Cardiovascular Diseases in Europe - Euro Heart Survey

Cardiovascular Diseases in Europe

Euro Heart Survey and National Registries of Cardiovascular Diseases and Patient Management

Edited by Wilma Scholte op Reimer, Anselm Gitt, Eric Boersma, Maarten Simoons

With contributions from Fernando Áros, Alex Battler, Shlomo Behar, Héctor Bueno, John Cleland, Harry Crijns, Hugo Ector, Kim Fox, Lucas Kappenberger, Michel Komajda, Barbara Mulder, Lars

Ryden, Jochen Senges, Alec Vahanian, Lars Wallentin, William Wijns, on behalf of the investigators

Sophia Antipolis, France 2004

The designations employed and the presentation of the material in thispublication do not imply the expression of any opinion whatsoever on thepart of the European Society of Cardiology concerning the legal status ofany country, territory, city or area or of its authorities, or concerning thedelimitation of its frontiers or borders. The names of countries used inthis publication are those obtained at the time the original languageedition of the book was prepared.

Material from this publication may be used with reference to this source: Scholte op Reimer WJM, Gitt AK, Boersma E, Simoons ML (eds.).Cardiovascular Diseases in Europe. Euro Heart Survey and NationalRegistries of Cardiovascular Diseases and Patient Management – 2004.Sophia Antipolis; European Society of Cardiology; 2004.

© European Society of Cardiology— Cardiovascular Diseases in Europe—2004

Contents

Introduction .................................................................................................................................................. 2

Euro Heart Survey Programme .................................................................................................................... 4

Cardiovascular Mortality in Europe............................................................................................................... 5

Euro Heart Survey on Acute Coronary Syndromes...................................................................................... 6

German Registries of Myocardial Infarction ................................................................................................. 9

Spanish Registries of Acute Coronary Syndromes .................................................................................... 10

Swedish Registry for Cardiac Intensive Care ............................................................................................. 11

Euro Heart Survey on Stable Angina Pectoris............................................................................................ 12

Euro Heart Survey on Diabetes and the Heart ........................................................................................... 13

Euro Heart Survey on Coronary Revascularisation.................................................................................... 14

Coronary Revascularisation in Europe ....................................................................................................... 16

SHAKESPEARE – International PCI Registry............................................................................................ 17

Euro Heart Survey on Heart Failure ........................................................................................................... 18

Euro Heart Survey on Valvular Heart Disease ........................................................................................... 20

Euro Heart Survey on Adult Congenital Heart Disease.............................................................................. 22

Pacemakers and Implantable Cardioverter Defibrillators ........................................................................... 23

Euro Heart Survey on Atrial Fibrillation ...................................................................................................... 24

Trends in Management and Outcome of AMI Patients in Israel 1992-2002............................................... 26

Concluding Remarks .................................................................................................................................. 28

Contributors to the Euro Heart Survey Programme.................................................................................... 30

Contributors to other European Surveys and Registries of ........................................................................ 33

Euro Heart Survey Sponsors...................................................................................................................... 34

ESC Brochure demo left


2

Cardiovascular disease is the major cause of death and disability in the Western world. The European Society of Cardiology (ESC) is dedicated to improve health in Europe by re-ducing the impact of diseases of the heart and blood vessels. Therefore the ESC sup-ports research in this area. Additionally, the ESC has developed a series of guidelines and education programmes to improve quality of care, including prevention, diagnosis and pa-tient management. The ESC has launched the Euro Heart Survey Programme to monitor routine clinical practice. These efforts can be summarised as a cycle of quality improve-ment.

Guidelines for the practice of cardiology and cardiovascular medicine are established by European experts appointed by the ESC, often in collaboration with other international professional organisations. Most guidelines are developed at the European level, and subsequently adopted by the National Socie-ties of Cardiology and related organisations throughout Europe. Guidelines are regularly updated, to include new findings from clinical studies and basic research.

European, national and local education

programmes have been developed to in-form physicians about guidelines for patient management. Such education programmes are a crucial part of continuing medical edu-cation (CME).

Surveys and registries of clinical prac-tice such as the Euro Heart Survey pro-gramme close the circle. The Euro Heart Sur-vey programme has been launched by the ESC in order to evaluate:

to which extent clinical practice corre-sponds with existing guidelines

the applicability of evidence based medi-cine

the outcome of different strategies for pa-tient management.

Currently, participation in surveys and registries is largely voluntary, but we envis-age that systematic surveys and registries will evolve to become a mandatory part of quality assurance programmes, which may be requested by national health authorities in the near or more distant future.

The conduct of national and international registries and surveys would be greatly facili-tated by systematic data collection in clinical practice. Therefore the ESC, in cooperation with the European Union, initiated develop-ment of Cardiology Audit and Registration Data Standards (CARDS). Data standards have been developed for three priority areas: acute coronary care, interventional cardiol-ogy and clinical electrophysiology. Other top-ics will be addressed in the coming years.

This third ESC report on Cardiovascular Diseases in Europe, presents some highlights from the Euro Heart Surveys, as well as other European cardiovascular surveys and registries over the last five years.

EducationEducation

GuidelinesGuidelines

Surveys Surveys

ResearchResearch

Introduction

ESC Brochure demo right

3


Salient findings in this report are:

There is still a significant variation in the burden of cardiovascular diseases across the ESC member countries, with low mor-tality in Southern and Western Europe, and high mortality in Eastern Europe.

Clinical practice varies significantly among hospitals in Europe, both with regard to patient characteristics and the application of diagnostic and therapeutic measures.

A significant and appropriate increase in the use of medication, percutaneous coro-nary procedures, pacemakers, and Im-plantable Cardioverter Defibrillator sys-tems (ICD) was observed. In contrast, the total volume of cardiac surgery procedures stabilised, and the duration of hospitalisa-tion was gradually reduced.

The adherence to guidelines for prevention and management of cardiovascular dis-ease did improve, and was associated with improved patient outcome. Yet, in many hospitals these guidelines have only partly been implemented and the adherence to guidelines should be further improved.

Quality assurance in medicine is a con-tinuous process and involves many different components. The ESC will continue to pro-mote research, guideline development, edu-cation and a critical review of the practice of cardiology and cardiovascular medicine through surveys and registries. This report is an illustration of this ongoing process.

Maarten L. Simoons, MD, FESC

Chairman Euro Heart Survey

Jean Pierre Bassand, MD, FESC

President ESC 2002-2004

Michal Tendera, MD, FESC

President ESC 2004-2006

Introduction



4

Euro Heart Survey Programme

The European Society of Cardiology launched the Euro Heart Survey programme in 1998. Since then a series of surveys have been completed:

1999 Secondary prevention of coronary ar-tery disease

2000 Heart failure

Acute coronary syndromes

2001 Valvular heart disease

2002 Coronary revascularisation

2003 Stable angina pectoris

Diabetes and the heart

2004 Adult congenital heart disease

Atrial fibrillation

A second survey on acute coronary syn-dromes is ongoing, while surveys are being planned on acute heart failure, cardiac ar-rhythmias and indications for the application of internal cardioverter defibrillator therapy.

Most ESC member countries are currently participating in the survey programme. In fact, the participation in the programme evolved from 47 hospitals and 15 countries participating in 1999 to 182 hospitals and 35 countries participating in the 2004 survey on atrial fibrillation.

In order to achieve a better representa-tion of the practice of cardiology throughout Europe, the number of sites has been in-creased, while the number of patients en-rolled at each site has decreased. In the coming years participation of additional hos-pitals and countries will be further facilitated with online (web based) data entry and stan-dardised patient record forms. Thus the Euro Heart Survey Programme will offer a bench-marking service for quality assurance for all the participating hospitals.

