1. Nuevos Retos en la Cardiologa Intervencionista.Posicin de la
Sociedad Espaola de Cardiologa Programa INCARDIO Jos Ramn Gonzlez
Juanatey Presidente de la Sociedad Espaola de Cardiologa Hospital
Clnico Universitario de Santiago de Compostela 2. CV mortality and
life-spectancy in Spain 1980 a 2009 Garca Gonzlez JM, et al. Rev
Esp Cardiol 2013. Women 1980-2009 Men 1980-2009 Lifestyle changes
Prevention Health system improvements Treatment RESEARCH INNOVATION
3. Cardiovascular Disease: a complex disease needs integrated
solutions Education Raising awareness Adherence to therapy
Implementation Tools Programs Quality controls Implementation
Surveys Quality controls Impact on outcome Trials Guidelines
Recommendations Knowledge/Science (including clinical trials)
Refinement 4. ACS. An Extraordinary Journey Innovation Year Impact
CCU Blue Code. Nurses 60 & 70 Mortality B-Blockers 70 Mortality
Thrombolysis 80 Mortality ASA 80 Mortality 1 PCI 90 Mortality
Statins Late 90 Mortality ASA+Clopi Late 90 Morbidity Better
anticoagulation 00 Morbi-mortality Prasugrel, Ticagrelor 00
Morbi-mortality Team Work, STEMI code 00 Mortality? Hypothermia 10
Mortality? 30% 5% 5. IHD 2Prev. An Extraordinary Journey Innovation
Year Impact B-Blockers 70 Mortality ASA 80 Mortality Life-style
changes/Rehab 70-15 Mortality ACE Ih 80-90 Morbi-mortality Statins
90 Mortality Team Work 90 Mortality Revasc (subgroups) 00
Morbi-mortality Vorapaxar 13 Morbi-mortality Rivaroxaban 13
Morbi-mortality Ticagrelor 15 Morbi-mortality Ezetimibe 15
Morbi-mortality 10 %/y 2 %/y 6. Heart Failure. An Extraordinary
Journey Innovation Year Impact ACE Inhibitors 80 Mortality
B-Blockers 00 Mortality Aldosterone Recept Block 00 Mortality
Defibril/Cardiac RT 00 Mortality Nurses Process 00 Mortality-morbi
Cardiac Transplant 80-00 Mortality Ivabradin 10 Morbi-mortality? VA
Devices 10 Morbi-mortality LCZ-696 14 Morbi-mortality Acute HF code
00-15 Mortality-Morbi? Gene therapy 15? Mortality? 40% 10% 7. Three
priorities. Role SEC Excellent science Industrial leadership
Societal challenges European Research Council Future and Emerging
Technologies Marie Skodowska-Curie actions Research infrastructures
Reserch Grants Leadership in enabling and industrial technologies
Access to risk finance Innovation in SMEs Innova-SEC Health,
demographic change and wellbeing Food security, sustainable
agriculture and forestry, marine and maritime and inland water
research and the Bioeconomy Secure, clean and efficient energy
Smart, green and integrated transport Climate action, environment,
resource efficiency and raw materials Inclusive, innovative and
reflective societies Secure societies Science with and for society
Spreading excellence and widening participation RECALCAR/INCA RDIO
8. Diferencias Interterritoriales Existen importantes variaciones
interterritoriales en la dotacin de recursos, frecuentacin,
produccin y calidad en la atencin al paciente cardiolgico, as como
en la forma de organizar y gestionar la asistencia cardiolgica.
RECALCAR 2012 Recursos en Cardiologa 9. RECALCAR y retos de la
cardiologa Ha aumentado la representatividad de la muestra.
Aportacin de informacin de los registros de las Secciones.
Cumplimentar el el registro no es una rutina para todas las UAC del
SNS. Se inici en 2013 en el proceso de retroalimentacin a las UAC
informantes. 1. Mejorar la base de datos de UAC, especialmente en
porcentaje de unidades que responden, permitiendo un anlisis en
todas las Comunidades Autnomas y retroalimentando la informacin a
las UAC que participan. 3. Trabajar en estrecha colaboracin con
mdicos de otras especialidades y unidades que atienden a pacientes
con enfermedades cardiolgicas y con los equipos de atencin
primaria. Son minoritarias las UAC que han establecido un cardilogo
como referente de cada equipo de atencin primaria de su rea de
influencia y desarrollado instrumentos de trabajo conjunto.4. Crear
redes asistenciales de UAC. 5. Regionalizar unidades de referencia.
Slo el 12% de las UAC refieren estar integradas en una red de mbito
regional (600.000 o ms habitantes). 6. Poner el nfasis en el
aumento de la calidad (gestin por procesos) y la eficiencia, ms que
en la dotacin de recursos. Baja implantacin de una gestin por
procesos. Amplias variaciones en el rendimiento de los recursos.Un
28% de UAC con ms de 24 camas no tienen asignada guardia de
presencia fsica. Algunas UAC con unidad de hemodinmica o ciruga
cardiovascular no tienen camas asignadas. Un 77% de los servicios
de ciruga cardiovascular hace menos de 600 intervenciones
quirrgicas mayores. 7. Evitar riesgos potenciales de malas
prcticas: ausencia de guardias de presencia fsica en unidades con
ms de 1.500 ingresos y/o procedimientos complejos; actividad de
hemodinmica y ciruga cardiovascular en centros sin camas asignadas
a cardiologa; volmenes de actividad por debajo de los recomendados.
8. Reducir las desigualdades interterritoriales en buenas prcticas
vinculadas a resultados (por ejemplo: redes y actividad de ICP-p en
IAM). Existen notables diferencias entre Comunidades Autnomas, que
probablemente inciden en la calidad asistencial y resultados de la
atencin a los pacientes con cardiopata en los distintos territorios
10. CMBD Un 48% de los episodios de ingreso hospitalario con
diagnstico de alta de enfermedad del rea del corazn es dado de alta
por servicios distintos al de cardiologa CMBD_CAR contiene 3,7
millones episodios de hospitalizacin con diagnstico principal al
alta de enfermedad del rea del corazn durante el perodo 2003-2012
La Insuficiencia Cardiaca Crnica es uno de los principales retos
del Sistema Nacional de Salud y de la cardiologa (escasos progresos
en frecuentacin, estancia media y reingresos). Existen notables
mrgenes de mejora en la calidad de la asistencia hospitalaria
prestada a los pacientes con enfermedades del rea del corazn. 11.
