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
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
NUM BER OF PATIENTS ENROLLED
300 to 400200 to 300
< 100100 to 200
400 to 500> 500No data
Patients
ESC Brochure demo right
5
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
%
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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 Syndromes
ACUTE CORONARY SYNDROM ES:
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo right
7
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
Acute Coronary Syndromes
Acute Coronary Syndromes
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
Acute Coronary Syndromes
0
20
40
60
80
100
Country
%
Beta-blocker therapy at hospital discharge
in Acute Coronary Syndromes
0
20
40
60
80
100
Country
%
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
8
Euro Heart Survey
Acute Coronary Syndromes
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.
Acute Coronary Syndromes
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
%
ESC Brochure demo right
9
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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 Coronary Syndromes
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
10
Acute Coronary Syndromes
Spanish Registries of
Acute Coronary Syndromes
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
ESC Brochure demo right
11
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
Acute Coronary Syndromes
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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:
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo right
13
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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:
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
14
Coronary Revascularisation
Euro Heart Survey
Coronary Revascularisation
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:
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo right
15
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
Coronary Revascularisation
Coronary Revascularisation
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
PCI CABG Non-Invasive
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
PCI CABG Non-Invasive
%
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
16
Coronary Revascularisation
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
ESC Brochure demo right
17
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
Coronary Revascularisation
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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:
NUM BER OF PATIENTS ENROLLED
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
%
ESC Brochure demo right
19
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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:
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo right
21
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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:
NUM BER OF PATIENTS ENROLLED
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?
ESC Brochure demo right
23
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
NUM BER OF PATIENTS ENROLLED
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
ESC Brochure demo right
25
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
by type of atrial fibrillation
0
20
40
60
80
100
First detected Paroxysmal Persistent Permanent
%
Electrical cardioversion
by type of atrial fibrillation
0
10
20
30
40
50
First detected Paroxysmal Persistent
%
Pharmacological conversion
by type of atrial fibrillation
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
2ACS-Surveys in Israel
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.
3ACS-Surveys in Israel
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
%
4ACS-Surveys in Israel
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%
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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)
%
ESC Brochure demo right
29
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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.
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
Euro Heart Survey programme
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
32
Contributors to the
Euro Heart Survey programme
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
ESC Brochure demo right
33
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo left
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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
ESC Brochure demo right
35
© European Society of Cardiology— Cardiovascular Diseases in Europe—2004
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