EURO HEART S URV EY

PARTI CIPATING COUNTRIES

SECONDARY P REVENTION 1999

NUM BER OF PATIENTS ENROLLED

300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

ATRIAL FIBRILLATION 2004


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients


5


Cardiovascular disease is the main cause of death in most countries in Europe. Unfortu-nately, major differences remain in cardio-vascular mortality rates between different countries with high mortality figures in East-ern Europe, and relatively low mortality fig-ures in Northern, Western and Southern Europe. Central and Eastern European coun-tries have a cardiovascular mortality rate ranging from 5 per 1,000 inhabitants (Poland) to 9 per 1,000 inhabitants (Bulgaria and Ukraine). This represents a two to three fold increased risk compared with France, Iceland, Italy, Spain, and The Netherlands, countries with the lowest mortality rates due to cardiovascular diseases (< 3 per 1,000 inhabitants).

Trends of age and gender standardised cardiovascular mortality during the 1980-2002 period show a similar pattern to all cause mortality: down sloping curves in the Nordic, Western and Southern region (except Greece), but stable, or up sloping curves in Central and Eastern European countries (e.g., Bulgaria, Romania, Ukraine).

It should be noted, however, that while standardised mortality rates continue to de-cline, the crude, non-standardised mortality rates remain approximately stable (e.g., It-aly, Spain, The Netherlands) or even in-crease (e.g., Bulgaria, Greece, Romania, Ukraine). Hence, the total burden of cardio-vascular disease remains high, due to the ageing of the population.

Data Source:

WHO mortality database

Cardiovascular Mortality in Europe

CARDIOVAS CULAR

MORTALITY ~ 2001

4 to 5

< 33 to 4

5 to 66 to 77 to 8

> 8No data

Age and gender

standardised mortality

Number/thousand

Age and gender standardised cardiovascular

mortality per 1,000 inhabitants

2

3

4

5

6

7

8

9

10

1980 1985 1990 1995 2000

Ukraine

Bulgaria

Romania

Hungary

Czech Republic

Poland

Greece

Germany

Finland

United Kingdom

Sweden

Italy

Netherlands

Spain

France

Crude cardiovascular mortality

per 1,000 inhabitants

2

3

4

5

6

7

8

9

10

1980 1985 1990 1995 2000

Ukraine

Bulgaria

Romania

Hungary

Czech Republic

Greece

Sweden

Germany

Poland

Finland

Italy

United Kingdom

Netherlands

Spain

France

%



6

The Euro Heart Survey on Acute Coronary Syndromes (ACS) was designed to delineate the characteristics, treatments and outcome of ACS patients in Europe, and to compare adherence to current guidelines. During 2000-2001, 10,484 consecutive patients with a discharge diagnosis of ACS were enrolled in 103 hospitals from 25 countries.

Although guidelines strongly recommend reperfusion therapy in all patients with ST-elevated myocardial infarction, 44% of pa-tients did not receive this therapy. The most important reason for not providing reperfu-sion therapy was late arrival at the hospital. The majority of patients receiving reperfu-sion therapy were treated with fibrinolytic therapy (65%), while 35% received primary percutaneous coronary intervention (PCI).

A large variation in application of reperfusion therapy was observed between hospitals and countries, ranging from 8% to 89%. Also the percentage of primary PCI among patients with acute myocardial infarction that received reperfusion ther-apy varied across hospitals and countries, with a range from 0% to 84%. In the majority of patients who received reperfusion therapy, the time interval be-tween symptom onset and reperfusion ther-apy exceeded the recommended 30 minutes. In about half of patients, it took more than 30 minutes after hospital arrival before thrombolytic therapy was started, while in about 60% of those referred for primary PCI the treatment delay in hospital was more than the recommended 90 minutes. Mean time from emergency room to start of fibri-nolytic therapy varied among hospitals from 25 to 90 minutes.

Euro Heart Survey

Acute Coronary Syndromes


ACUTE CORONARY SYNDROM ES:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

PERCENTAGE REP ERFUSION THERAP Y

IN MYOCARDIAL INFARCTION

60 to 7050 to 60

< 4040 to 50

70 to 80> 80No data

Percentage

PERCENTAGE PRIM ARY PCI AM ONG

PATIENTS RECEIVING REP ERFUSION THERAP Y

15 to 2010 to 15

< 55 to 10

20 to 25No data

Percentage


7


According to the guidelines, antiplatelet ther-apy was prescribed in the large majority of ACS patients. Although recommended by guidelines, beta-blocker therapy was pre-scribed less often and varied from 43% to 91% of ACS patients. Similarly, ACE-inhibitors were prescribed in only 24% up to 82% of patients, while most patients with coronary artery disease do benefit from such therapy.

In addition, lipid-lowering therapy was being prescribed in 60% on average, ranging from less than 20% to 70% of patients with an acute coronary syndrome (page 8).

Mortality rates in ACS patients varied, both for ACS patients with and without ST elevation. Part of this variation may be re-lated to patient selection in participating hos-pitals. For example, some hospitals may not have included all consecutive patients in the survey. Yet, similar findings were reported by the Swedish registry (page 11). Thirty-day mortality was highest in patients with an undetermined ECG at admission (13%), and in patients with Q-wave myocardial infarction as discharge diagnosis (11%). These mortal-ity figures are considerably higher than those in recent clinical trials in similar patient populations. Patients in clinical trials in fact often represent a low risk subset of the total population of patients.

The Euro Heart Survey on Acute Coronary Syndromes II is currently ongoing.

Euro Heart Survey



Time from emergency room to start of

fibrinolytic therapy

0

60

120

180

240

300

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

minutes

Country

240

300

180

120

60

0

Antiplatelet therapy at hospital discharge in


0

20

40

60

80

100

Country

%

Beta-blocker therapy at hospital discharge

in Acute Coronary Syndromes

0

20

40

60

80

100

Country

%



8

Euro Heart Survey


Publications:

Hasdai D, Behar S, Wallentin L, Danchin N, Gitt

AK, Boersma E, Fioretti PM, Simoons ML, Battler A. A prospective survey of the characteristics, treatments and outcomes of patients with Acute Coronary Syndro-mes in Europe and the Mediterranean basin: The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23:1190-1201.

Hasdai D, Lev EI, Behar S, Boyko V, Danchin N,

Vahanian A, Battler A. Acute coronary syndromes in patients with pre-existing to severe valvular disease of the heart: lessons form the Euro Heart Survey of Acute Coronary Syndromes. Eur Heart J 2003;24:623-629.

Lev EI, Battler A, Behar S, Porter A, Haim M,

Boyko V, Hasdai D. Frequency, characteristics and out-come of acute coronary syndromes—The Euro Heart Survey of Acute Coronary Syndromes experience. A J Cardiol 2003;91;224-227.

Hasdai D, Behar S, Boyko V, Danchin N, Bassand

JP, Battler A. Cardiac biomarkers and acute coronary syndromes – The Euro Heart Survey Acute Coronary Syndromes Experience. Eur Heart J 2003;24:1189-1194.

Hasdai D, Haim M, Behar S, Boyko V, Battler A.

Acute Coronary Syndromes in patients with prior cere-brovascular events: lessons from the Euro Heart Survey on Acute Coronary Syndromes. Am Heart J 2003;24:832-838.

Hasdai D, Porter A, Rosengren A, Behar S, Boyko

V, Battler A. Effect of gender on outcome of acute co-ronary syndromes. Am J Cardiol 2003;91:1466-1469.

Hasdai D, Behar S, Boyko V, Battler A. Treatment

modalities of diabetes mellitus and outcomes of acute coronary syndromes. Coronary Artery Disease 2004;15:129-135.

Haim M, Battler A, Behar S, Boyko V, Fioretti PM,

Hasdai D. Acute coronary syndromes complicated by symptomatic and asymptomatic heart failure. Does cur-rent treatment comply with guidelines? Am Heart J 2004;147:859-864.

Rosengren A, Wallentin L, Gitt AK, Behar S, Batt-

ler A, Hasdai D. Sex, age and clinical presentation of acute coronary syndromes. Eur Heart J 2004;25:663-670.


