BARCELONA, Spain – Where is the best place to have a heart attack in Europe?
The answer will surprise you (see chart, page 8).
Europe has made patchwork progress in extending primary percutaneous coronary intervention (PCI) since 2003, when the European Society of Cardiology (ESC; Sophia Antipolis, France) adopted guidelines recommending timely revascularization in the treatment of ST-elevation acute myocardial infarction (STEMI) over intravenous thrombolytic (TL) therapy for reperfusion.
In other words, the prevalent practice today for treating acute, and urgent, coronary arteries is to send in the Roto-Rooter to reopen plugged pipes instead of washing them with drain cleaner.
Where there may be as many as 10 cath labs operating in most European cities, good luck finding one open if, like half of all people, you are having your heart attack outside of business hours.
To address the uneven access for citizens to urgent primacy PCI, a pan-European program called Stent For Life was launched at EuroPCR, the annual gathering of interventional cardiologists held here recently.
In late June, the heads of cardiology societies from almost 50 countries will respond to the call to action issued during the Presidents Dinner and those agreeing to participate in this bottom-up effort will set up a national task force.
The variations in primary PCI delivery in Europe vary from one country to another.
For example, a patient will more likely have a faster door-to-balloon time in Poland than in the UK.
And access to urgent cardiac intervention also can vary from one region to another within a given country
For example, if you are lucky enough to be in Croatia, you have a better chance of survival doing business in Belgrade than vacationing on the Dalmatian coast.
Only part of the problem is explained by the classic European conundrum of trying to coordinate care among multiple, independent-minded countries with mixed healthcare systems and finances.
And the problem is not a lack of equipment. In fact, Europe has a surprisingly high concentration of cath labs.
The real problem is that in Europe, most cath labs operate only during daylight hours for scheduled, elective procedures.
"Any cath lab that is not open 24/7 should be closed," said Petr Widimsk, MD, of the University Hospital Královské Vinohrady (Prague, Czech Republic), who is the prime mover behind the Stent For Life program.
Told by colleagues that his statement was harsh, Widimský softened his tone in Slavic fashion by saying, "If a cath lab is not open 24/7, it should not receive reimbursement."
William Wijns, MD, who took up Widimský's cause in his final act as outgoing president of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), said he was inspired by the iconoclastic tone that underscores the need to stir up a European cardiology community that he believes has become too comfortable playing with gadgets instead of caring for patients and too cozy with an industry that continues to aggressively promote a stream of new devices (see accompanying sidebar, "Mea culpa of a European cardiac interventionalist").
Wijns, of Cardiovascular Center Aalst (Aalst, Belgium), said the response to Stent For Life was "enthusiastically positive from all stakeholders and a strong coalition was quickly created."
The Stent for Life partnership includes the ESC Working Group on Acute Cardiac Care, EAPCI, and Eucomed (Brussels, Belium), the European trade association for medical device manufacturers that will give industry a voice at the table so that, according to Wijns, "they can help to do the right thing for patients."
A pilot group of six countries, including Bulgaria, France, Greece, Serbia, Spain and Turkey, has already been formed to explore best practices where 24/7 service is offered.
The program's mission is to improve the delivery and patient access to the life saving indications of PCI thereby reducing the mortality and morbidity of patients suffering from acute coronary syndromes.
The specific objectives are to increase the use of primary PCI to more than 70% among all STEMI patients, to achieve primary PCI rates of more than 600 per 1 million inhabitants per year, and to organize 24/7 service networks among PCI centers to assure delivery of care to a population in a given region.
"This is a huge project," Zuzana Kaifoszova, MD, the program director, told Medical Device Daily.
"We are using a bottom-up approach to mobilize countries to commit the energy and resources through their national societies to identify barriers and understand why the situation exists today," she said.
The largest barrier to offering 24/7 PCI is reimbursement, the payment for physicians outside of their working hours, and "We will need to convince governments of the cost-effectiveness of these procedures," said Wijns.
Three reimbursement situations in European countries were described:
• Where PCI-capable hospitals are economically motivated to perform the procedure and the non-PCI hospital receiving the patient does not lose money by transferring that patients. While this ideal condition is the case in many countries, PCI is still not offered optimally due to other issues, such as transportation barriers, staffing and hours of operations.
• Where PCI-capable hospitals are economically motivated to perform the procedure, but non-PCI hospitals are motivated to keep their patients.
• Where PCI-capable hospitals are not economically motivated to perform primary PCI and non-PCI hospitals are motivated to keep STEMI patients.
Wijns said, "All too often we find PCI resources are not targeted at those patients who would benefit the most. Many countries, including my own, have the capacity in place but do not deliver. There are obstacles of all kinds, yet all represent bad reasons for not doing the right thing."
Kaifoszova said that in Europe, "the Netherlands is the pioneer in this area, the first to clinical implementation, the first to show the benefits and the country where primary PCI is practiced at a high volume, as many as 1,500 cases per year in some centers."
She also noted that "Their experience shows a wide public education campaign is essential to success, to teach people that any of us can have an infarct. So we expect to see a lot of work with national governments beyond just reimbursement issues."
According to Wijns, with the six pilot countries, "The nice thing is that we are fortunate to have best practice examples in very different systems, so that everyone will be able to find in these practices something that is applicable within his own country regardless of the specific issues of the healthcare delivery system or the economic situation."