The principles of the initiative Stent for Life in Poland: advantages and difficulties of implementing

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Antoni Andrzejewski
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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 Epidemiology of ACS in Poland All ACS 120, ,000/year STEMI 40,000/year NSTE-ACS 80, ,000/year NSTEMI 40,000-50,000/year UA 40,000-50,000/year

5 Some history 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)

6 PCI for acute myocardial infarction (STEMI and NSTEMI) % 45% 50.7% 51.4% 44% % 44.5% 36% 30% 21% % - percentage of PCI procedures for acute myocardial infarction (STEMI and NSTEMI) in relation to all PCIs in the same year year

7 ACS treated invasively in ppci/mln STEMI (39%) NSTEMI (29%) UA (32%) All

8 Epidemiology of ACS in Poland and penetration of PCI All ACS 120, ,000/year ppci STEMI 40,000/year NSTE-ACS 80, ,000/year ppci NSTEMI 40,000-50,000/year PCI UA 40,000-50,000/year PCI

9 ppci for STEMI in 2011 in the Polish regions (numbers per million inhabitants ) POLSKA Zachodniopomorskie Wielkopolskie Warmińsko-Mazurskie Świętokrzyskie Śląskie Pomorskie Podlaskie Podkarpackie Opolskie Mazowieckie Małopolskie Łódzkie Lubuskie Lubelskie Kujawsko-Pomorskie Dolnośląskie

10 DES penetration in PCI for ACS STEMI NSTEMI UA CAD Number of PCI BMS (71%) (60%) (46%) (35%) DES (17%) (25%) (39%) (52%) BMS i DES 678 (2%) 684 (3%) 888 (4%) (4%) POBA (9%) (11%) (11%) (9%)

IIb/IIIa inhibitors in 2011r Abciximab 6.

11 IIb/IIIa inhibitors in 2011r Abciximab (41%) Tirofiban 156 Eptifibatide (58%) All

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 ) POLSKA Zachodniopomorskie Wielkopolskie Warmińsko-Mazurskie Świętokrzyskie Śląskie Pomorskie Podlaskie Podkarpackie Opolskie Mazowieckie Małopolskie Łódzkie Lubuskie Lubelskie Kujawsko-Pomorskie Dolnośląskie

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

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

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

17 LifeNet receiver station at the Institute of Cardiology

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

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

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

Elements of delay 1st contact - balloon All patients, median times in minutes 2-stage transport 70 45 43

23 Elements of delay 1st contact - balloon All patients, median times in minutes 2-stage transport direct transport st 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 Patients form zone 1, median times in minutes 2-stage transport stage transport direct transport direct transport st contact - departure for ICC journey to ICC delay within ICC st contact - departure for ICC journey to ICC delay within ICC Patients from zone 2, median times in minutes Patients from zone 3, median times in minutes 2-stage transport stage transport direct transport direct transport st contact - departure for ICC journey to ICC delay within ICC st contact - departure for ICC journey to ICC delay within ICC

ECG teletransmission and direct transport in Poland - 2008 1 stacja odbiorcza 7 nadajników 1 stacja odbiorcza 12 nadajników 1 stacja odbiorcza 14 nadajników 5 stacji odbiorczych 55 nadajników 2

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

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

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

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

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

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

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

32 7-year follow up of ppci pts ANIN Myocardial Infarction Registry , N=1064

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

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)

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

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!

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