SEC quality of care virtuose circle 12. Definir los indicadores de
calidad asistencial en Cardiologa Sociedad de Ciruga Torcica y
Cardiovascular S E C T C V 13. Hospital I Low complexity II
Intermediate Complexity III High Complexity Volume: Beds < 200
200 to 500 > 500 Volume: Cardio < 500 patients / year 500 to
1000 patients / year > 1000 patients / year Organization
Cardiology not considered as an independent unit Cardiology
independent unit (own beds) Cardiology independent unit (own beds)
Intensive Cardiac Care Unit No, or yes but transfers complex
patients to other hospitals Yes, No dedicated ICCU Dedicated ICCU
Interventional cardiology unit No Yes, but complex cases are
transferred to other hospitals PCI not available 24h / 7 days Yes,
including complex cases PCI available 24h / 7 days Interventional
electrophysiology No, except pacemakers Yes, but complex cases are
transferred to other hospitals Yes, including ICD / CRT
implantation, and treatment of complex arrhythmias Cardiac surgery
No No Yes, available 24h / 7 days Transfer of patients All cases
for PCI, complex arrhythmias & Cardiac Surgery Transfer of
complex cases to another hospital including complex PCI,
arrhythmias or surgery Minimal (e.g.: heart transplant) Receives
complex patients from other hospitals INCARDIO. Clasificacin de los
Hospitales 14. Metric Suggested Reference Value Relevance
Difficulty Auditable Evidence References Mortality* STEMI mortality
(excluding patients unconscious at admission) < 5% (a) 1 1 1 A
115, 116, 131, 132,, 141 Non STE-ACS mortality (excluding patients
unconscious at admission) < 5% (a) 1 1 1 A 117, 118, 131, 132,
141 Staged PCI mortality < 1% (a) 1 1 1 A 140-142 TAVI mortality
< 10% (a) 1 1 1 A 147 - 149 VT after AMI and other complex
catheter ablation mortality < 3% (a) 1 1 1 A 150 - 152
Pacemaker, ICD, CRT implant mortality < 1% (a) 1 1 1 A 153, 154
Heart Failure mortality < 7% (a) 1 1 1 A 160, 161 Staged 1st
Aortic valve surgery replacement mortality (excluding TAVI) < 5%
(a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery
replacement mortality < 7% (a) < 9% (b) 1 1 1 A 159 - 161
Staged 1st Mitral valve surgery repair mortality < 3% (a) <
5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined surgery)
mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st
combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A 159 -
161 Heart transplant < 15% (a) (c) 1 1 1 A 161b INCARDIO STEMI
mortality 75 / year Primary PCI > 50 year (PPCI per operator
> 11 year) PCI in hospitals without cardiac/vascular surgery:
Volumes > 200 / year and protocol for team work with hospital
with cardiac surgery Complex PCI cases including coronary and
structural interventions only acceptable in hospitals with
cardiac/vascular surgery Interventional Cardiology 33. 156 390 90
173 7.8 45.7 34. Cath Lab Unit Technology Reference hospital with
cardiac/vascular surgery for high risk PCI or reference in
structural interventions Cath labs technology < 10 years old 2
cath labs in hospital with a Primary PCI Program 1 Complete cath
lab with clear maintenance protocols. Includes defibrillator,
mechanical ventilator, OCT, IVUS and IABP or LVAD in labs
performing routine high risk procedures Interventional Cardiology
35. Cath Lab Unit Staffing Certified interventional cardiologists,
minimal 1, optimal all Nurses with > 1 year experience in cath
lab, minimal 2, desirable 3/lab N Interventional Cardiologists >
4 if Primary PCI Program Interventional Cardiology 36.
Accreditation Certification of qualification coferred by external
organizations Cardiologist with accreditation in PCI highly
recommended Interventional Cardiology Patient Services Cath Lab
open 24 / 7 /365 days recommended in hospitals > 300.000
(population) Regional Network for STEMI and other ACS 37. Local
Protocols (diagnosis and treatment for each technique based on
ESC/AHA/ACC guidelines) Risk stratification (GRACE, TIMI, SINTAX,
NCDR) HEART TEAM decission in all non-emergency procedures Optimal
Medical Treatment according to ESC/AHA/ACC guidelines Renal
Protection Protocol Alergic reactions Protocol Diabetic patients
Protocols Radial Use > 50% Interventional Cardiology 38. Trends
in in-hospital mortality rates after isolated CABG surgery in
Ontario 1991-2006 2.95 2.83 3.17 2.83 2.42 2.32 2.2 2.29 2.18 2.32
2.08 1.03 1.23 1.39 1.1 1.17 0 0.5 1 1.5 2 2.5 3 3.5 1991 1992 1993
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Fiscal Year In-HospitalMortalityRate(%) Confidential reporting
Public reporting 39. SEC quality of care virtuose circle 40.
Diferencias Interterritoriales (IAM. 2012) Frec. EM TBM %
Reingresos Andaluca 116,9 6,8 8,5% 7,7% Aragn 114,0 9,5 10,0% 5,0%
Asturias 156,1 7,1 7,2% 6,3% Baleares 113,7 7,0 5,7% 4,9% Canarias
100,0 9,7 7,0% 3,3% Cantabria 117,8 6,2 8,1% 3,7% Castilla y Len
144,5 7,1 8,0% 6,2% Castilla-La Mancha 109,7 7,2 8,6% 3,7% Catalua
117,8 6,9 6,3% 6,7% Comunidad Valenciana 109,9 6,8 8,6% 4,9%
Extremadura 132,0 7,4 7,4% 5,3% Galicia 127,8 8,4 6,8% 5,3% Madrid
86,0 7,5 6,1% 3,5% Murcia 123,3 7,4 6,9% 7,2% Navarra 93,9 9,0 6,2%
6,4% Pas Vasco 89,1 7,9 7,5% 4,0% Rioja 125,6 8,9 6,9% 5,4% Total
general 112,8 7,3 7,5% 5,7% Promedio 116,4 7,7 7,4% 5,3% Mediana
116,9 7,4 7,2% 5,3% DS 18,4 1,0 1,1% 1,3% Max 156,1 9,7 10,0% 7,7%
Min 86,0 6,2 5,7% 3,3% RECALCAR 2012 STEMI. Risk-adjusted Mortality
41. RECALCAR-2012 Mortalidad Intrahospitalaria de la PCI en
Pacientes sin IAM 42. STEMI Mortality rate 2010-2012 IAMCAT II1
2003 IAMCAT III2 2006 Codi Infart3 2010 Codi Infart3 2011 Codi
Infart3 2012 30-day mortality 11,7 % 7,4% 6,8% 6,3% 6,4% 1-year
mortality NA NA 9,9 % 10,4 % 8,6 % Catalunya Codi Infart 1.
