Киевский Курс по коронарным реваскуляризациям 2012 г.

1. The principles of the initiative
„Stent for Life” in Poland:
advantages and difficulties of
implementing
Maciej Karcz
Institute of Cardiology
Warsaw, Poland

2. Poland
North-eastern Europe
312,000 sq kms (roughly 600 by 600 kms)
Mostly lowlands
38 million inhabitants

3. Deaths in Poland by causes for 10,000
inhabitants (all causes 99,5/10,000)
acute MI = 21,200 deaths per year

4. All ACS 120,000-140,000/year
STEMI
40,000/year
NSTEMI
40,000-50,000/year
Epidemiology of ACS in Poland
NSTE-ACS 80,000-
100,000/year
UA
40,000-
50,000/year

5. •1979 – first mechanical recanalisation of IRA (guidewire
only, no balloon angioplasty) Rentrop et al., Getingen,
Germany
•1983 – first series of balloon angioplasties in acute MI
(preceded or not by intracoronary streptokinse) – Hartzler
et al., Kansas City, USA
•1984 – first PCI in acute MI in Poland – Dąbrowski,
Rużyłło, et al., Institute of Cardiology, Warsaw
•1987 – first cathlab on 24-hour duty – Śląskie Centrum
Chorób Serca, Zabrze (Silesian Centre for Heart Disease)
Some history

6. PCI for acute myocardial infarction
(STEMI and NSTEMI) 2002-2011
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
10200
17211
25773
31236
35392
40329
44354
42966
47977 49057
21%
36%
44.5%
45%
30%
% - percentage of PCI procedures for acute myocardial infarction
(STEMI and NSTEMI) in relation to all PCIs in the same year year
46.7%
50.7%
51.4%
44%
45%

7. ACS treated invasively in 2011
 STEMI 28.060 (39%)
 NSTEMI 20.997 (29%)
 UA 22.649 (32%)
All 71.706
736 pPCI/mln

8. All ACS 120,000-140,000/year
STEMI
40,000/year
NSTEMI
40,000-50,000/year
Epidemiology of ACS in Poland and
penetration of PCI
NSTE-ACS 80,000-
100,000/year
UA
40,000-
50,000/year
28 060 pPCI
20 997 PCI
22 649 PCI
71 706 pPCI

9. pPCI for STEMI in 2011 in the Polish regions
(numbers per million inhabitants )
0 200 400 600 800 1 000
Dolnośląskie
Kujawsko-Pomorskie
Lubelskie
Lubuskie
Łódzkie
Małopolskie
Mazowieckie
Opolskie
Podkarpackie
Podlaskie
Pomorskie
Śląskie
Świętokrzyskie
Warmińsko-Mazurskie
Wielkopolskie
Zachodniopomorskie
POLSKA

10. DES penetration in PCI for ACS
STEMI NSTEMI UA CAD
Number of PCI 28.060 20.997 22.649 37.111
BMS 20.046
(71%)
12.627
(60%)
10.528
(46%)
13.029
(35%)
DES 4.714
(17%)
5.241
(25%)
8.765
(39%)
19.156
(52%)
BMS i DES 678
(2%)
684
(3%)
888
(4%)
1.500
(4%)
POBA 2.539
(9%)
2.265
(11%)
2.382
(11%)
3.440
(9%)

11. IIb/IIIa inhibitors in 2011r
 Abciximab 6.627 (41%)
 Tirofiban 156
 Eptifibatide 9.417 (58%)
All 16.200

12. Who does it?
 Number of Cathlabs– 137
 Number of laboratories that sent data to the national
database SISN PTK– 131 (96%)
 Number of Cathlabs on duty 7 days/24h – 114
 Number of Cathlabs on duty a few days a week– 16
 Number of Cathlabs not on duty – 7
 Number of certificated diagnosticians – 674
 Number of certificated operators – 532
 Number of fellow - 31

13. Cathlabs in 2011 in the Polish regions
(Numbers per million inhabitants )
0 1 2 3 4 5 6
Dolnośląskie
Kujawsko-Pomorskie
Lubelskie
Lubuskie
Łódzkie
Małopolskie
Mazowieckie
Opolskie
Podkarpackie
Podlaskie
Pomorskie
Śląskie
Świętokrzyskie
Warmińsko-Mazurskie
Wielkopolskie
Zachodniopomorskie
POLSKA