Lipid lowering therapy at hospital discharge

in Acute Coronary Syndromes

0

20

40

60

80

100

Country

%

30-day mortality in myocardial infarction

admitted with ST-elevation

0

10

20

30

40

50

Country

%

30-day mortality in Acute Coronary

Syndromes admitted without ST-elevation

0

10

20

30

40

50

Country

%


9


Since 1994 several prospective multicenter registries on acute myocardial infarction (MITRA 1+2, MIR 1+2, ACOS) have been conducted in Germany to document patient characteristics, acute treatment as well as hospital and long-term outcome in clinical practice.

To close the circle between existing guidelines and clinical practice all registries used regular benchmarking reports to give feedback to the participating centers for quality control. The patient characteristics of the consecutive patients with myocardial in-farction did not change between 1994 and 2002. However, the administration of acute reperfusion therapy for ST-elevation myocar-dial infarction improved from 49% to 72% of all consecutive patients. In addition, the acute adjunctive therapy with antiplatelet drugs, beta-blockers, ACE-inhibitors and statins significantly improved within the years.

Associated with the improvement of acute treatment of ST-elevation myocardial infarc-tion in clinical practice according to existing guidelines, a significant reduction of hospital mortality from initially 16.2% in 1994 to 9.9% in 2002 was observed.

Data Source:

MITRA-Plus; MI Research Institute Ludwig-shafen, Germany

German Registries of

Myocardial Infarction


Acute Reperfusion of STEMI

Development 1994-2002

0

20

40

60

80

100

1994-95 1996-97 1998-99 2000-02

p<0.001 for trend

%

n=36523

MITRA, ACOS, M IR 1

Adjunctive Tx for STEMI

- Acute Phase -

0

20

40

60

1994-95 1996-97 1998-99 2000-02

0 1 2 3 4No of Drugs

p<0.001 for trend

Combination Therapy (Number of Drugs)

Antiplatelet / BB / ACE-I / Statinn=36523

%

MITRA, ACOS, M IR 1

Hospital Mortality of STEMI

Development 1994-2002

0

5

10

15

20

1994-95 1996-97 1998-99 2000-02

p<0.001 for trend

n=36523

%

MITRA, ACOS, M IR 1



10


Spanish Registries of


The data presented are from two Spanish registries: DESCARTES and PRIAMHO II. DESCARTES (Descripción del Estado de los Síndromes Coronarios Agudos en un Registro Temporal Español) is a nation-wide prospec-tive register of 2,017 consecutive non ST-elevated ACS patients, enrolled during 2002 in 55 randomly selected hospitals. PRIAMHO II (The Proyecto de Registro de IAM Hospita-larios) includes 6,221 consecutive patients from 58 hospitals with a Coronary Care Unit in 2000.

Both studies show a significant variation in diagnostic and therapeutic procedures among participating hospitals. A typical ex-ample is the application of cardiac troponin measurements. Cardiac troponin measure-ments are the gold standard for the detec-tion of myocardial necrosis (evidence of myocardial infarction), and these measures were applied in 85% of patients on average. However, there were hospitals in which car-diac troponin was measured in only 10% of patients, whereas other hospitals applied the measurement in all patients. Another exam-ple is the application of percutaneous coro-nary intervention (PCI) in ACS patients with-out ST elevation, which varied from 5% to 55%. In patients with ST segment elevation myocardial infarction, the application of fibri-nolytic therapy ranged from 10% to 60%, while primary PCI was performed in 0% to 30% of patients.

Publications: Arós F, Cuñat J, Loma-Osorio A, Torrado E, Bosch X, Rodríguez J, Bescós L, Ancillo P, Pabón P, Heras M, Mar-rugat J, on behalf of the investigators of the PRIAMHO II study. Management of Myocardial Infarction in Spain in the Year 2000. The PRIAMHO II Study. Rev Esp Cardiol 2003;56:1165-1173.

Variability in use of diagnostic studies

in Non ST Elevation Acute Coronary Syndromes

0

10

20

30

40

50

60

70

80

90

100

Lipid profile

Echo PCI CABGTroponins EarlyCath

Non-invas ive

test

Average use

DESC ARTE S

%

Variability in treatment

in Non ST Elevation Acute Coronary Syndromes

0

10

20

30

40

50

60

70

80

90

100

Heparin Clopi-

dogrel

GP

IIb/IIIaInh.

B-

blocker

Statin*ASA ACE-I*

Average use

* In patients with indication DESC ARTE S

%

Variability in treatment in ST Elevation Myocardial Infarction

100

90

70

60

50

40

80

30

20

10

0

%

Fibrino-

lysis

Prim ary

perfus ion

ASA

CICU Discharge

B-blockers

CICU Discharge

ACE-I

CICU Discharge

Lipid-lowering

CICU Discharge

Average use

PRIAMHO II


11


The purpose of RIKS-HIA, the Register of Information and Knowledge about Swedish Heart Intensive care Admissions, is to im-prove acute coronary care through continu-ous information about need of care, therapy and results of therapy and changes within a hospital as well as in comparison with other hospitals. In 2002 there were 70 participat-ing hospitals, which covered 95% of all pa-tients admitted to a coronary care unit in Sweden.

Data with regard to myocardial infarction show a similar situation as observed in Spain: a large variability exists in baseline characteristics, patient management and outcome between the participating sites. For example, the interval between patient arrival in the hospital and the initiation of fibri-nolytic therapy varied from 20 minutes in some hospitals to more than 1 hour in oth-ers. Again 30-day mortality varied from less than 5% to about 15%. Interestingly, the type of hospital and the number of patients treated seems to be importantly associated with differences in patient management. Outcome was better in larger hospitals, with invasive facilities, treating a high number of patients.

The results of the RIKS-HIA registry were similar to the Euro Heart Survey (page 6-8). For example, under-treatment with reperfu-sion therapy was observed in 40% of pa-tients, and the median delay time between onset of chest pain and start of fibrinolytic therapy was 2-2.5 hours on average, and until start of direct PCI 3.5 hours.

Data Source:

Stenestrand U, Wallentin L. RIKS-HIA report 2002.

Swedish Registry for

Cardiac Intensive Care


Reperfusion treatment

in ST-elevation myocardial infarction.

Swedish Registry 2002.

Median (95% confidence interval) time from

emergency room to start of fibrinolytic therapy.

Swedish Registry 2002.

30-day mortality in myocardial infarction

Swedish Registry 2002



12

Euro Heart Survey

Stable Angina Pectoris

The Euro Heart Survey on Stable Angina Pec-toris (2003) included 3,779 ambulatory pa-tients from 36 countries, presenting to a car-diologist as an outpatient. The population consisted of patients at new presentation to a cardiologist in whom a diagnosis was made of stable angina, caused by myocardial is-chaemia due to coronary disease based on clinical assessment, and who did not have unstable angina. The 197 participating hospi-tals were a mix of hospitals with non-invasive diagnostic facilities only (33%), with both non-invasive and invasive cardiology facilities (19%), and hospitals that had, in addition to a catheterization laboratory, car-diac surgery facilities on site (31%).

After assessment by a cardiologist, the majority of patients (81%) were taking or were prescribed on an antiplatelet agent. However, percentages of patients treated with antiplatelet drugs ranged from 44% to 100% between countries. In all, 48% were on statin treatment, 67% were receiving beta-blockers, 61% were on a nitrate, 27% were taking a calcium channel blocker, and 40% were using ACE-inhibitors. Although there remains room for further improve-ment, these figures compare favourably with the 1999 survey on secondary prevention.

The majority of patients (59%) were on two or more anti-anginal drugs after assess-ment by a cardiologist, and 13% on no anti-anginal drug. The number of anti anginal drugs per patient did not differ significantly between males and females, but did increase with age up to 70 years.