www.catcardio.cat 2. Med Clin (Barc) 2009;133:694 3. Registre Codi
Infart. Departament de Salut. Generalitat de Catalunya, 2010-2012
43. Berlin Myocardial Infarction Registry 10 year changes in
treatment and outcome Jens-Uwe Rehnisch et al ECC 2011# 5207
Berliner Herzinfarktregister Hospital Mortality for STMI &
NSTMI Medications and Reperfusion therapy Year Ptrend 300.000) 198
Accreditation At least 1 cardiologist accredited in acute cardiac
care 198 Any accreditation conferred by any external organizations
198 Patient services Regional network for STEMI and other ACS 115
Cath lab available 2/7 115 Bundle of care treatment for sudden
death (includes temperature management) 14528 Risk stratification
(GRACE, TIMI, CRUSADE) 115 - 118, 223 Process of delivery care for
diagnosis, treatment, prevention and patient education Local
protocols based on ESC /AHA- ACC guidelines STEMI and Non-STEMI
protocols 115 - 118, 145 Optimal medical treatments according to
ESC / AHA ACC guidelines 115 - 118 Multidisciplinary protocols
Prehospital systems, emergency department, cardiac unit. 115 - 118
Heart failure: Cardiac unit, internal medicine, emergency
department 289, 290 Results Outcomes in selected populations as
described in table # 5 Quality controls Adherence to ESC / AHA-ACC
guidelines Patients with primary PCI in STEMI: > mean value in
national registries Time to call-door-balloon/lytic: < 60 min
after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI
diagnosis Patients with dual antiplatelet therapy in ACS: > mean
value in national registries 115 - 118 Acute Cardiac Care /
Intensive Cardiac care ICCU: Recommended 4-5 beds/100.000
inhabitants Cardiologist on call 24 h (recommended in Hospitals
> 300.000 inhabitants) All Nurses with > 1 year Cardiology
Experience. Experience in Acute Cardiac Care 46. UCAC No UCAC p TBM
hosp % 7.57 6.58 0.058 RAMER hosp % 7.78 6.96 0.02 TBM: Tasa bruta
de mortalidad. RAMAR: Razn de mortalidad ajustada por riesgo
Mortalidad por IAM en Espaa Unidades Cuidados Cardiolgicos Agudos
Rev Esp Cardiol 2013; 66: 935-942 47. 12,000 22,000 32,000 42,000
52,000 62,000 72,000 82,000 92,000 102,000 112,000 2003 2004 2005
2006 2007 2008 2009 2010 2011 2012 INSUFICIENCIA CARDIACA INFARTO
AGUDO MIOCARDIO ARRITMIAS C. ISQUEMICA CRONICA C. ISQUEMICA AGUDA
Hospital admission for Cardiac Diseases RECALCAR 2012 48. Heart
Failure Units Metric Recommendation Reference s Structure.
Resources directly related to patient care Hospital volumes N
patients with heart failure discharged from hospital Desired
technology Natriuretic peptides 120, 156, 369 Type II and III
hospitals: ECHO available 24 hours. Multidisciplinary heart failure
outpatient clinic., ICD and CRT therapy 11, 120, 369, 371- 373 Type
III hospitals: Intensive CCU, Circulatory assist devices 120, 369
Staffing Type II and III hospitals: Cardiologists assigned to heart
failure management 11, 119 Type III hospitals: Accredited
cardiologists assigned to advanced heart failure program 11, 119
Type III hospitals: Specialized nurses assigned to heart failure
management . Nurse outpatient consult 11, 119, 213, 371- 373
Accreditation Type III hospitals: Accredited multidisciplinary
Heart failure program, including cardiologists, internal medicine,
oncology, rehabilitation specialists, internal medicine, general
physicians, other 120, 369 Type III hospitals: Accredited Advanced
heart failure cardiologists 372 Patient services Type III
hospitals: Heart failure outpatient clinic 11, 156, 157, 120, 369,
370 Type III hospitals: Heart failure in-hospital management
program 156, 157, 120, 369, 370 , All hospitals: On site or access
to Rehabilitation, advance heart failure unit, heart transplant,
complex pulmonary hypertension units and palliative care units 120,
369, 373 Heart Failure Units Type III hospitals: Specialized nurses
assigned to heart failure management. Nurse outpatient clinic. N
patients with HF discharged from hospital 49. Cardiac imaging
Metric Recommendation References Structure. Resources directly
related to patient care Hospital volumes TTE, TOE, stress echo:
recommended: > 1500 and 300 / studies / staff / y) 265, 266 CCT
studies (recommended > 250 / year) 267 CMR studies (recommended
> 300 / year)* Desired technology TTE, in all hospitals. TOE and
stress echo, in type II and III hospitals. 3D echo in type III
hospitals. CCT, SPECT or PET Scanner and CMR in-house type II and
III hospitals or in reference hospital. 194, 255 - 264 Staffing
Cardiac Imaging certified cardiologists (recommended 1 per
technique: Echo, CMR, CCT), Level 2/3 194, 255 - 264 Certified
technicians (recommended 1 per technique) in all hospitals Nurses
with experience in stress testing and transesophagic ECHO 194, 255
264, 264b Accreditation Official accreditation (ESC or similar) of
Echo lab, CCT lab, CMR lab 194, 255 - 264 Patient services TT
Echocardiography available 24/7/365 in hospitals II and III Process
of delivery of care for diagnosis and treatment Local protocols For
indications based on ESC /AHA.ACC guidelines for each technique
204, 205, 267 - 276 Protocols to reduce radiation from CCT All
cases < 15 mSv 273 -275 Waiting list Outpatient, nonurgent,
studies, recommended 100% < 30 days 194 Hospitalized patient,
recommended 90%) 264, 282, 285 Report of radiation dose Recommended
in 100% of cases (CCT) 272, 286, 287 Waiting list Recommended: <
mean value in local registries Cardiac Imaging Certified
technicians (recommended > 1 per technique) Nurses with
experience in stress echo and TEE TTE available 24/7/365 in
hospitals II and III 50. Cath Lab Unit Volumes PCI: optimal >
400 year. If < 200 / year cath lab should be part of a larger
network PCI per operator > 75 / year Primary PCI > 50 year
(PPCI per operator > 11 year) PCI in hospitals without
cardiac/vascular surgery: Volumes > 200 / year and protocol for
team work with hospital with cardiac surgery Complex PCI cases
including coronary and structural interventions only acceptable in
hospitals with cardiac/vascular surgery Interventional Cardiology
51. Cath Lab Unit Technology Reference hospital with
cardiac/vascular surgery for hogh risk PCI or reference in
structural interventions Cath labs technology < 10 years old 2
cath labs in hospital with a Primary PCI Program 1 Complete cath
lab with clear maintenance protocols. Includes defibrillator,
mechanical ventilator, OCT, IVUS and IABP or LVAD in labs
performing routine high risk procedures Interventional Cardiology
52. Cath Lab Unit Staffing Certified interventional cardiologists,
minimal 1, optimal all Nurses with > 1 year experience in cath
lab, minimal 2, desirable 3/lab N Interventional Cardiologists >
4 if Primary PCI Program Interventional Cardiology 53.