14. PolAmiDelay
0-60min
10%
60-90min
16%
90-120min
23%
>120min
51%
pPCI for STEMI in
Mazowsze province in
2007
(n=2 265)
1st contact - balloon

15. Conventional 2-stage transport
of MI patients to primary PCI
home
community hospital
interventional cardiology centre
1st ambulance
2nd ambulance

16. Proposed direct transport
of MI patients to primary PCI
home
community hospital
interventional cardiology centre
1st ambulance
2nd ambulance
ambulance with 12
lead ECG +
teletransmission to
ICC

17. LifeNet receiver station
at the Institute of
Cardiology

20. Algorithm for ambulance staff
who encounter a patient with suspected ACS
Suspected ACS
Transmit ECG to the Interventional Cardiology Centre
Direct transport to the ICC;
aspirin, heparin, clopidogrel
Call interventional cardiologist on duty
12-lead ECG at home
Wait for a call back from the cardiologist on duty
STEMI or highest risk
NSTE-ACS
Transport to the nearest non-
PCI hospital
other NSTE-ACS

21. Percentage of pts with 1st contact-to-balloon times ≤120 minutes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
all patients
2-stage transport direct transport
57%
20%
Δ=+37%

22. Percentage of pts with 1st contact-to-balloon times less than 120
mins in various zones
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
zone 0 zone 1 zone 2 zone 3
2-stage transport direct transport
33%
94%
84%
39%
11% 0%
54%
16%
0-15 kms 20-40 kms 60-80 kms 90-120 kms
Δ=+61% Δ=+45% Δ=+16%Δ=+43%

23. Elements of delay 1st contact - balloon
All patients, median times in minutes
30
70
43
45
40
43
0 30 60 90 120 150 180 210
direct transport
2-stage transport
1st contact - departure for ICC journey to ICC delay within ICC

24. Elements of delay 1st contact – balloon
in various zones
Patients from zone 0, median times in minutes
31
91
9
7
41
37
0 30 60 90 120 150 180 210
direct transport
2-stage transport
1st contact - departure for ICC journey to ICC delay within ICC
Patients form zone 1, median times in minutes
28
68
30
32
39
40
0 30 60 90 120 150 180 210
direct transport
2-stage transport
1st contact - departure for ICC journey to ICC delay within ICC
Patients from zone 2, median times in minutes
30
67
45
45
38
43
0 30 60 90 120 150 180 210
direct transport
2-stage transport
1st contact - departure for ICC journey to ICC delay within ICC
Patients from zone 3, median times in minutes
32
68
76
75
40
47
0 30 60 90 120 150 180 210
direct transport
2-stage transport
1st contact - departure for ICC journey to ICC delay within ICC

25. 5 stacji odbiorczych
55 nadajników
1 stacja odbiorcza
17 nadajników
6 stacji
odbiorczych
59 nadajników
2 stacje odbiorcze
26 nadajników
6 stacji
odbiorczych
93 nadajniki
1 stacja
odbiorcza
14 nadajników
1 stacja odbiorcza
9 nadajników
1 stacja
odbiorcza
34 nadajniki2 stacje odbiorcze
9 nadajników
1 stacja odbiorcza
7 nadajników
1 stacja odbiorcza
12 nadajników
5 nadajników
7 nadajników
3 nadajniki
1 stacja
odbiorcza
19 nadajników
1 stacja odbiorcza
14 nadajników
2 stacje odbiorcz3
17 nadajników
1 stacja odbiorcza
5 nadajników
1 stacja odbiorcza
6 nadajników
3 nadajniki
ECG teletransmission and direct transport in Poland - 2008
1 stacja odbiorcza
7 nadajników
1 stacja
odbiorcza
8 nadajników
1 stacja
odbiorcza
15 nadajników
430 transmitters to 36 receiver stations (total number of ambulances in Poland is 1,400)