STABLE ANGINA PECTORIS:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

Medical therapy in patients newly presenting

with stable angina pectoris

0

20

40

60

80

100

%

Antiplatelets Statin B-blockers Nitrates Ca-blockers

ACE- I

Anti-anginal drugs per patientin patients with newly presenting stable angina pectoris

by European region

0

10

20

30

40

50

60

North West Central Mediterranean Overall

0 1 2 > 2

%

No of Drugs


13


The Euro Heart Survey on Diabetes and the Heart was carried out in 2003. The survey included 4,961 patients from 110 hospitals in 25 countries. Included patients were referred to a cardiologist due to coronary artery dis-ease out of whom 2,107 (43%) were admit-ted on acute basis and 2,854 (57%) had sta-ble coronary artery disease. An oral glucose tolerance test (OGTT) was recommended by the protocol and gluco-metabolic characteri-zation performed according to present WHO recommendations.

The survey revealed that diabetes is known to be present in about a third of pa-tients with coronary artery disease: 29% in acute patients and 34% in patients with a stable cardiac condition. In addition, when an oral glucose tolerance test was performed in patients with acute coronary artery dis-ease, another 15% of patients were shown to have diabetes that was not yet recog-nised. In patients with stable coronary artery disease the corresponding proportion was 10%. Furthermore, in both acute and stable cardiac patients, about a third had abnormal fasting glucose or impaired glucose toler-ance. Thus, the majority of patients with acute or chronic coronary disease have an abnormal glucose metabolism. Since several studies have shown that such patients do have impaired outcome, systematic screen-ing for abnormal glucose metabolism seems appropriate.

Publications: Bartnik M, Rydén L, Ferrari R, Malmberg K, Pyörälä k, Simoons M, Standl E, Soler-Soler J, Öhrvik J, on behalf of the Euro Heart Survey Investigators. The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe (Eur Heart J, in press).

Euro Heart Survey

Diabetes and the Heart

DIABETES AND THE HEART:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

Prevalence of abnormal glucose regulation in patients with acute coronary artery disease

Known

diabetes

Newly

detected

diabetesImpaired

fasting

glucose

Impaired

glucose

tolerance

Normal

Prevalence of abnormal glucose regulationin patients with stable coronary artery disease

Known

diabetes

Newly

detected

diabetes

Impaired

fasting

glucose

Impaired

glucose

tolerance

Normal



14

Coronary Revascularisation

Euro Heart Survey


The Euro Heart Survey on Coronary Revas-cularisation included consecutive patients who presented for coronary angiography and had significant coronary disease (any steno-sis over 50% in diameter). In 2000-2001, over 8,000 procedures were screened and 5,767 cases were included from 132 hospi-tals of 31 ESC member countries.

Coronary revascularisation is recom-mended for patients with stable and unstable coronary disease to relieve anginal symp-toms, to retard disease progression, and to prevent death or myocardial infarction. In patients presenting with evolving myocardial infarction, immediate coronary revascularisa-tion by means of a ‘primary’ percutaneous intervention (PCI) is nowadays considered the best treatment option, as it is more ef-fective and safer than fibrinolysis. In clinical practice, however, indications for revascu-larisation are determined as much by avail-ability as by risk assessment. The percent-age of invasive (PCI and CABG) and non-invasive treatment in patients with a stenose over 50% varied largely across hospitals.

In patients undergoing PCI for acute coronary syndromes, GP IIb/IIIa receptor blockers are recommended by guidelines. A large variation (from 0% to 100%) between hospitals was observed in the percentage of PCI patients in which GP IIb/IIIa blockers were prescribed.

CORONARY REV ASCULARISATION:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

Treatment of patients with stenosis > 50%

0%

20%

40%

60%

80%

100%

PCI CABG Non-Invasive

Hospi tal

GP IIb/IIIa inhibitors in PCI patients

0

20

40

60

80

100

%

Hospi tal


15


One-year mortality and reported quality of life of patients varied. Average mortality was 4.9% and ranged from 0% to 20% between hospitals.

Quality of life was assessed with the Eu-roqol 5D, a standardised quality of life meas-ure. An Euroqol score of zero indicates a situation comparable to death from a society perspective, and the best possible score is 1. After 30-days, patients who underwent CABG had the lowest Euroqol score whereas PCI patients perceived the best quality of life, which is comparable to quality of life levels of their age counterparts in the general population. The lower score after CABG re-flects the prolonged recovery period after major surgery. After one year, a consider-able improvement was observed in the CABG group, up to the level of the PCI group. The PCI group remained at a high Euroqol quality of life score, while quality of life of patients in the non-invasively treated group wors-ened.

Half of all patients, and especially those who did not undergo an invasive treatment (59%), indicated one or more problems with respect to mobility, self-care, activity, dis-comfort/pain, or anxiety/depression. Almost half of the medically treated patients (45%) experienced problems with respect to pain and discomfort, as compared to 30% in the PCI and CABG group.

Euro Heart Survey



1-year mortality

in patients with stenosis > 50%

0

10

20

30

40

50

%

Hospi tal

Quality of life after 30 days and 1 year

Euroqol total score

0.5

0.6

0.7

0.8

0.9

1


Best possible score

30 days 1 year

Quality of life after 1 yearPatients indicating problems per treatment group

0

10

20

30

40

50

Mobility Selfcare Activity Discomfort

Pain

Anxiety

Depression


%



16


Coronary Revascularisation in Europe

Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting have been developed to treat symptoms of patients with manifest coronary artery disease. To date, percutaneous coronary interventions (PCI) have a wide indication. Whereas some years ago surgery was the dominant thera-peutic option, nowadays most patients are eligible for percutaneous treatment. This in-cludes patients with multivessel coronary disease. Accordingly, increasing annual vol-umes of percutaneous interventions and sta-bilising levels of coronary surgery are ob-served in most European countries. Ger-many, The Netherlands and Sweden are il-lustrative examples. Currently, high annual levels of percutaneous interventions are ob-served in Belgium, Denmark, Germany, Ice-land, Israel, and Switzerland (over 1500 PCI procedures per 1 million inhabitants). Most other Northern, Western, and Southern countries have intermediate levels, whereas the Central European countries often have annual levels below 300 PCI procedures per million inhabitants.

Data source:

National Cardiac Society Reports

300 to 600

600 to 900

> 1800

< 300

900 to 1200

1200 to 1500

1500 to 1800

No data

PERCUTANEOUS CORONARY

INTERV ENTIONS ~ 2000

PCI per m illion inhabitants

Time trends in the annual use of PCI numbers per 1 million inhabitants

0

500

1000

1500

2000

2500

1980 1985 1990 1995 2000

Germany

France

Netherlands

Italy

Finland

Sweden

Czech Republic

United Kingdom

Spain

Poland

Hungary

Romania

T ime trends in the annual use of CABG numbers per 1 million inhabitants

0

500

1000

1500

2000

2500

1980 1985 1990 1995 2000

Germany

Sweden

Netherlands

Finland

France

United Kingdom

Italy

Czech Republic

Hungary

Spain

Poland

Romania


17


Between Feb 2002 and Feb 2003, 12,400 consecutive patients undergoing a percuta-neous coronary intervention (PCI) in 30 cen-ters in France, Germany, Israel, Italy, Po-land, Portugal and the UK were enrolled in the SHAKESPEARE Registry to document pa-tient characteristics, procedural data as well as outcome in clinical practice.

Data from randomised controlled trials provide evidence that especially diabetics with acute coronary syndromes (ACS) under-going PCI benefit from the use of GP IIb/IIIa receptor blockers (GP IIb/IIIa). Two thirds underwent PCI for ACS of whom 23% had known diabetes. Less than half of these dia-betics received GP IIb/IIIa during PCI, De-spite the evidence of an improved outcome in especially diabetics, the frequency of GP IIb/IIIa use during PCI for ACS was not dif-ferent from that in non-diabetics in clinical practice, although diabetics had more often been identified as high risk patients by the interventional cardiologists.

