Framework for a National STEMI Program: consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India.

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of "systems of care" for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, "state-of-the-art" information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.

Stent for Life Initiative: leading example in building STEMI systems of care in emerging countries.

This paper describes the opportunities and challenges in building ST-elevation acute myocardial infarction (STEMI) systems of care in Stent for Life affiliated and collaborating so-called emerging countries, namely India, China, South Africa and Mexico, where CAD mortality is increasing and becoming a significant healthcare problem. The Stent for Life model supports the implementation of ESC STEMI Guidelines in Europe and endeavours to impact on morbidity and mortality by improving services and developing regional STEMI systems of care, whereby STEMI patients' timely access to a primary percutaneous coronary intervention (PPCI) is assured. In India, the STEMI India model incorporates a dual approach of combining PPCI with a pharmacoinvasive strategy of reperfusion. The architecture of the system is based on a hub and spoke model with each unit called a STEMI cluster. The project is driven by a private non-profit organisation. In China, the STEMI PCI programme is led by the Chinese College of Cardiovascular Physicians and supported by the national government. Although primary PCI is performed nationwide, a thrombolytic treatment strategy is still the first option in many rural areas because of logistic considerations. Establishing local STEMI transfer networks and then implementing a pharmacoinvasive strategy of reperfusion are being considered and promoted currently. In South Africa, the pharmacoinvasive approach currently dominates as STEMI treatment option in many areas. A pilot study shows that low symptom awareness leads to long patient delays. The education of all role players, from patients to healthcare professionals and including institutions and governmental structures, is needed to achieve prompt diagnosis and treatment. In Mexico, improving the treatment of STEMI requires considering myocardial infarction to be an emergency that must be treated by an entire system and not just by a particular service. Patients need to receive quick treatment from clinical and interventional cardiologists, and the emergency medical system (EMS) must understand the importance of early reperfusion therapy when appropriate. Mexican health authorities have used registries as their main strategy for improving the use of health resources for ACS patients. In general, building regional STEMI systems of care and an EMS system infrastructure are critical success factors in the stepwise development of STEMI systems of care at a national level in emerging countries as they are in Europe. An in-depth understanding of healthcare system-level barriers to timely and appropriate reperfusion therapy facilitates the development of more effective strategies for improving the quality of STEMI care in each region and country.

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries.

AIMS: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. METHODS AND RESULTS: A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. CONCLUSION: Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

Variable penetration of primary angioplasty in Europe--what determines the implementation rate?

Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). A survey conducted in 2008 in the European Society of Cardiology (ESC) countries reported that the annual incidence of hospital admissions for acute STEMI is around 800 patients per million inhabitants. The survey also showed that STEMI patients' access to reperfusion therapy and the use of PPCI or thrombolytic therapy (TT) vary considerably among countries. Northern, Western and Central Europe already had well-developed PPCI services, offering PPCI to 60-90% of all STEMI patients. Southern Europe and the Balkans were still predominantly using TT and had a higher proportion of patients who were left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients' access to life-saving PPCI and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. The aim of the SFL Initiative is to improve the delivery of life-saving PPCI for STEMI patients. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-PPCI hospitals and PPCI centres is considered to be a critical factor in implementing PPCI services effectively. Better monitoring of STEMI incidence and prospective registration of PPCI in all countries is required to document improvements in health care and to identify areas where further effort is required. Furthermore, studies on potential factors or characteristics that explain the national penetration of PPCI are needed. Such knowledge will be necessary to increase the effectiveness and efficiency of the implementation, and will be the first step in ensuring equal access to PPCI treatment for STEMI patients in Europe. Establishing the delivery of PPCI in an effective, high-quality and timely manner is a great challenge.

Stent for Life: how this initiative began?

The Stent for Life Initiative was founded in September 2008 as a coalition of the European Society of Cardiology, European Association for Percutaneous Cardiovascular Interventions and Eucomed. The aim is to promote the life-saving indications for percutaneous coronary interventions--especially in all forms of acute myocardial infarction. This article describes how this initiative began.

Implementation of primary angioplasty in Europe: stent for life initiative progress report.

AIMS: Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, a 2007 study reported that only 40-45% of European STEMI patients were treated with PPCI, with large variations in treatment availability between countries. In 2008, the Stent for Life (SFL) initiative was launched by the European Association of Percutaneous Cardiovascular Interventions and EuroPCR in partnership with the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care and country-specific national cardiac societies. The aim is to promote the prioritisation of percutaneous coronary intervention treatment towards those who will benefit most, namely STEMI patients. The following countries are currently participating: Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey. METHODS AND RESULTS: Since SFL was launched, several activities have been initiated in the participating countries. Preliminary reports suggest that major increases have been seen in the numbers of PPCI performed, with some countries reporting very significant increases in PPCI use from 2008-2010. Improvements in STEMI mortality rates have also been observed. CONCLUSIONS: This report summarises the progress of the SFL initiative in the 10 target countries.

Status of Stent for Life Initiative across Europe.

