The document proposes new certification requirements for interventional cardiologists in the Czech Republic based on European models. It recommends interventional cardiology become a certified subspecialty after completing cardiology training. The proposed requirements include 1 year of full-time interventional cardiology training, courses, publications, and a final board exam. Accredited centers must have experienced trainers, cath labs, ICU, and imaging. Up to 100 experienced interventional cardiologists could be initially certified without the exam to start the program.

1. Структура «Реперфузионной
Сети» Чешской Республики:
первичное стентирование для
всех STEMI пациентов страны.
Петр Видимский
(г. Прага, Чешская республика)

2. Thrombolysis
(50% success rates
7% reocclusion risk)
Primary PCI
(90% success rates
3% reocclusion risk)
Modern therapy of AMI:
Thrombus removal,
Flow restoration

3. University Hospital Prague - change of AMI treatment
strategy on October 5, 1995:
thrombolysis declared non-lege artis
0
2
4
6
8
10
12
STEMI mortality
1994
1996

4. CZ 1995: STEMI mortality in the real life
according to the hospital type
29
17 17
8
0
5
10
15
20
25
30
In-hospital mortality
Small hospitals
Medium size
hospitals
Tertiary hospitals
without PCI
Tertiary hospitals
with PCI

5. PRAGUE-1: Combined end-
point at 30 days
23%
15%
8%
0
5
10
15
20
25
A B C
+/reMI/stroke

7. VINO Study: primary PCI for non-STEMI
Eur Heart J. 2002 Feb;23(3):230-8.
30days 6months
Invasive
Conserv
7.5%
13.4%
1.6%
3.1%
p<0.05

8. CZECH GUIDELINES FOR STEMI
PCIPCIPCIPain-ECG
3-12 hours
TLPCIPCIPain-ECG
< 3 hours
ECG-PCI
> 90 min.
ECG-PCI
30-90 min.
ECG-PCI
< 30 min.
STEMI
(Cor et Vasa 2002; 44: K123-143)

9. The Czech Soc.of Cardiology guidelines: the
world first guidelines proposing primary PCI
as the default treatment strategy
 2002 Czech Society of Cardiology
 2003 European Society of Cardiology
 2004 American College of Cardiology / American
Heart Association

10. Transport distances to PCI centers (all 22
operating non-stop) in the Czech Republic.

11. Czech STEMI registries 1998 vs 2005: The nationwide
implementation of P-PCI strategy increased the use of ANY
reperfusion therapy from 45% to 93%
7%
55%
38%
TL P-PCI No reperfusion therapy
1%
7%
92%
P-PCI TL No reperfusion therapy

12. Czech STEMI registries 1999 vs 2005: The nationwide
implementation of P-PCI strategy completely abolished
mortality differences between smaller hospitals and tertiary
PCI centers
8
18
0
5
10
15
20
In-hospital mortality
Tertiary PCI centers Hospitals without cath-lab
6,8 6,9
0
5
10
15
20
In-hospital mortality
Tertiary PCI centers Hospitals without cath-lab

13. Optimal workload and outcomes
 PCI center (CZ): >600 PCI’s / year (primary +
elective), >100 primary PCI / year
 Operator >100 PCI / year (for all operators in this
center).
 In-hospital mortality of all primary PCI patients
<10%
 Mortality for Killip class I pts. <3%.

14. All PCI procedures in the Czech Republic
320
1829
9270
16338
21676
22545
21624
0
5000
10000
15000
20000
25000
1990 1995 2000 2002 2004 2009 2013
PCI/rok/ČR
PCI/rok/ČR
PRAGUE-1
1999
PRAGUE-2
2002

15. Primary PCI procedures for STEMI per 1 million inhabit.
0 3
99
726 712
0
100
200
300
400
500
600
700
800
Procedures per million
1990
1994
1998
2004
2005
PRAGUE-1 and -2
results published:
Mean number of primary PCI for STEMI:
381 / year / center
103 / year / operator
CAG: 5830 / mil.
Any PCI: 2170 / mil.
Prim. PCI: 726 / mil.