Accreditation Certification of qualification coferred by external
organizations Cardiologist with accreditation in PCI highly
recommended Interventional Cardiology Patient Services Cath Lab
open 24 / 7 /365 days recommended in hospitals > 300.000
(population) Regional Network for STEMI and other ACS 54. Local
Protocols (diagnosis and treatment for each technique based on
ESC/AHA/ACC guidelines) Risk stratification (GRACE, TIMI, SINTAX,
NCDR) HEART TEAM decission in all non-emergency procedures Optimal
Medical Treatment according to ESC/AHA/ACC guidelines Renal
Protection Protocol Alergic reactions Protocol Diabetic patients
Protocols Radial Use > 50% Interventional Cardiology 55.
Interventional Cardiology All nurses with > 1 year experience in
cath lab, minimal 2, desirable 3/lab HEART TEAM decision in all
non-emergency procedures including nurses PCI: optimal > 400
year: If < 200 year, cath lab should be part of a larger network
PCI per operator > 70 year Primary PCI > 36-50 year (PPCI per
operator > 11 / year Cath lab open 24/7/365 recommended in
hospitals>300000 (population) 56. Metric Suggested Reference
Value Relevance Difficulty Auditable Evidence References Mortality*
STEMI mortality (excluding patients unconscious at admission) <
5% (a) 1 1 1 A 115, 116, 131, 132,, 141 Non STE-ACS mortality
(excluding patients unconscious at admission) < 5% (a) 1 1 1 A
117, 118, 131, 132, 141 Staged PCI mortality < 1% (a) 1 1 1 A
140-142 TAVI mortality < 10% (a) 1 1 1 A 147 - 149 VT after AMI
and other complex catheter ablation mortality < 3% (a) 1 1 1 A
150 - 152 Pacemaker, ICD, CRT implant mortality < 1% (a) 1 1 1 A
153, 154 Heart Failure mortality < 7% (a) 1 1 1 A 160, 161
Staged 1st Aortic valve surgery replacement mortality (excluding
TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral
valve surgery replacement mortality < 7% (a) < 9% (b) 1 1 1 A
159 - 161 Staged 1st Mitral valve surgery repair mortality < 3%
(a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined
surgery) mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged
1st combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A
159 - 161 Heart transplant < 15% (a) (c) 1 1 1 A 161b TAVI
mortality 100 general catheter ablation procedures/y. 133, 350, 351
Non-complex procedures (ablation of paroxysmal supraventricular
tachycardia, AV nodal ablation, and common atrial flutter.
Recommended >100 procedures/year. 350, 351 Pacemaker implants
(>12 implants/y per operator), ICDs (>10 implants/y), and
CRTs (>10 implants/y) 352, 353 Desired technology Accredited
Arrhythmia Unit in hospitals >100 invasive EP procedures/y 350,
354 Dedicated RX lab 59, 350, 355, 356 Staffing >2 certified
cardiologists accredited in arrhythmias 59, 356 358 Certified
cardiologist accredited in arrhythmias responsible for the unit
356, 357, 359 Nurses with > 1 year experience in arrhythmias,
ablation and device implantation and follow-up, minimal 2,
desirable 3/ lab Arrhythmias nurse outpatient consult desirable
(pacemarker and device follow-up) 356, 356b, 256c Accreditation
Accredited Arrhythmia Unit (EHRA, SEA, Certification ISO 9001:2008)
357, 359 Patient services Arrhythmia Ablation, Pacemaker AND ICD,
CRT implantation 59, 356 Arrhythmia outpatient clinic 59, 356
Electrophysiology and arrhythmias All nurses with > 1 year
experience in arrhythmias, ablation and device implantation and
follow-up minimal 2, desirable 3/lab Arrhythmias nurse outpatient
consult desirable (PM and device follow-up) Complex procedures:
Atrial Fibrillation. Recommended > 50 / year Complex procedures:
ventricular Tachy recommended only in labs with > 100 general
cath ablation procedures/year Pacemaker implants (10 implants/y,
CRT> 10 implants/y 58. Radiation dose measure (fluoroscopy time
/ dose for patient and staff Interventional Cardiology 59. Metric
Suggested Reference Value Relevance Difficulty Auditable Evidence
References Mortality* STEMI mortality (excluding patients
unconscious at admission) < 5% (a) 1 1 1 A 115, 116, 131, 132,,
141 Non STE-ACS mortality (excluding patients unconscious at
admission) < 5% (a) 1 1 1 A 117, 118, 131, 132, 141 Staged PCI
mortality < 1% (a) 1 1 1 A 140-142 TAVI mortality < 10% (a) 1
1 1 A 147 - 149 VT after AMI and other complex catheter ablation
mortality < 3% (a) 1 1 1 A 150 - 152 Pacemaker, ICD, CRT implant
mortality < 1% (a) 1 1 1 A 153, 154 Heart Failure mortality <
7% (a) 1 1 1 A 160, 161 Staged 1st Aortic valve surgery replacement
mortality (excluding TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 -
161 Staged 1st Mitral valve surgery replacement mortality < 7%
(a) < 9% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery
repair mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged
1st CABG (without combined surgery) mortality < 3% (a) < 5%
(b) 1 1 1 A 159 - 161 Staged 1st combined CABG + AVR mortality <
6% (a) < 8% (b) 1 1 1 A 159 - 161 Heart transplant < 15% (a)
(c) 1 1 1 A 161b INCARDIO STEMI mortality 1 y / operating room
Accreditation Accredited cardiac surgery unit Patient services
Urgent cardiac surgery Scheduled priority system 161 Prevention of
infections protocol 161 Process of delivery care Protocols for
evaluation and treatment according to ESC / AHA-ACC Guidelines Risk
evaluation using protocols: Euro Score2, SINTAX, other 161
Protocols for indication of cardiac surgery, major procedures 320
HEART TEAM approach for all major surgery indications 161, 345, 346
Scheduled priority system Transfer protocols from hospitals type I
and II to III Use of medication for secondary prevention at
hospital discharge. Recommended > 90% in all hospitals 115 - 118
161, 377, Results Outcomes in selected populations as described in
table # 5 Quality controls ESC / AHA-ACCC / Guideline adherence
Prescription of appropriate medication for secondary prevention at
hospital discharge Recommended: > 90% in patients without
contraindications 115 - 118 161, 377, 398 Other: Waiting list,
Infections, Bleeding and other complications, Recommended < mean
value in local registries Cardiac Surgery Nurses assigned to
cardiac surgery, experience > 1 year / operating room Major
cardiac surgery procedures. Recommended > 500 year or > 70 /
cardiac surgeron / year HEART TEAM approach for all major surgery
indications. Including Nurses 61. Metric Suggested Reference Value
Relevance Difficulty Auditable Evidence References Mortality* STEMI