Independent determinants for the use of GP IIb/IIIa during PCI for ACS in clinical practice were cardiogenic shock, multivessel PCI and male gender. Determinants against GP IIb/IIIa were age >70 years and history of stroke. Known diabetes did not influence the decision for the use of GP IIb/IIIa in clinical practice.

Source:

Gitt et al., ESC 2004, Munich (Abstract)

MI Research Institute Ludwigshafen,

Germany

SHAKESPEARE

International PCI Registry


PCI for ACS

Use of GP IIb/IIIa

0

10

20

30

40

50

GP IIb/IIIa Abciximab Eptifibatide Tirofiban

Diabetics Non-Diabetics

%

nsns

ns

ns

PCI for ACS

Reason for GP IIb/IIIa-Use

0

20

40

60

80

ACS Pt considered

high risk

Difficult PCI Others

Diabetics Non-Diabetics

Statement of the Interventional Cardiologist

p<0.001

ns

ns

p<0.001

%

Determinants of GP IIb/IIIa

in PCI for ACS

Contra GP IIb/IIIa <OR> Pro GP IIb/IIIa

Card Shock

Multivessel PCI

Stenting

Male Gender

Diabetes

Prior CABG

Heart Failure

Hypertension

Prior MI

Prior PCI

Age > 70 y

Prior Stroke

0 0,5 1 1,5 2 2,5

Multivariate Analysis



18

Euro Heart Survey

Heart Failure

The Euro Heart Survey on Heart Failure was undertaken during 2000-2001 in 115 hospi-tals from 24 European countries. Case notes of 46,782 consecutive death or discharges (all causes) from internal medicine, geriatric, cardiology and cardiac surgery wards were reviewed. Of them, 10,701 (24%) were iden-tified with suspected or confirmed heart fail-ure. Heart failure was the principal reason for admission in 40% of cases. These data illustrate that known or suspected heart fail-ure comprises a large proportion of hospital admissions.

The great majority of patients had had an ECG (95%), chest X-ray (92%), haemoglo-bin, electrolytes and renal function measured (>90%) as recommended in ESC guidelines. Echocardiography was, however, performed in only 66% of patients. Variation between hospitals in application of diagnostic meas-ures was large. For example, application of echocardiography ranged between hospitals from 27% to 89% of patients.

Almost 80% of patients with heart failure due to left ventricular systolic dysfunction (LVSD) received an ACE-inhibitor as recom-mended by the guidelines. Among patients receiving ACE-inhibitors, however, only 29% received the dose as recommended in clinical trials, and 51% received half or more of the recommended dose. The application of ACE-inhibitors varied from 27% to 92% between participating hospitals.

Beta-blocker therapy were prescribed in only 49% of patients with heart failure due to LVSD. Among patients receiving beta-blockers, 4% received the dose as recom-mended in clinical trials, and 16% half or more of the recommended dose. Application

HEART FAILURE:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

Echocardiography

0

20

40

60

80

100

%

Hospi tal

ACE-Inhibitor therapy at hospital discharge

0

20

40

60

80

100

Hospi tal

%


19


of beta-blocker therapy varied between hos-pitals from 3% to 89%.

Current guidelines are mainly based on clinical trials in heart failure patients with LVSD. Almost half (46%) of the enrolled heart failure patients, however, did not have left ventricular systolic dysfunction. Evidence to support treatment of this large group of heart failure patients is still very limited.

Large differences were observed in pa-tient outcomes between hospitals; 30-day mortality varied from 5% to 37%. In all, 13% of patients died and 27% were readmit-ted within 12 weeks. These data illustrate the continuing high mortality and morbidity among heart failure patients.

The Euro Heart Survey on Heart Failure II will start in the second half of 2004.

Publications: Cleland JGF, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, Dietz R, Gavazzi A, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS, Preda I, Van Gilst WH, Widimsky J, for the Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology, Freemantle N, Eastaugh J, Mason J. The EuroHeart Failure survey programme – a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003;24:442-463.

Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A, Dietz R, Gavazzi A, Van Gilst WH, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS, Preda I, Widimsky J, Freemantle N, Eastaugh J, Mason J; Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The EuroHeart Failure Survey Programme – a survey on the quality of care among patients with heart failure in Eu-rope. Part 2: treatment. Eur Heart J 2003;24:464-474.

Lenzen MJ, Scholte op Reimer WJM, Boersma E, Vantrimpont PJMJ, Follath F, Swedberg K, Cleland J, Komajda M. Differences between patients with a preser-ved and a depressed left ventricular function: a report from the EuroHeart Failure Survey. Eur Heart J 2004;25:1214-1220.

Euro Heart Survey

Heart Failure

Beta-blocker therapy at hospital discharge

0

20

40

60

80

100

Hospi tal

%

Preserved Left Ventrical Function

0

20

40

60

80

100

%

Hospita l

30-day mortality

0

10

20

30

40

50

%

Hospi tal



20

Euro Heart Survey

Valvular Heart Disease

The Euro Heart Survey on Valvular Heart Disease (VHD) was conducted in 2001. In 92 centres from 25 countries, 5,001 adult pa-tients were included with moderate to severe native VHD, infective endocarditis, or previ-ous valve intervention. Enrolled patients were hospitalised in medical (43%) or surgi-cal (19%) cardiology departments, or visited the outpatient clinic (38%).

In the field of VHD exists a lack of large clinical trials providing a high level of evi-dence, and as a consequence the guidelines are usually not based on a ranked strength of evidence. The aim of the Euro Heart Sur-vey on Valvular Heart Disease was to com-pare, whenever possible, the management of VHD with available guidelines and to try to define the rationale for decisions.

Aetiology was predominantly degenera-tive for aortic stenosis and rheumatic for mi-tral stenosis. Valve repair was the treatment of choice in about half of patients with mitral regurgitation, while autografts and mechani-cal prostheses were equally used in aortic stenosis.

The application of mechanical prostheses as compared to bioprostheses in patients op-erated on for aortic stenosis varied largely by age, as appropriate. Mechanical prostheses were predominantly applied in young pa-tients, whereas in elderly patients a biopros-thesis was the preferred treatment.

Overall the indications for interventions in the asymptomatic patient were in agree-ment with guidelines in the majority of pa-tients (66%-79%), and among the different single native valve disease patients. On the other hand, however, two thirds of patients with severe valve disease and severe symp-toms were not operated on.

VALVULAR HEART DISEAS E:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

Interventions in native valve disease

0%

20%

40%

60%

80%

100%

Mitral Valve

Regurgitation

Mitral Valve

Stenosis

Aortic Valve

Regurgitation

Aortic Valve

Stenosis

Autograft Homograft

Mechanical Prosthesis Bioprosthesis

Valve Repair Percutaneous Intervention

Distribution of mechanical and bioprosthesisaccording to age

in patients operated on for aortic stenosis

0%

20%

40%

60%

80%

100%

<60 60-65 65-70 70-75 75-80 80-85 85-90

Mechanical prosthesis Bioprosthesis


21


The reasons for not advising intervention were either cardiac, extra-cardiac or both. However, the multifactorial nature of the de-cision process in such patients and the ab-sence of precise recommendations in the field of VHD explains the wide variability of advice given and makes it difficult to make meaningful comparisons with guidelines.

A total of 169 patients had acute infec-tive endocarditis. Of them, 55% underwent valve replacement during the survey, which is slightly better than the most recent sur-veys, but remains probably too low when compared with current recommendations.

Antibiotic prophylaxis was inadequately applied in patients with infective endocardi-tis, since half of the patients did not receive prophylaxis during a procedure at risk. Variation in antibiotic prophylaxis was ob-served between hospitals, but in most hospi-tals such medication was prescribed in less than 40% of patients.

Furthermore, education on use of antibi-otic prophylaxis should be improved. Only 30% to 50% of patients were followed by dentists, and 50% to 70% received educa-tion. The same findings were observed with regard to the application of management of anti-coagulant therapy since only 22% of the patients received education, with large varia-tion between hospitals from 5% to 80% of patients.

