 300 to 600 date, percutaneous coronary interventions 600 to 900 900 to 1200 (PCI) have a wide indication. Whereas some 1200 to 1500 1500 to 1800 years ago surgery was the dominant thera- > 1800 No data peutic option, nowadays most patients are eligible for percutaneous treatment. This in- cludes patients with multivessel coronary disease. Accordingly, increasing annual vol- PERCUT ANEOUS CO RO NARY INTERV ENTIONS ~ 2000 umes of percutaneous interventions and sta- bilising levels of coronary surgery are ob- served in most European countries. Ger- many, The Netherlands and Sweden are il- T ime trends in the annual use of PCI numbers per 1 million inhabitants lustrative examples. Currently, high annual 2500 levels of percutaneous interventions are ob- Germany served in Belgium, Denmark, Germany, Ice- 2000 France Netherlands land, Israel, and Switzerland (over 1500 PCI 1500 Italy Finland procedures per 1 million inhabitants). Most Sweden other Northern, Western, and Southern Czech Republic 1000 United Kingdom countries have intermediate levels, whereas Spain Poland the Central European countries often have 500 Hungary Romania annual levels below 300 PCI procedures per 0 million inhabitants. 1980 1985 1990 1995 2000 Data source: National Cardiac Society Reports T ime trends in the annual use of CABG numbers per 1 million inhabitants 2500 Germany 2000 Sweden Netherlands Finland 1500 France United Kingdom Italy 1000 Czech Republic Hungary Spain 500 Poland Romania 0 1980 1985 1990 1995 2000 16 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004
  19. 19. Coronary Revascularisation ESC Brochure demo right SHAKESPEARE International PCI Registry Between Feb 2002 and Feb 2003, 12,400 PCI for ACS consecutive patients undergoing a percuta- Use of GP IIb/IIIa % neous coronary intervention (PCI) in 30 cen- 50 ns ters in France, Germany, Israel, Italy, Po- 40 land, Portugal and the UK were enrolled in the SHAKESPEARE Registry to document pa- 30 ns tient characteristics, procedural data as well 20 ns as outcome in clinical practice. ns 10 Data from randomised controlled trials 0 provide evidence that especially diabetics GP IIb/IIIa Abciximab Eptifibatide Tirofiban with acute coronary syndromes (ACS) under- Diabetics Non-Diabetics going PCI benefit from the use of GP IIb/IIIa receptor blockers (GP IIb/IIIa). Two thirds underwent PCI for ACS of whom 23% had known diabetes. Less than half of these dia- PCI for ACS betics received GP IIb/IIIa during PCI, De- Reason for GP IIb/IIIa-Use % Statement of the Interventional Cardiologist spite the evidence of an improved outcome 80 in especially diabetics, the frequency of GP p<0.001 IIb/IIIa use during PCI for ACS was not dif- 60 ferent from that in non-diabetics in clinical 40 practice, although diabetics had more often p<0.001 ns ns been identified as high risk patients by the 20 interventional cardiologists. 0 ACS Pt considered Difficult PCI Others Independent determinants for the use of high risk GP IIb/IIIa during PCI for ACS in clinical Diabetics Non-Diabetics practice were cardiogenic shock, multivessel PCI and male gender. Determinants against GP IIb/IIIa were age >70 years and history of stroke. Known diabetes did not influence Determinants of GP IIb/IIIa in PCI for ACS the decision for the use of GP IIb/IIIa in Multivariate Analysis clinical practice. Card Shock Multives s el PCI Stenting Source: Male Gender Diabetes Gitt et al., ESC 2004, Munich (Abstract) Prior CABG Heart Failure MI Research Institute Ludwigshafen, Hypertension Germany Prior MI Prior PCI Age > 70 y Prior Stroke 0 0,5 1 1,5 2 2,5 Contra GP IIb/IIIa <OR> Pro GP IIb/IIIa 17 © European Society of Cardiology— Cardiovascular Diseases in Europe—2004

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