16. Ko DT et al.
Trends in revascularization
(New York, Ontario)
Circulation. 2010;121:2635-2644
CZ: 216 PCIs / 100 000 inhabit.
CZ: 45 CABGs / 100 000 inhabit.

17. How to set up effective prehospital & interhospital
program for AMI ?
 Wide population knowledge about importance of time and
PCI in the acute phase of AMI.
 Emergency Medical Services: prehospital 12-lead ECG to
every call for chest pain.
 Regional networks: EMS  PCI center  Regional
hospital.
 CAG should be the first examination after ECG.
 PCI centers should keep pts. < 24-48 hours and return
them to their regional hospitals.
 Discharge and post-discharge care should be done by
regional hospital, not by PCI center.

18. How to minimize time delays ?
 Direct transfer first contact - cath-lab ! (Passing nearest hospital,
passing ER or CCU in the PCI center !). This can keep ECG – PCI
time almost always below 90 min.
 Cath-lab has to be prepared during the transport – patient thus
arrives to an empty room with waiting personnel.

19. Primary PCI organization:
 GOLDEN „30 MINUTES RULE“:
 First call – diagnosis < 30 min.
 (Diagnosis in non-PCI hospital - departure < 30
min.)
 Transport duration < 30 min.
 Arrival to cathlab – first balloon inflation < 30 min.
 Interventional cardiologist: call-needle <30min.

20. 52-years, man, first STEMI, Killip
RCA 100%, LAD 90%, OM 80%

21. CZECH-1 centers vs. CZECH-2 centers
CZECH-1: all hospitals in 2 counties
+ all PCI centers in the Czech Republic
CZECH-2: all hospitals in 4 counties.
No other PCI centers.

22. Incidence of acute coronary syndromes
(Widimský P. et al. Int J Cardiol 2007, Toušek P. et al. Int J Cardiol 2014)
Registry CZECH (2005)  CZECH-2 (2012):
• Any form of ACS: 3248  2149 / million / year
• AMI (STEMI + nonSTEMI): 1960  1680 / million
• STEMI: 661  661 / million

23. Stent for Life
Petr Widimský

24. How the Stent for Life initiative began ?
• E-journal of cardiology practice, Vol N°36, May 27, 2008
• www.escardio.org/communities/councils/ccp/e-journal/volume6/Pages/vol6n36.aspx
• ESC Board meeting, London, June 22, 2008:
William Wijns + Petr Widimský defined the goal
• Brussels, September 13, 2008:
The first SFL meeting

26. 92 92
86
81 81
75 75 72 70
66 64
59
49
45 45
35 33 30 30 28 24 23 19 19
9 8 5
0 1
0 7
2 12
5
3
15
8 10
31
15
15
40
35
28
26
35
30
55
25
44
33
41
29
45
8 7
14 12
17 13
20
25
15
26 26
10
36
40
15
30
39
44
35
42
21
52
37
48 50
63
50
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NL 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
Europe 2007
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

27. Only 55 % of EU cardiology centers offer non-stop (24/7) acute PCI services.
NL + CZ: all existing PCI centers must offer 24/7 service.
Aim: to apply the same for all EU.
0
20
40
60
80
100
NL CZ FR BE HU HR PL NO
CH IL DE AT DK IT SK BG
LIT PT SE ES SLO GR UK TR
LAT SRB FIN RO
 55%

28. Population per one primary PCI (24/7) center:
cath-lab geographic density is not important
0,5 – 1,0 million population / p-PCI center is optimal
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 NL HU ES
BG SLO DK LIT SK TR GR UK
 917 614

29. Nationwide „thrombolytic strategy“ for STEMI results in 46%
untreated STEMIs.
Trully nationwide p-PCI strategy (CZ, NL) results in 7% untreated
STEMIs
7
46
0
5
10
15
20
25
30
35
40
45
50
No reperfusion used
NL + CZ
Countries with
thrombolysis
dominance
% from all STEMI

30. ≥600 p-PCI / million / year
400-599 p-PCI / million / year
200-399 p-PCI / million / year
<200 p-PCI / million / year
Data not known
Primary PCI / million / year in 2007

34. 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).