mortality (excluding patients unconscious at admission) < 5% (a)
1 1 1 A 115, 116, 131, 132,, 141 Non STE-ACS mortality (excluding
patients unconscious at admission) < 5% (a) 1 1 1 A 117, 118,
131, 132, 141 Staged PCI mortality < 1% (a) 1 1 1 A 140-142 TAVI
mortality < 10% (a) 1 1 1 A 147 - 149 VT after AMI and other
complex catheter ablation mortality < 3% (a) 1 1 1 A 150 - 152
Pacemaker, ICD, CRT implant mortality < 1% (a) 1 1 1 A 153, 154
Heart Failure mortality < 7% (a) 1 1 1 A 160, 161 Staged 1st
Aortic valve surgery replacement mortality (excluding TAVI) < 5%
(a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery
replacement mortality < 7% (a) < 9% (b) 1 1 1 A 159 - 161
Staged 1st Mitral valve surgery repair mortality < 3% (a) <
5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined surgery)
mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st
combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A 159 -
161 Heart transplant < 15% (a) (c) 1 1 1 A 161b INCARDIO STEMI
mortality 50% after AMI? ACS (Ideally all patients should be
offered some kind of rehabilitation program) 376, 385, 395, 397
Control of major risk factors and adherence to guideline
recommendations for life style Smoking: sustained smoking
abstinence >50% in CVD 384 - 386, 392, 393, 395, 397, 399
Hypertension optimal control (< 140/90) > 50%? 376, 386, 393,
397 LDL < 70, recommended target > 70% (1,8 mmml/L) or
highest tolerated dose of statins > 50% of patients 376, 385,
394, 397, 400 Adherence to guideline recommendations of lifestyle
Exercise, Diet, smoking counselling: Recommended in 100% 376, 387,
390, 397, 399 Adherence to ESC / AHA-ACCC guideline recommendation
for 2nd prevention treatment Antiplatelet, Statins, Beta-blockers,
ACE-I, aldosterone blockers unless contraindicated. Recommended
>90 % unless contraindicated 115 - 118, 376, 397, 398 % of
patients admitted in a rehabilitation program after 1st ACS or
revascularization Recommended > mean value in local registries
Cardiac Rehabilitation. Quality controls Smoking: sustained smoking
abstinence > 50% Exercise, diet, smoking counselling:
recommended in 100% 86. IHD 2Prev. An Extraordinary Journey
Innovation Year Impact B-Blockers 70 Mortality ASA 80 Mortality
Life-style changes/Rehab 70-15 Mortality ACE Ih 80-90
Morbi-mortality Statins 90 Mortality Team Work 90 Mortality Revasc
(subgroups) 00 Morbi-mortality Vorapaxar 13 Morbi-mortality
Rivaroxaban 13 Morbi-mortality Ticagrelor 15 Morbi-mortality
Ezetimibe 15 Morbi-mortality 10 %/y 2 %/y 87. 0 2000 4000 6000 8000
10000 12000 14000 16000 18000 smoking cessation program, high risk
CAD smoking cessation program, low risk CAD Post AMI ACE-inh
Cardiac Rehab post AMI BBL post MI Statins (4S) CABG/PCI AAS
Thrombolytic th. The cardiologist and smoking cessation. Aboyans,
Victor; Thomas, Daniel; Lacroix, Philippe Current Opinion in
Cardiology. 25(5):469-477, September 2010. DOI:
10.1097/HCO.0b013e32833cd4f7 Cost per life year gained Cambios en
Estilo de Vida en Prevencin Secundaria. Lo mas coste-efectivo 88.
En 2013: 7434 pacientes rehabilitados 76.666 SCA 85% EC crnica +
aguda 64 % fueron SCA 4.757 pacientes con SCA 6,2% 2.Escaso nmero
de pacientes atendidos en las Unidades de Rehabilitacin Cardiaca La
Rehabilitacin Cardaca uno de los grandes retos de la enfermera en
Espaa 89. Proyecto para pacientes y profesionales La Enfermera como
el Centro del Proceso 90. Coordinador: Dr. Lorenzo Fcila Dra.
Almudena Castro 1. Desarrollo web 2. Paciente experto 1. MimoApp 2.
MimoKids 1. MimoFarmacias 91. Cardiac imaging Metric Recommendation
References Structure. Resources directly related to patient care
Hospital volumes TTE, TOE, stress echo: recommended: > 1500 and
300 / studies / staff / y) 265, 266 CCT studies (recommended >
250 / year) 267 CMR studies (recommended > 300 / year)* Desired
technology TTE, in all hospitals. TOE and stress echo, in type II
and III hospitals. 3D echo in type III hospitals. CCT, SPECT or PET
Scanner and CMR in-house type II and III hospitals or in reference
hospital. 194, 255 - 264 Staffing Cardiac Imaging certified
cardiologists (recommended 1 per technique: Echo, CMR, CCT), Level
2/3 194, 255 - 264 Certified technicians (recommended 1 per
technique) in all hospitals Nurses with experience in stress
testing and transesophagic ECHO 194, 255 264, 264b Accreditation
Official accreditation (ESC or similar) of Echo lab, CCT lab, CMR
lab 194, 255 - 264 Patient services TT Echocardiography available
24/7/365 in hospitals II and III Process of delivery of care for
diagnosis and treatment Local protocols For indications based on
ESC /AHA.ACC guidelines for each technique 204, 205, 267 - 276
Protocols to reduce radiation from CCT All cases < 15 mSv 273
-275 Waiting list Outpatient, nonurgent, studies, recommended 100%
< 30 days 194 Hospitalized patient, recommended 90%) 264, 282,
285 Report of radiation dose Recommended in 100% of cases (CCT)
272, 286, 287 Waiting list Recommended: < mean value in local
registries Cardiac Imaging Certified technicians (recommended >
1 per technique) Nurses with experience in stress echo and TEE TTE
available 24/7/365 in hospitals II and III 92. Enfermera
Cardiolgica e Imagen Cardiovascular 93. Acute cardiac care /
Intensive cardiac care Metric Recommendation References Structure.
Resources directly related to patient care Hospital volumes 4-5
ICCU beds / 100.000 inhabitants 198 Desired technology Intensive
care environment technology 198 Staffing All nurses with > 1
year cardiology experience. Experience in acute cardiac care 198 At
least 1 cardiologist certified in acute coronary care (optimal: 1 /
3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals
> 300.000) 198 Accreditation At least 1 cardiologist accredited
in acute cardiac care 198 Any accreditation conferred by any
external organizations 198 Patient services Regional network for
STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care
treatment for sudden death (includes temperature management) 14528
Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process
of delivery care for diagnosis, treatment, prevention and patient
education Local protocols based on ESC /AHA- ACC guidelines STEMI
and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments
according to ESC / AHA ACC guidelines 115 - 118 Multidisciplinary
protocols Prehospital systems, emergency department, cardiac unit.