Publications: Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, Tornos P, Vanoverschelde J, Vermeer F, Boersma E, Ravaud P, Vahanian A. A pro-spective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003;24:1231-1243.

Euro Heart Survey

Valvular Heart Disease

Comparison of the indications retained for

intervention and the current guidelines in asymptomatic patients

0

20

40

60

80

100

Aortic stenosis Aortic regurgitation Mitral regurgitation

Over use Agreement Under use

%

Antibiotic prophylaxis

prior to infective endocarditis

0

20

40

60

80

%

Hospi tal

Education on anti-coagulation

0

20

40

60

80

%

Hospi tal



22

Euro Heart Survey

Adult Congenital Heart Disease

In the past decades, prognosis and life ex-pectancy of patients with congenital heart disease have dramatically improved, mainly as a result of improved surgical techniques. Increasing numbers of these patients are now reaching adulthood, which has led to a new population of patients consisting of adults with a surgically corrected heart de-fect. The Euro Heart Survey on Adult Con-genital Heart Disease was conducted in 2003 and 2004. In 79 centres (47 specialised; 32 non-specialised) from 26 countries, 4,168 patients with adult congenital heart disease were included.

The survey focused on 8 selected de-fects: Atrial Septal Defect (22%), Ventricular Septal Defect (VSD) (15%), Tetralogy of Fal-lot (20%), Aortic Coarctation (13%), Trans-position of Great Arteries (9%), Marfan Syn-drome (7%), Fontan Circulation (5%), and Cyanotic defect (9%).

Guidelines showed to be reasonably ap-plied in clinical practice, with variation per type of defect and with a closer adherence for interventions than for diagnostic work-up. For example, according to guidelines, all patients aged 40 years or older should have a coronary angiography before undergoing a cardiac operation, while, on the other hand, angiography is not indicated in patients younger than 40 years of age. The data showed that in 575 patients operated on during follow up, angiography was under-used in 92 and over-used in 55 patients.

In patients with VSD, numbers of under-treatment and over-treatment were rela-tively low, illustrating reasonable adherence to guidelines.

ADULT CONGENITAL HEART DIS EASE:


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

575 operated patients

+ 208

+ 116 + 55

Under use

angio

Over use

angio?

- 367

- 92 - 312

Indication?

Angio-graphy?

363 not closed at inclusion

+ 81

+ 39 + 2

Under-treatment Over-treatment

- 282

- 42

+ 36 - 6 - 2

- 280

VSD

Indication?

Operated?

Valid reason?


23


The application of pacemakers varies largely across the ESC member countries, ranging from about 200 to over 800 per million in-habitants per year. Major differences are ap-parent even between countries with similar economies. These differences have been known for several years, but are still largely unexplained.

In most countries the use of pacemakers is gradually increasing. This may be due to the ageing of the population, to the introduc-tion of special pacemaker systems for treat-ment of tachyarrhythmia’s and to the treat-ment of selected groups of patients with heart failure. The highest use of pacemakers is currently reported in Austria, Belgium, France, and Germany.

Implantable Cardioverter Defibrillators (ICD) have been introduced for treatment of patients with a previous cardiac arrest. More recently, ICDs have been recommended for other groups of patients who are at high risk for the development of life threatening ven-tricular arrhythmias. This has led to a rapid increase in the use of these devices in recent years and a further increase is expected in the coming years. Currently the highest use of ICDs is reported in Germany, which is about twice as high as in other Western European countries.

Data Source:

Registry European Heart Rhythm Association

Pacemakers and

Implantable Cardioverter Defibrillators

200 to 300

300 to 400

> 800

< 200

400 to 500

600 to 700

700 to 800

No data

PACEM AKERS ~ 2001

Pacemakers/million

Time trends in the use of Pacemakers numbers per 1 million inhabitants per year

0

200

400

600

800

1000

1990 1995 2000

Germany

Belgium

France

Italy

Czech Republic

Sweden

Spain

Finland

Netherlands

United Kingdom

Poland

Hungary

T ime trends in the use of Implantable Cardioverter Defibrillators

numbers per 1 million inhabitants per year

0

20

40

60

80

100

120

1990 1995 2000

Germany

Belgium

Italy

Netherlands

Finland

United Kingdom

Greece

Czech Republic

France

Sweden

Poland



24

Euro Heart Survey

Atrial Fibrillation

The Euro Heart Survey on Atrial Fibrillation was conducted in 2004, and some prelimi-nary results are presented in this report. In 182 centres from 35 countries, data were collected on characteristics, management and outcome of 5,330 patients. The popula-tion comprised consecutive in– and out-patients with atrial fibrillation. Patients were enrolled only if an ECG diagnosis of atrial fib-rillation was made. The qualifying episode of atrial fibrillation should have occurred within the last year.

Atrial fibrillation is a disorder with high prevalence figures in the elderly. Atrial fibril-lation is often secondary to coronary artery disease, heart failure, or valvular heart dis-ease, but it can also occur as a primary con-dition. Patients with paroxysmal atrial fibril-lation most often have no other cardiovascu-lar disease (20%), while the relatively old group of patients with permanent atrial fibril-lation is less often free from other cardiovas-cular diseases (7%).

Since patients with atrial fibrillation have an increased risk for stroke, anticoagulation therapy is recommended by guidelines. Yet, the survey revealed that a significant propor-tion of patients did not receive such therapy. Anticoagulation therapy in patients with atrial fibrillation varied largely between hos-pitals from 8% to 100% of patients. Addi-tional analysis of these data is required to verify this observation, and to assess which proportion of patients is under-treated.

ATRIAL FIBRILLATION


300 to 400200 to 300

< 100100 to 200

400 to 500> 500No data

Patients

No other cardiovascular disease

by type of atrial fibrillation

0

10

20

30

40

50

First detected Paroxysmal Persistent Permanent

%

Anticoagulation therapy

in atrial fibrillation

0

20

40

60

80

100

%

Hospi tal


25


As expected, anticoagulation therapy was prescribed predominantly in patients with persistent (79%) or permanent (76%) atrial fibrillation, whereas such therapy was less often prescribed in patients with a first epi-sode of atrial fibrillation (53%) or paroxys-mal atrial fibrillation (50%).

Since cardiac function is impaired in pa-tients with atrial fibrillation, which limits ex-ercise tolerance, cardioversion is often at-tempted to return to normal sinus rhythm. Such cardioversion may be achieved by anti- arrhythmic drugs (pharmacological conver-sion) or by electric shock. The latter proce-dure is used particularly in patients with per-sistent atrial fibrillation (36%), while phar-macological conversion is most often applied in patients with first detected (39%) or par-oxysmal atrial fibrillation (33%).

Euro Heart Survey

Atrial Fibrillation

Anticoagulation therapy at discharge


0

20

40

60

80

100

First detected Paroxysmal Persistent Permanent

%

Electrical cardioversion


0

10

20

30

40

50

First detected Paroxysmal Persistent

%

Pharmacological conversion


0

10

20

30

40

50

First detected Paroxysmal Persistent

%

1ACS-Surveys in Israel

AMI PatientsCharacteristics and Risk Factors

(%)

303028252824Diabetes

484343404237Hypertension

363835353735Smoking

504632282420Hyperlipidemia

182016141314Familyhistory

7

46

63.4

28

72

(n=941)

1994

(n=1490)

(n=1308)

(n=1118)

(n=931)

(n=941)

No. of Pts

Age: >80yrs

7 8 9 10 11

Age: >65yrs

46 44 48 45 47

Age:yrs(mean)