Early revascularization with primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) has been shown to reduce mortality, rates of nonfatal reinfarction and stroke, as compared to previous standard of care with thrombolytic therapy. Despite substantial evidence of its effectiveness, the use of PPCI varies considerably across Europe. The Stent for Life Initiative supports implementation of local STEMI treatment guidelines, helps to identify specific barriers to implementation of guidelines and defines actions to make sure that the majority of STEMI patients have access to PPCI. Launching a successful programme for PPCI requires the commitment and collaboration of a broad variety of members of the healthcare system. This narrative review is intended to describe some of the progress already seen in the 10 countries currently included in the Stent for Life Initiative and to report and discuss the engagement of the various stakeholders involved.

La iniciativa Stent for Life en Europa / The Stent-for-Life initiative in Europe

La iniciativa Stent for Life es un proyecto europeo de características únicas, en el que participan cardiólogos intervencionistas, representantes de la administración sanitaria de cada país, miembros de la industria farmacéutica y pacientes. Su objetivo es conseguir que la mayoría de las personas que sufren un infarto agudo de miocardio con elevación del segmento ST tengan un rápido acceso al mejor tratamiento de reperfusión coronaria, que es la intervención coronaria percutánea primaria (ICPp). La iniciativa Stent for Life fue puesta en marcha conjuntamente, en el año 2008, por la European Association of Percutaneous Cardiovascular Interventions y el EuroPCR (www.stentforlife.com). Tiene como misión mejorar la utilización y el acceso de los pacientes a la ICPp en las situaciones en que esta puede salvarles la vida y reducir con ello la morbilidad y la mortalidad de quienes padecen un síndrome coronario agudo. Las distintas estrategias adoptadas por los países integrantes de esta iniciativa pretenden facilitar el acceso de los pacientes a la ICPp. El ideal planteado por esta iniciativa es que se realicen al año 600 ICPp por millón de habitantes e intentar disponer de centros de ICPp con una densidad media de un centro por cada 750.000 habitantes; de esta forma se podría llegar a satisfacer las necesidades de todos sus pacientes con infarto agudo de miocardio con elevación del segmento ST. Los países en que casi todos los centros de ICPp existentes ofrecen servicios ininterrumpidos de ICPp parecen ser los que alcanzan mejores resultados. Sin embargo, en general, hay considerables diferencias en la práctica clínica de este tratamiento en toda Europa, y hay muchas posibilidades de mejorar la asistencia prestada. Una cooperación estrecha entre sociedades nacionales de cardiología, administraciones nacionales, organismos de financiación de la asistencia sanitaria (es decir, compañías de seguros y prestadores de la asistencia sanitaria pública), hospitales, servicios de emergencias médicas y otros organismos relacionados resulta muy eficaz para asegurar que los programas de ICPp se apliquen plenamente y para crear formalmente programas nacionales de ICPp. Hasta la fecha, se han adherido a esta iniciativa diez países europeos por medio de sus respectivas sociedades de cardiología. Las sociedades nacionales de cardiología de Bulgaria, Egipto, Francia, Grecia, Portugal, Serbia, España y Turquía han manifestado también su compromiso con dicha iniciativa. En 2011, 3 años después de la puesta en marcha de la iniciativa Stent for Life, la European Association of Percutaneous Cardiovascular Interventions llevará a cabo un estudio para evaluar y actualizar la situación de la ICPp en Europa (AU)

The Stent-for-Life (SFL) Initiative is a unique European venture that enables interventional cardiologists, government representatives, industry partners and patients to collaborate and ensure that, by shaping health-care systems and medical practices, the majority of patients with ST-elevation myocardial infarction (STEMI) will have equal access to the lifesaving treatment of primary percutaneous coronary intervention (PCI). The SFL Initiative was launched in 2008 by a coalition of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR (www.stentforlife.com). The mission of the SFL Initiative is to improve the delivery of and access to the life-saving indication of PCI, thereby reducing mortality and morbidity in patients with acute coronary syndrome. National primary PCI strategies for STEMI will result in more patients being offered reperfusion therapy. Countries that perform 600 primary PCIs per million population annually and have a mean density of one primary PCI center for every 750,000 inhabitants are able to meet the needs of all their STEMI patients. Countries in which nearly all existing PCI centers offer primary PCI services on a 24-hour basis appear to achieve the best results. Overall, however, there is a substantial variation in practice throughout Europe and there are many opportunities for improving care. Close cooperation between national cardiology societies, national governments, health-care financing organizations (i.e. insurance companies and public health providers), hospitals, emergency medical services and other related bodies is very effective both for ensuring that primary PCI programs are fully implemented and in creating formalized National Cardiology Programs. To date, the SFL Initiative has been introduced into 10 European countries. The national cardiology societies of Bulgaria, Egypt, France, Greece, Portugal, Serbia, Spain and Turkey have all declared a commitment to the Initiative. In 2011, 3 years after the launch of the SFL Initiative, the EAPCI will carry out a survey to assess the use of reperfusion therapy throughout Europe (AU)