115 - 118 Heart failure: Cardiac unit, internal medicine, emergency
department 289, 290 Results Outcomes in selected populations as
described in table # 5 Quality controls Adherence to ESC / AHA-ACC
guidelines Patients with primary PCI in STEMI: > mean value in
national registries Time to call-door-balloon/lytic: < 60 min
after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI
diagnosis Patients with dual antiplatelet therapy in ACS: > mean
value in national registries Patients with statins at discharge:
> mean value in national registries Aspirin at admission: >
mean value in national registries 115 - 118 Safety Infections:
Recommended < mean value in national registries Transfusions:
Recommended < mean value in national registries 115 - 118 291
Acute cardiac care / Intensive cardiac care All nurses with > 1
year cardiology experience. Experience in acute cardiac care
Cardiologist on call 24 h (recommended in hospitals > 300.000)
94. ACS. An Extraordinary Journey Innovation Year Impact CCU Blue
Code. Nurses 60 & 70 Mortality B-Blockers 70 Mortality
Thrombolysis 80 Mortality ASA 80 Mortality 1 PCI 90 Mortality
Statins Late 90 Mortality ASA+Clopi Late 90 Morbidity Better
anticoagulation 00 Morbi-mortality Prasugrel, Ticagrelor 00
Morbi-mortality Team Work, STEMI code 00 Mortality? Hypothermia 10
Mortality? 30% 5% 95. UCAC No UCAC p TBM hosp % 7.57 6.58 0.058
RAMER hosp % 7.78 6.96 0.02 TBM: Tasa bruta de mortalidad. RAMAR:
Razn de mortalidad ajustada por riesgo Mortalidad por IAM en Espaa
Unidades Cuidados Cardiolgicos Agudos Rev Esp Cardiol 2013; 66:
935-942 96. Heart Failure Units Metric Recommendation Reference s
Structure. Resources directly related to patient care Hospital
volumes N patients with heart failure discharged from hospital
Desired technology Natriuretic peptides 120, 156, 369 Type II and
III hospitals: ECHO available 24 hours. Multidisciplinary heart
failure outpatient clinic., ICD and CRT therapy 11, 120, 369, 371-
373 Type III hospitals: Intensive CCU, Circulatory assist devices
120, 369 Staffing Type II and III hospitals: Cardiologists assigned
to heart failure management 11, 119 Type III hospitals: Accredited
cardiologists assigned to advanced heart failure program 11, 119
Type III hospitals: Specialized nurses assigned to heart failure
management . Nurse outpatient consult 11, 119, 213, 371- 373
Accreditation Type III hospitals: Accredited multidisciplinary
Heart failure program, including cardiologists, internal medicine,
oncology, rehabilitation specialists, internal medicine, general
physicians, other 120, 369 Type III hospitals: Accredited Advanced
heart failure cardiologists 372 Patient services Type III
hospitals: Heart failure outpatient clinic 11, 156, 157, 120, 369,
370 Type III hospitals: Heart failure in-hospital management
program 156, 157, 120, 369, 370 , All hospitals: On site or access
to Rehabilitation, advance heart failure unit, heart transplant,
complex pulmonary hypertension units and palliative care units 120,
369, 373 Heart Failure Units Type III hospitals: Specialized nurses
assigned to heart failure management. Nurse outpatient clinic. N
patients with HF discharged from hospital 97. 12,000 22,000 32,000
42,000 52,000 62,000 72,000 82,000 92,000 102,000 112,000 2003 2004
2005 2006 2007 2008 2009 2010 2011 2012 INSUFICIENCIA CARDIACA
INFARTO AGUDO MIOCARDIO ARRITMIAS C. ISQUEMICA CRONICA C. ISQUEMICA
AGUDA Hospital admission for Cardiac Diseases RECALCAR 2012 98.
Heart Failure. An Extraordinary Journey Innovation Year Impact ACE
Inhibitors 80 Mortality B-Blockers 00 Mortality Aldosterone Recept
Block 00 Mortality Defibril/Cardiac RT 00 Mortality Nurses Process
00 Mortality-morbi Cardiac Transplant 80-00 Mortality Ivabradin 10
Morbi-mortality? VA Devices 10 Morbi-mortality LCZ-696 14
Morbi-mortality Acute HF code 00-15 Mortality-Morbi? Gene therapy
15? Mortality? 40% 10% 99. Roccaforte, et al. Eur J Heart Fail
2005; 7: 1133-44 Metaanlisis de Programas Asistenciales en IC.
Papel Central de la Enfermera Enfermera asistencial 100.
Interventional Cardiology All nurses with > 1 year experience in
cath lab, minimal 2, desirable 3/lab HEART TEAM decision in all
non-emergency procedures including nurses PCI: optimal > 400
year: If < 200 year, cath lab should be part of a larger network
PCI per operator > 70 year Primary PCI > 36-50 year (PPCI per
operator > 11 / year Cath lab open 24/7/365 recommended in
hospitals>300000 (population) 101. La Enfermera en Cardiologa
Intervencionista Atencin Paciente Intrumentacin Control Tcnico
Control Material 102. Andaluca 8,33 7,94 -0,39 Aragn 8,13 7,18
-0,95 Asturias 7,99 7,55 -0,44 Baleares 7,47 6,33 -1,14 Canarias
8,03 7,75 -0,28 Cantabria 8,11 7,56 -0,55 Castilla y Len 8,08 7,00
-1,08 Castilla La Mancha 7,28 7,26 -0,02 Catalua 6,96 6,66 -0,30
Valenciana 9,57 8,49 -1,08 Extremadura 7,98 7,54 -0,44 Galicia 7,64
7,14 -0,50 Madrid 7,73 6,61 -1,12 Murcia 7,78 7,40 -0,38 Navarra
6,06 6,08 0,02 Pas Vasco 8,71 7,29 -1,42 Rioja 7,34 7,09 -0,25
PROMEDIO 7,84 7,31 -0,53 CCAA Mortalidad IAM (%) Evolucin RECALCAR
2012 STEMI. Risk-adjusted Mortality 2011 2012 103. Desigualdades
Interterritoriales (IAM. 2012) Lmite inferior Lmite superior
Mortalidad_IAM_esperada ,876 ,003 0,000 ,870 ,881
Mortalidad_IAM_prevista ,882 ,003 0,000 ,876 ,888
Mortalidad_IAM_nulo ,598 ,005 ,000 ,589 ,607 Variables resultado de
contraste rea EE p Intervalo de confianza asinttico al 95% OR Sexo
(Mujer vs Hombre)1,214 1,116 1,320 Edad (ao) 1,069 1,065 1,074
Shock 23,152 20,818 25,748 DM comp 1,608 1,400 1,846 ICC 1,730
1,589 1,883 ECV 2,283 2,003 2,602 Tumor 1,994 1,662 2,395 EAP 2,153
1,599 2,897 IRA 2,631 2,379 2,912 Arritmia 1,749 1,609 1,899
Centro: Identity |0.3431 0,265 0,397
------------------------------------------------------------------------------
LR test vs. logistic regression: chibar2(01) = 86.73
Prob>=chibar2 = 0.0000 IC95% El ajuste llevado a cabo por la SEC
es mas completo. Ajustes por edad y sexo son extraordinariamente
limitados 104. Electrophysiology and arrhythmias Metric
Recommendation References Structure. Resources directly related to
patient care Hospital volumes Complex procedures: Atrial
Fibrillation. Recommended > 50 / year 347 - 350 Complex
procedures: Ventricular tachycardia. Recommended only in labs with
>100 general catheter ablation procedures/y. 133, 350, 351
Non-complex procedures (ablation of paroxysmal supraventricular
tachycardia, AV nodal ablation, and common atrial flutter.