63.2 62.5 63.6 63.6 64.2

Women 25 25 26 23 23

Men 75 75 74 77 77

YEAR 1992 1996 1998 2000 2002


Trends in Hospital Treatment inAll Patients

7283

91 94 96 93

3143

55 60 6475

3750 53 53

63

010

1829

57

1900

20

40

60

80

100

1992 1994 1996 1998 2000 2002

ASABBACE-ILLD

%

ACSIS is a biannual survey that has been conducted since 1992 in all 25 cardiac departments operating in Israel. The surveys are performed over a two-month period, and include all patients with a diagnosisof acute coronary syndrome (acute myocardial infarction or unstable angina pectoris).The goals of ACSIS includeexamination of trends over time in the management of patients with acute myocardial infarction hospitalized in cardiac departments in Israel, and evaluation of the impact of management on clinical outcome and mortality in acutemyocardial infarction patients. The data presented here describe the characteristics of the patients, management modalities, and their outcome over the last decade (1992-2002).Table 1 shows the demographic characteristics of the patients surveyed during the different time periods, as well as the prevalenceof cardiovascular risk factors.Throughout the decade, the proportion of male and femalepatients remained similar, with approximately three quarters of patients being men and one quarter, women.The mean age of the patients also remained stable over time, although an increase in the proportion of patients over the age of 80 wasnoted. With respect to risk factors, the frequency of diagnoses of

Trends of Management and Outcome of AMI Patients in Israel 1992-2002

Trends in Management and Outcome of AMI Patients in Israel 1992-2002

diabetes, hypertension, and hyperlipidemia increased over time.Figure 1 illustrates trends in hospital treatment over time. Substantial increases in the use of aspirin, beta-blockers, ACE inhibitors, and lipid- lowering drugswere observed throughout thedecade studied. Trends in the use of reperfusion and coronary interventions are demonstrated in Figure 2. These data indicate that the use of coronary angiography, PTCA/CABG, and primary PTCA have increased steadily over a tenyear period, while a decrease in the use of thrombolysis wasobserved between 1996 and 2002. Figure 3 shows the extent to which 7-day, 30-day, 6-month, and 1-year mortality was reducedbetween 1992 and 2002. For each of these endpoints substantial reductions were observed, with the most striking found for 7 and 30-day mortality. These changes probably reflect the improvement in management and medical treatment of myocardial infarction patients.National surveys and registries are of utmost importance for the evaluation of guideline implementation in the community and their impact on patientoutcome in real life practice.


Trends in Reperfusion and Coronary Interventions in All

Patients

44 4452

4236

22

0 2 4 6 9

1822

2935

4956

69

1019

2632

44

59

010203040506070

1992 1994 1996 1998 2000 2002

ThrombolysisPrimary PTCACoronary angioPTCA/CABG

%


Mortality Reduction in All Patients

8.8

13.5

16.9

19.1

4.6

6.9

10.812.8

0

5

10

15

20

7-Day 30-Day 6-Months 1-Year

19922002

%-33%

-36%

-49%

-48%



28

Concluding Remarks

nary artery disease it is apparent that chronic treatment (secondary prevention) is improving over the years. Future sur-veys should monitor such improvement in management of coronary artery disease as well as in other fields of cardiology and cardiovascular medicine.

The Euro Heart Survey programme was de-veloped to achieve three main goals.

1. To assess the adherence of guidelines for the prevention, diagnosis and manage-ment of cardiovascular disease in clinical practice in the ESC member countries.

2. To evaluate to what extent patients who are seen in the daily clinical practice of cardiology and cardiovascular medicine are appropriately represented in clinical trials, which are the main source for guide-line development (evidence based medi-cine).

3. To assess the relation between the ad-herence to clinical practice guidelines and patient outcome.

The data presented in this report demon-strate that the Euro Heart Survey pro-gramme is successful. Surveys have been conducted on secondary prevention of coro-nary artery disease, heart failure, acute coronary syndromes, coronary revascularisa-tion, valvular heart disease, stable angina pectoris, atrial fibrillation, diabetes and the heart and adult congenital heart disease. Surveys and registries in different countries in Europe have focused on acute coronary syndromes, coronary revascularisation and device therapy for arrhythmias (pacemakers and implantable cardioverter defibrillators).

The currently available data provide answers to the three questions raised.

1. There is a wide variation in practice among hospitals in Europe, as well as among hospitals in individual countries. Adherence to guidelines is variable and can be improved. Comparing the results of successive surveys in patients with coro-

2. As expected, patients seen in routine clinical practice differ significantly from those selected for participation in clinical trials as they are older, more often female, have a more severe cardiac condition and more often suffer from concomitant other diseases. Specific studies of diagnostic procedures and therapy are required in these patient groups.

3. There appears to be a relation between guideline adherence and outcome: hospi-tals with best guideline adherence have overall best patient outcome (report in preparation).

0

20

40

60

80

100

anti-platelets

(incl anticoag)

bèta-blockers

statins

ACE-inhibitors

Secondary prevention evolution 1995-2002

EuroAsp-I

(95/96)

EuroAsp-II

(99)

ACS

(00/01)

Revasc

(01/02)

%


29


In the coming years, the European Society of Cardiology will further improve the survey programme. For example, different surveys related to management of coronary artery disease can be coordinated. In fact there is a large overlap between surveys on acute coronary syndromes, stable angina, and coronary revascularisation. Furthermore, surveys on secondary prevention (EuroAspire) address patients previously ad-mitted for acute coronary syndromes or pre-viously undergoing revascularisation. Accord-ingly, it will be efficient to organise future surveys on secondary prevention in a coordi-nated fashion with the follow-up of surveys on acute coronary syndromes and revascu-larisation. Issues related to diabetes and hy-pertension can be integrated in the acute and follow-up surveys of coronary artery dis-ease. Similarly, surveys on acute and chronic heart failure, resynchronisation therapy and the use of implantable cardioverter defibrilla-tors may be integrated. Dedicated consistent questionnaires will be developed for these surveys, based on data standards as agreed in the CARDS project. In addition to the top-ics indicated above other topics may be ad-dressed at longer intervals including valvular heart disease, adult congenital heart disease and cardiac imaging.

Improved online data collection using simpli-fied case report forms will allow continuous registration of specific patient groups and procedures by interested hospitals. Such continuous registries have been developed in different countries, and are likely to be intro-duced throughout Europe in the coming years. Continuous registries offer “quality assurance” and “benchmarking” to the par-

Concluding Remarks

ticipating hospitals. This certainly will lead to improved quality of care, as has been dem-onstrated in different studies.

In the coming years, procedures for data col-lection and quality control will be improved, and the programme will be extended to other hospitals throughout Europe. Further-more, we expect that the Euro Heart Survey programme will be integrated with national registries and surveys. Hospital information systems will evolve to allow online data col-lection in clinical practice, for reporting by the responsible physician as well as access to national and international registries sur-vey programmes.

The Euro Heart Survey committee is grateful to all contributors to this report and in par-ticular to the participating hospitals which provide insight into the actual practice of cardiology.



30

Contributors to the

Euro Heart Survey programme

EURO HEART SURVEY

SCIENTIFIC EXPERT COMMITTEES

ACUTE CORONARY SYNDROMES I

Alexander Battler (Chairman)

Shlomo Behar

Martine Bernstein

Nicolas Danchin

Paolo Fioretti

Anselm Gitt

David Hasdai

Jochen Senges

Philip Urban

Frans Van de Werf

Lars Wallentin

ACUTE CORONARY SYNDROMES II

Shlomo Behar (Chairman)

Alex Battler

Eric Boersma

Valentina Boyko

David Hasdai

Nicolas Danchin

Anselm Gitt

Yeonatan Hasin

Gerasimos Filippatos

Lori Mandelzweig

Jaume Marrugat

Lars Wallentin

Frans Van de Werf

ANGINA PECTORIS

Kim Fox (Chairman)

Eric Boersma

Caroline Daly

Nicolas Danchin

François Delahaye

Anselm Gitt

Desmond Julian

José-Luis Lopez-Sendon

David Mulcahy

EURO HEART SURVEY COMMITTEE

Maarten L. Simoons (Chairman)

David Wood (Past Chairman)