26. 5 Lifenetów
64 amb.
1 Lifenet
17 amb.
9 Lifenetów
63 amb.
2 Lifenety
26 amb.
9 Lifenetów
110 amb.
1 Lifenet
16 amb.
1 Lifenet
3 amb.
1 Lifenet
18 amb.
1 Lifenet
7 amb.
1 Lifenet
21 amb. 1 Lifenet
24 amb.
5 amb.
6 amb.
3 Lifenety
19 amb.
1 Lifenet
14 amb.
1 Lifenet
15 amb.
2 Lifenet
7 amb.
1 Lifenet
9 amb.
1 Lifenet
10 amb.
1 Lifenet
14 amb.
1 Lifenet
12 amb.
2 Lifenety
16 amb.
1 Lifenet
5 amb.
1 Lifenet
16 amb.
1 Lifenet
15 amb.
1 Lifenet
14 amb.
1 Lifenet
10 amb.
1 Lifenet
8 amb.
1 Lifenet
5 amb.
1 Lifenet
4 amb.
1 Lifenet
7 amb.
1 Lifenet
5 amb.
1 Lifenet
9 amb.
1 Lifenet
6 amb.
1 Lifenet
11 amb.
1 Lifenet
8 amb.
1 Lifenet
5 amb.
1 Lifenet
4 amb.
1 Lifenet
16 amb.
1 Lifenet
6 amb.
1 Lifenet
6 amb.
1 Lifenet
6 amb.
1 Lifenet
8 amb.
1 Lifenet
13 amb.
1 Lifenet
5 amb.
1 Lifenet
8 amb.
ECG teletransmission and direct transport in Poland – Feb. 2012
841 transmitters to 79 receiver stations (total number of ambulances in Poland is 1,400)

27. - Cathlabs on 24 hr duty
- Other cathlabs
Cathlabs in 2007
100 kms

28. - Cathlabs on 24 hr duty
- Other cathlabs
Cathlabs in 11/2011
100 kms

29. Zintegrowany system telemedyczny Lifenet –
transmisja diagnostycznego badania ekg
z karetek i SOR-ów do pracowni
hemodynamicznych
na Mazowszu
Województwo
Mazowieckie
population: 5,1 mln
area: 35,600 sq km
Instytut Kardiologii „Anin”
Instytut Kardiologii „Spartańska”
Szpital Kliniczny W.U.M. „Banacha”
Pracownie hemodynamiczne z zaznaczonym
obsługiwanym regionem
Rozmieszczenie karetek i SOR-ów uczestniczących w systemie w chwili obecnej
Rawa Maz.
Ryki
Centralny Szpital Kliniczny „Wołoska”
Łuków
Wojewódzki Szpital Specjalistyczny Radom
Radomski Szpital Specjalistyczny Radom
Szpital Specjalistyczny Ostrołęka
Stoczek
31.01.2012
Szpital Specjalistyczny Siedlce
Szpital Wojewódzki Płock
Kolno
Biała Podlaska
Szpital Specjalistyczny Ciechanów
Radzyń
Szpital Grochowski
Wojskowy Instytut Medyczny „Szaserów”
Szpital Bielański
Szpital Zachodni Grodzisk Maz.
Centrum Kardiologii „Józefów
100 kms

30. From pharmacologically assisted early transfer to a
universal primary angioplasty service: the experience of
the Małopolska region
Stent for Life Initiative ;EuroIntervention Supplement
The map of the Malopolska
Region, Poland showing the
geographical distribution of
primary PCI and non-primary
PCI hospitals in 2001

31. From pharmacologically assisted early transfer to a
universal primary angioplasty service: the experience of
the Małopolska region
Stent for Life Initiative ;EuroIntervention Supplement
The map of the Malopolska
Region, Poland showing the
geographical distribution of
primary PCI and non-primary
PCI hospitals in 2012

32. 7-year follow up of pPCI pts
ANIN Myocardial Infarction Registry
02.2001-10.2002,
N=1064

33. no shock (n=1021)
shock (n=43)
7-year follow up of pPCI pts
ANIN Myocardial Infarction Registry

34. Difficulties
•Logistics, regulations of the payer
•Penetration of PCI among ACS patients in critical condition (shock,
pulmonary oedema, resuscitated SCD)
•Time delays (both related to patient and medical services)
•Uncontrolled growth of the number of cathlabs leading to reduction in
procedure volumes per centre
•Relative shortage of operators (it takes more time to have certified
operators than to open another cathlab)
•Lack of strict quality control (to be implemented shortly under the auspices
of Working Group on Cardiovascular Interventions of the Polish Cardiac
Society)

35. Advantages
•Easy access to PCI in ACS throughout whole country, 24/24, 7/7
•High penetration (more 50% of ACS pts treated invasively, in particular ¾
of STEMI pts)
•Growing number of cathlabs, also outside large cities, makes timely access
to PCI in ACS more likely (no hard data on that as yet)
•Excellent short- and long-term results
•A story of success!