Recommended >100 procedures/year. 350, 351 Pacemaker implants
(>12 implants/y per operator), ICDs (>10 implants/y), and
CRTs (>10 implants/y) 352, 353 Desired technology Accredited
Arrhythmia Unit in hospitals >100 invasive EP procedures/y 350,
354 Dedicated RX lab 59, 350, 355, 356 Staffing >2 certified
cardiologists accredited in arrhythmias 59, 356 358 Certified
cardiologist accredited in arrhythmias responsible for the unit
356, 357, 359 Nurses with > 1 year experience in arrhythmias,
ablation and device implantation and follow-up, minimal 2,
desirable 3/ lab Arrhythmias nurse outpatient consult desirable
(pacemarker and device follow-up) 356, 356b, 256c Accreditation
Accredited Arrhythmia Unit (EHRA, SEA, Certification ISO 9001:2008)
357, 359 Patient services Arrhythmia Ablation, Pacemaker AND ICD,
CRT implantation 59, 356 Arrhythmia outpatient clinic 59, 356
Electrophysiology and arrhythmias All nurses with > 1 year
experience in arrhythmias, ablation and device implantation and
follow-up minimal 2, desirable 3/lab Arrhythmias nurse outpatient
consult desirable (PM and device follow-up) Complex procedures:
Atrial Fibrillation. Recommended > 50 / year Complex procedures:
ventricular Tachy recommended only in labs with > 100 general
cath ablation procedures/year Pacemaker implants (10 implants/y,
CRT> 10 implants/y 105. Radiation dose measure (fluoroscopy time
/ dose for patient and staff Electrophysiology and arrhythmias
Interventional Cardiology 106. Cardiac Surgery Metric
Recommendation References Structure. Resources directly related to
patient care Hospital volumes Major cardiac surgery procedures.
Recommended: >500 / year or > 70 / cardiac surgeron / year
161, 401 Desired technology Dedicated Cardiac surgery operating
rooms, at least 1 full time 161 Fully staffed and equipped Cardiac
Surgery Intensive Care Unit 401 Staffing Certified cardiac surgeons
Anaesthesiologists, intensivist and cardiac surgeon accredited in
post cardiac surgery intensive care Nurses assigned to cardiac
surgery, experience > 1 y / operating room Accreditation
Accredited cardiac surgery unit Patient services Urgent cardiac
surgery Scheduled priority system 161 Prevention of infections
protocol 161 Process of delivery care Protocols for evaluation and
treatment according to ESC / AHA-ACC Guidelines Risk evaluation
using protocols: Euro Score2, SINTAX, other 161 Protocols for
indication of cardiac surgery, major procedures 320 HEART TEAM
approach for all major surgery indications 161, 345, 346 Scheduled
priority system Transfer protocols from hospitals type I and II to
III Use of medication for secondary prevention at hospital
discharge. Recommended > 90% in all hospitals 115 - 118 161,
377, Results Outcomes in selected populations as described in table
# 5 Quality controls ESC / AHA-ACCC / Guideline adherence
Prescription of appropriate medication for secondary prevention at
hospital discharge Recommended: > 90% in patients without
contraindications 115 - 118 161, 377, 398 Other: Waiting list,
Infections, Bleeding and other complications, Recommended < mean
value in local registries Cardiac Surgery Nurses assigned to
cardiac surgery, experience > 1 year / operating room Major
cardiac surgery procedures. Recommended > 500 year or > 70 /
cardiac surgeron / year HEART TEAM approach for all major surgery
indications. Including Nurses 107. A B Predicted Mortality Observed
Mortality Trends in outcomes for mortality after AVR 108. La
Enfermera Investigadora en Cardiologa en Sistema Nacional de Salud
La Misin: Se que me voy a curar y, sobre todo, que ME VAN A CUIDAR
109. Master propio de Tecnicos en Ecocardiografia 110. 0 2000 4000
6000 8000 10000 12000 14000 16000 18000 smoking cessation program,
high risk CAD smoking cessation program, low risk CAD Post AMI
ACE-inh Cardiac Rehab post AMI BBL post MI Statins (4S) CABG/PCI
AAS Thrombolytic th. The cardiologist and smoking cessation.
Aboyans, Victor; Thomas, Daniel; Lacroix, Philippe Current Opinion
in Cardiology. 25(5):469-477, September 2010. DOI:
10.1097/HCO.0b013e32833cd4f7 Cost per life year gained Cambios en
Estilo de Vida en Prevencin Secundaria. Lo mas coste-efectivo 111.
R- EUReCa- Participacin Mapa por provincias de centros que
participan en el registro segn dependencia funcional (n=91) 1 1 2 4
1 1 2 3 2 1 1 1 1 11 2 4 1 2 3 1 1 4 2 1 1 5 3 2 4 1 1 2 Privados
(n=29) Pblicos (n=54) 1 1 1 1 2 1 1 2 1 1 1 1 1 1 Mutuas (n=8) 1 1
1 112. 80.2 8.8 2.2 2.21.1 1.1 1.1 2.2 1.1 Cardiologa Medicina
fsica y rehabilitacin Medicina Interna Cardiologa y Rehabilitacin
Cuidados intensivos INEF Fisioterpia Medicina y fisiologa del
deporte No contestan R- EUReCa ESPECIALIDAD y DEDICACIN del
director/coordinador/responsable del Programa de Rehabilitacin
Cardiaca (PRC) Papel Central ENFERMERAESPECIALIDAD DEDICACIN n=91
n=91 27.5 72.5 Tiempo completo Tiempo parcial Fisioterapi a 113. R-
EUReCa- Participacin Mapa por provincias de centros que participan
en el registro segn dependencia funcional (n=91) 1 1 2 4 1 1 2 3 2
1 1 1 1 11 2 4 1 2 3 1 1 4 2 1 1 5 3 2 4 1 1 2 Privados (n=29)
Pblicos (n=54) 1 1 1 1 2 1 1 2 1 1 1 1 1 1 Mutuas (n=8) 1 1 1 114.