Secretaries

Malika Manini

Keith McGregor

Angeles Alonso

Dietrich Andresen

Alexander Battler

Shlomo Behar

Eric Boersma

John Cleland

Harry Crijns

Kim Fox

Anselm Gitt

Sam Lévy

Barbara Mulder

Markku Nieminen

Sylvia Priori

Lars Rydén

Luigi Tavazzi

Alec Vahanian

Panos Vardas

William Wijns

Uwe Zeymer

METHODOLOGY AND DATA

MANAGEMENT COMMITTEE

Eric Boersma (chairman)

Malgorzata Bartnik

Caroline Daly

Peter Engelfriet

Nick Freemantle

David Hasdai

Bernard Iung

Mattie Lenzen

Malika Manini

Tanja Megens

Nestor Mercado

Javier Muniz

Robby Nieuwlaat

ESC Brochure demo right 313

31


Witold. Ruzyllo

Luigi Tavazzi

Kristian Thygesen

Freek Verheugt

ATRIAL FIBRILLATION

Harry Crijns (Chairman)

Sam Lévy (Vice-Chairman)

Dietrich Andresen

Johnn Camm

Alessandro Capucci

Wyn Davies

Robby Nieuwlaat

Bertil Olsson

Consultants

Etienne Aliot

Gunther Breithardt

Stuart Cobbe

Jean-Yves Le Heuzey

Massimo Santini

Panos Vardas

CONGENITAL HEART DISEASE

Barbara Mulder (Chair)

Luciano Daliento

Peter Engelfriet

Michael Gatzoulis

Rafael Hirsh

Harald Kaemmerer

Tanja Megens

Folkert Meijboom

Philip Moons

Erwin Oechslin

Jana Popelovà

Erik Thaulow

Ulf Thilen

Jan Tijssen

CORONARY REVASCULARISATION

William Wijns (Chairman)

Nestor Mercado

Contributors to the


Michel Bertrand

Willibald Maier

Bernhard Meier

Cesar Moris

Federico Piscione

Udo Sechtem

Elisabeth Stahle

Felix Unger

Jeroen Vos

Petr Widimsky

DIABETES & THE HEART

Lars Ryden (Chairman)

Karl Malmberg (Co-Chairman)

Malgorzata Bartnik

Roberto Ferrari

Kalevi Pyörälä

Maarten L. Simoons

Jordi Soler-Soler

Eberhard Standl

EUROASPIRE II

Guy De Backer (Chairman)

David Wood (Co-ordinator)

Giovanni Ambrosio

Philippe Amouyel

Dennis V. Cokkinos

Jaap Deckers

Leif Erhardt

Ian Graham

Irena Keber

Ulrich Keil

Seppo Lehto

Erika Ostör

Andrzej Pajak

Kalevi Pyörälä

Susana Sans

Jaroslav Simon



32

Contributors to the


VALVULAR HEART DISEASE

Alec Vahanian (Chairman)

Eric G. Butchart

François Delahaye

Christa Gohlke-Bärwolf

Bernard Iung

Olaf W. Levang

Pilar Tornos

Jean-Louis Vanoverschelde

Frank Vermeer

EURO HEART SURVEY TEAM

Keith McGregor, Scientific Director

Malika Manini, Operations Manager

Claire Bramley, Data monitor

Valérie Laforest, Data Monitor

Charles Taylor, Database Administrator

Susan Del Gaiso, Admistrator

EUROASPIRE III

Jaakko Tuomilehto (Chairman)

Guy de Backer

Ian Graham

Andrzej Rynkiewicz

Annika Rosengren

Troels Thomsen

David Wood

John Yarnell

HEART FAILURE I

John Cleland (Chairman)

Michel Komajda (Co-Chairman)

Eric Boersma

Alain Cohen-Solal

Juan Cosin-Aguilar

Rainer Dietz

Joanne Easthaugh

Ferenc Follath

Nick Freemantle

Antonello Gavazzi

Richard Hobbes

Jerzy Korewicki

Hugo Madeira da Costa

James Mason

Karl Swedberg

Wiek H. van Gilst

Jiri Widimsky

HEART FAILURE II

Markku Nieminen (Chairman)

Dirk L. Brutsaert

Kenneth Dickstein

Helmut Drexler

Ferenc Follath

Veli-Pekka Harjola

Michel Komajda

J-L. Lopez-Sendon

Piotr Ponikowski

Luigi Tavazzi


33


Descripción del Estado de los Síndromes

Coronarios Agudos en un Registro Temporal

Español (DESCARTES)

Héctor Bueno

Alfredo Bardají

Antonio Fernández Ortiz

Magda Heras

Jaume Marrugat

The Proyecto de Registro de IAM Hospita-

larios (PRIAMHO II)

Fernando Arós (Chairman)

Pablo Ancillo

Xavier Bosch

José Cuñat

Magda Heras

Ángel Loma-Osorio

Lorenzo López Bescós

Jeame Marrugat

Pedro Pabón

Juan J Rodríguez

Elilberto Torrado

Register of Information and Knowledge

about Swedish Heart Intensive care Admis-

sions (RIKS-HIA)

Lars Wallentin (Chairman)

Ulf Stenestrand (Co-chaiman)

Ole Hansen

Cleas Held

Jan-Erik Karlsson

Ewa Mattson

Thomas Moe

Monica Sterner

Lars Svennberg

Per Werner

European Heart Rhythm Association

L. Kappenberger (President)

H. Ector

J.-Y. Le Heuzey

J. Brugada Terradellas

C. Blomström-Lundqvist

M. Borggrefe

C. Linde

P. E. Vardas

German ACS Registries MITRA-PLUS

Jochen Senges

Anselm Gitt

Martin Gottwik

Rudolf Schiele

Ulrich Tebbe

Ralf Zahn

Uwe Zeymer

Steffen Schneider

International SHAKESPEARE Registry

Anselm Gitt (Principal Investigator)

Jochen Senges (Principal Investigator)

Phil Reid

Martin Gottwik

Jean-Piere Bassand

Andrej Cieslinski

Keith Dawkins

Ricardo Seabra-Gomes

Poalo Fioretti

David Hasdai

Steffen Schneidner

Contributors to other European Surveys

and Registries of Cardiovascular Disease



34

Euro Heart Survey

Sponsors

Orquis

Ortho Biotech Products (J & J)

Pharmacia

Roche

Servier International

Wyeth-Ayerst

ACUTE CORONARY SYNDROMES I

Main sponsors

Centocor Europe

Schering-Plough

VALVULAR HEART DISEASE

Main sponsor

Toray

CORONARY REVASCULARISATION

Main sponsor

Eucomed

STABLE ANGINA PECTORIS

Main sponsor

Servier

DIABETES & THE HEART

Main sponsors

Aventis

GlaxoSmithKline

Merck Sharp & Dohme

Sponsor

Bayer AG

INSTITUTIONS

Austrian Society of Cardiology

Austrian Heart Foundation

Fédération Française de Cardiologie

Hellenic Cardiological Society

Netherlands Heart Foundation

Spanish Cardiac Society

Swedish Heart and Lung Foundation

the European Community

Individual Hospitals

EUROASPIRE II

Main sponsors

AstraZeneca

Bristol Myers

Merck & Co

Pfizer Inc.

HEART FAILURE I

Main sponsors

Astra Zeneca

GlaxoSmithKline

Medtronic Europe

Orion Pharma

Pfizer

Sponsors

Acorn

Agilent/ Phillips Medical

Aventis

Bristol Myers Squibb

Guidant Europe

Menarini UK

Merck KGa

Merck Sharp & Dohme UK

Novartis UK


35


ACUTE CORONARY SYNDROMES II

Main sponsor

Eli Lilly

ATRIAL FIBRILLATION

Main sponsors

AstraZeneca

Sanofi-Synthélabo

Sponsor

Eucomed

HEART FAILURE II

Main sponsor

GlaxoSmithKline

Sponsors

Orion

Roche

Sanofi-Synthélabo

Documents

Cardiovascular Diseases in Europe - Euro Heart Survey