35. 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).

36. 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).

38. Интервенционная кардиология:
ключевая субспециальность в
кардиологии.
Требования к подготовке
специалистов в Чешской республике и
в ЕС
Петр Видимский
(г. Прага, Чешская республика)

39. Board certification system in Czech
Republic and in the EU
A) Basic „stems“ of 2 years duration (e.g. internal
medicine)
B) 43 main specializations of 3-5 years duration (e.g.
cardiology 4 years)
C) 46 certified courses („subspecializations“) of 1-2
years duration on top of main disciplines (e.g. in
future interventional cardiology 1 year after
cardiology – if approved by the MoH)
Training allways only in accredited centers in the
form of full time job !

40. University
Medical Faculty
6 years
Basic stem
Internal medicine
2 years
Main Board
Specialization
Cardiology
4 years
Certified Course
Interventional
Cardiology
1 year

41. • Official proposal from the
Accreditation Board for
Cardiology to the Czech
Minister of Health
• New subspecialty:
Interventional cardiology
per analogiam to existing
interventional radiology

43. Joint proposal of the Accreditation Board for Cardiology &
the Czech Society of Cardiology & Kardio-35 (young
cardiologists organization)
• Cardiac surgery (independent specialty) is currently treating only
25% patients compared to interventional cardiology treating
75% CAD patients
• Interventional radiology is specialty on top of radiology. The
same should exists for interventional cardiology and cardiology.
• Interventional cardiology is practiced by 130 physicians in the
Czech Republic. New specialty will produce approx. 6-8 new
interventional cardiologists per year.
• They perform complex procedures with definite risks without
properly formalized training requirements and board
examinations
• UEMS & ESC 2013 published conditions for cardiology training
and board specialization / certification in Europe and both
documents recommend interventional cardiology as a key
subspecialty on top of cardiology (being baseline specialty).

44. Requirements for interventional
cardiologist – Czech proposal
• Completed board certification CARDIOLOGY
• At least 1-year FULL TIME training in a center
accredited for INTERVENTIONAL cardiology
• Courses on radial protection, hemodynamics and
diagnostic catheterization and interventional
cardiology
• 1 publication (as first author) in peer-reviewed
journal and 1 lecture at annual congress of CSC
• Final board examination from I.C.

45. Practical skills
• Level I.: Selecting the appropriate diagnostic and
therapeutic approach, ability to interpret results. During the
training must see such procedures and may assist these
interventions.
• Level II.: Must assist, but cannot work as first operator.
Must be able to interpret.
• Level III.: Must be able to perform independently as first
operator (incl. indications, interpret results and treat
complications).
• Trainee must have list of all patients and procedures, where
he participated actively with clear definition of his role (first
operator vs. assistance vs. observer). This role must be also
recorded in hospital documentation.

47. Final board examination
• Practical part – analysis of 5 patients: 2 CAGs,
2 hemodynamic exams (L+R cath) and 1
complex or complicated PCI.
• Theoretical part – 1 question from diagnostic
invasive cardiology or from interventional
cardiology.

48. Requirements for accredited center
• At least 2 trainers (interventional cardiologists
with >5 years experience)
• Head of department must be cardiologist
• ICU with unselected full case mix (incl. STEMI,
acute heart failure, resuscitated patients etc.)
• At least 2 cath-labs
• Non-invasive cardiac imaging (echo, CT)
• Cardiac surgery (may be subcontracted in
another hospital)

49. Temporary paragraph: Up to 100 most experienced interventional
cardiologists fullfilling criteria for trainers will be certified initially without
board examination to be able to initiate entire program.

50. This is a proposal, not yet a working program
Not yet approved by the Ministry of Health
(undergoing administrative and inter-
disciplinary discussions)