1. Inequalities across Europe in access to primary angioplasty to treat acute heart attack patients -the cross-border dimension- John Martin, MD, FRCP, FESC, FMedSci Chairman, European Critical Care Foundation Professor of Cardiovascular Medicine, University College London Adjunct Professor of Medicine, Yale University

2. Overview The science Myocardial Infarction – introduction Best treatment – what is primary angioplasty? Saving heart muscle – the importance of timing Emergency transport and borders Stent for Life Initative Guidelines Implementation Model Inequalities across Europe in access to best treatment Stent for Life Initiative mission & activities Key learning points and impact ACT NOW. SAVE A LIFE Campaign Border regions and access to primary angioplasty Discussion and Q&A

3. Closed Open artery ArrivalAfter balloon Balloon Primary angioplasty explained Coronary arteries: balloon angioplasty The European Society of Cardiology (ESC) guidelines recommend primary PCI as the preferred treatment whenever it is available within 90-120 minutes of the first medical contact

4. Angioplasty reduces mortality and morbidity Primary PCI vs. Thrombolysis in ST-Elevation Myocardial Infarction: Meta-analysis (23 Randomised controlled trials, N=7,739) DeathNonfatal MI Short-term Outcomes (4-6 weeks) Frequency (%) P <.000 1 P =.000 2 P <.000 1 PPCI Thrombolytic therapy Recurrent Ischemia Death, Nonfatal, Reinfarction, or Stroke Based on Keeley EC, et al. Lancet. 2003;361:13-20.

5. Death at 3 years – presentation delay Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)

6. 6 Time from symptom onset to treatment predicts 1 Year Mortality—Primary PCI The relative risk of 1 year mortality increases by 7.5% for each 30 minute delay. De Luca G, et al. Circulation. 2004;109:1223-1225. Y=2.86 (± 1.45) + 0.0045X 1 + 0.000043X 2 P<.001 Roughly 1% every 3 minutes

7. The ambulance arrives Acute electrocardiogram ST-segment Elevation

8. Call Ambulance 1) Transmission of electrocardiogram from ambulance to STEMI centre (hospital) 2) Hospital doctor makes the STEMI diagnosis and directs the ambulance to the STEMI centre.

9. Borders and access to pPCI Country ACountry B

10. Stent for Life Initiative Guidelines Implementation Model William Wijns, MD, PhD, FESC, FAHA Co-Founder, Stent for Life Initiative Co-Director, Cardiovascular Centre, O.L.V.Z. Aalst, Belgium

11. Reperfusion therapies differ between countries 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

13. Stent for Life Initiative Objectives 1.Define regions/countries with an unmet medical need in the optimal treatment of ACS. 2.Implement an action program to increase patient access to primary PCI where indicated: –To increase the use of primary PCI to more than 70% among all ST segment elevation myocardial infarction patients, –To offer 24/7 service for primary PCI procedures at all invasive facilities to cover the country STEMI population need.

14. SFL Impact on Access to PPCI

15. Stent for Life Initiative: ESC STEMI Guidelines Implementation in Countries - Key Learning Points Integrate SFL into National Cardiology Program Engage all stakeholders e.g. physicians, politicians, payers and patients’ organizations Build Regional Network and Infrastructure (EMS) Establish National ACS/AMI Registry Increase Disease Awareness (Educational campaign to government, payers and lay public)

16. Stent for Life Initiative Leading Example for Other Geographies SFL Member Countries Bulgaria, Cyprus, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain, Turkey, Ukraine, Bosnia and Herzegovina SFL Affiliate Countries and Organizations -Siberian Association of Interventional Cardiologists -STEMI INDIA -Emirates Cardiac Society -Saudi Heart Association SFL Alliances -European Critical Care Foundation -WIN

17. ACT NOW.SAVE A LIFE Campaign Objective Increase awareness of heart attack symptoms and the urgency of treatment among Europeans A key barrier in every country is lack of action to urgently call an ambulance as soon as heart attack symptoms are observed

18. Border regions and access to primary angioplasty John Martin, MD, FRCP, FESC, FMedSci Chairman, European Critical Care Foundation Professor of Cardiovascular Medicine, University College London Adjunct Professor of Medicine, Yale University

19. Borders and access to pPCI Country ACountry B

20. Urban areas near border regions 1.Badajoz, Spain/Portugal 2.Daugavpils, Latvia/Lithuania 3.Londonderry, N Ireland/Ireland 4.Enschede, Netherlands/Germany 5.Flensburg, Denmark/Germany 6.Kemi, Finland/Sweden 7.Komotini, Greece/Bulgaria 8.Lille, France/Belgium 9.Salzburg, Austria/Germany 10.Strasbourg, France/Germany 11.Szczecin, Poland/Germany 12.Trieste, Italy/Slovenia

21. Example:Badajoz

22. Urban areas near border regions ECCF briefing paper, preliminary areas identified Badajoz, Spain/Portugal Szczecin, Poland/Germany Strasbourg, France/Germany Enschede, Netherlands/Germany Flensburg, Denmark/Germany Salzburg, Austria/Germany Kemi, Finland/Sweden Londonderry, N Ireland/Ireland Lille, France/Belgium Trieste, Italy/Slovenia Daugavpils, Latvia/Lithuania Komotini, Greece/Bulgaria

23. Summary - options and ideas for cross border cooperation in access to primary angioplasty Specific to cross-border regions Generate political will based on saving citizens’ heart muscle Establish agreements to minimise delays for patients of border zones to facilitate more rapid access to 24/7 primary angioplasty centres Carry out research and collect additional data to identify border regions which could benefit from greater cross-border collaboration Identify cross-border and regional networks that are already working well and encourage transfer of best practices to other regions Identify and rank criteria necessary for successful cross-border pPCI networks Europe-wide Endorse and support the principle of pPCI networks across Europe Encourage use of a unified, EU-wide 112 emergency response number Support coordinated action to raise standards to the level of the best performing Member States

24. Thank you for your attention! John Martin: J.Martin@ucl.ac.uk William Wijns: William.Wijns@olvz-aalst.be