R- EUReCa % de centros n=91 Cules son las patologas ms frecuentes
en el PRC en Fase II en el ao 2013? Porcentaje de centros. *En el
caso de SCA con ciruga de By-pass, el porcentaje se corresponde con
sta ltima 95.6 63.7 48.4 37.4 35.2 34.1 15.4 14.3 8.8 8.8 6.6 4.4 0
20 40 60 80 100 SCA con o sin EST Ciruga de By-pass aortocoronario
ICP en angina estable Ciruga de recambio valvular Enfermedad
coronaria crnica Insuficiencia Cardiaca Por implantacin de DAI
Pacientes de alto riesgo cardiovascular Trasplante cardiaco Por
implantacin de marcapasos Enfermedad Arterial Perifrica Correccin
de cardiopata congnita 115. En 2013: 7434 pacientes rehabilitados
76.666 SCA 85% EC crnica + aguda 64 % fueron SCA 4.757 pacientes
con SCA 6,2% 2.Escaso nmero de pacientes atendidos en las Unidades
de Rehabilitacin Cardiaca La Rehabilitacin Cardaca uno de los
grandes retos de la enfermera en Espaa 116. Proyecto para pacientes
y profesionales La Enfermera como el Centro del Proceso 117.
Coordinador: Dr. Lorenzo Fcila Dra. Almudena Castro 1. Desarrollo
web 2. Paciente experto 1. MimoApp 2. MimoKids 1. MimoFarmacias
118. Integrating therapies Ibanez et al. JACC 2015 (In Press) 12/13
119. STEMI Heart Failure Heart Failure a nurse process Figure 1:
Projected cumulative (2011 to 2025) economic losses from all
non-communicable diseases worldwide. Adapted from ref 3. Figure 2:
1/16 120. Enfermera e Intervencionismo 121. Enfermera e
Intervencionismo 122. La Enfermera en Cardiologa Intervencionista
Atencin Paciente Intrumentacin Control Tcnico Control Material 123.
ACS. An Extraordinary Journey Innovation Year Impact CCU Blue Code.
Nurses 60 & 70 Mortality B-Blockers 70 Mortality Thrombolysis
80 Mortality ASA 80 Mortality 1 PCI 90 Mortality Statins Late 90
Mortality ASA+Clopi Late 90 Morbidity Better anticoagulation 00
Morbi-mortality Prasugrel, Ticagrelor 00 Morbi-mortality Team Work,
STEMI code 00 Mortality? Hypothermia 10 Mortality? 30% 5% 124. IHD
2Prev. An Extraordinary Journey Innovation Year Impact B-Blockers
70 Mortality ASA 80 Mortality Life-style changes/Rehab 70-15
Mortality ACE Ih 80-90 Morbi-mortality Statins 90 Mortality Team
Work 90 Mortality Revasc (subgroups) 00 Morbi-mortality Vorapaxar
13 Morbi-mortality Rivaroxaban 13 Morbi-mortality Ticagrelor 15
Morbi-mortality Ezetimibe 15 Morbi-mortality 10 %/y 2 %/y 125.
Heart Failure. An Extraordinary Journey Innovation Year Impact ACE
Inhibitors 80 Mortality B-Blockers 00 Mortality Aldosterone Recept
Block 00 Mortality Defibril/Cardiac RT 00 Mortality Nurses Process
00 Mortality-morbi Cardiac Transplant 80-00 Mortality Ivabradin 10
Morbi-mortality? VA Devices 10 Morbi-mortality LCZ-696 14
Morbi-mortality Acute HF code 00-15 Mortality-Morbi? Gene therapy
15? Mortality? 40% 10% 126. Hospital I Low complexity II
Intermediate Complexity III High Complexity Volume: Beds < 200
200 to 500 > 500 Volume: Cardio < 500 patients / year 500 to
1000 patients / year > 1000 patients / year Organization
Cardiology not considered as an independent unit Cardiology
independent unit (own beds) Cardiology independent unit (own beds)
Intensive Cardiac Care Unit No, or yes but transfers complex
patients to other hospitals Yes, No dedicated ICCU Dedicated ICCU
Interventional cardiology unit No Yes, but complex cases are
transferred to other hospitals PCI not available 24h / 7 days Yes,
including complex cases PCI available 24h / 7 days Interventional
electrophysiology No, except pacemakers Yes, but complex cases are
transferred to other hospitals Yes, including ICD / CRT
implantation, and treatment of complex arrhythmias Cardiac surgery
No No Yes, available 24h / 7 days Transfer of patients All cases
for PCI, complex arrhythmias & Cardiac Surgery Transfer of
complex cases to another hospital including complex PCI,
arrhythmias or surgery Minimal (e.g.: heart transplant) Receives
complex patients from other hospitals INCARDIO. Clasificacin de los
Hospitales 127. Metric Relevance Difficulty Auditable Evidence
Comments All cause Mortality 1 1 1 A Self-evident. Reliable only in
well organized, auditable registries / databases Cardiovascular
Mortality 1 2 2 A Difficult to ascertain. Needs adjudication.
Number of days in hospital 1 2 2 A Reason for hospitalization
dependent of health care systems and individual preferences Number
of days in any hospital 30 days after index hospitalization
preferred to days in hospital until discharge if feasible Stroke 1
2 2 A Difficult to ascertain. Needs adjudication No reliable risk
scores for corrections of results in different hospitals
Re-infarction 1 2 2 A Difficult to ascertain. Needs adjudication
Safety (Major bleeding, severe infections, medical errors, etc.) 1
2 2 A Difficult to ascertain. Needs adjudication and audits 128.
Metric Suggested Reference Value Relevance Difficulty Auditable
Evidence References Mortality* STEMI mortality (excluding patients
unconscious at admission) < 5% (a) 1 1 1 A 115, 116, 131, 132,,
141 Non STE-ACS mortality (excluding patients unconscious at
admission) < 5% (a) 1 1 1 A 117, 118, 131, 132, 141 Staged PCI
mortality < 1% (a) 1 1 1 A 140-142 TAVI mortality < 10% (a) 1
1 1 A 147 - 149 VT after AMI and other complex catheter ablation
mortality < 3% (a) 1 1 1 A 150 - 152 Pacemaker, ICD, CRT implant
mortality < 1% (a) 1 1 1 A 153, 154 Heart Failure mortality <
7% (a) 1 1 1 A 160, 161 Staged 1st Aortic valve surgery replacement
mortality (excluding TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 -
161 Staged 1st Mitral valve surgery replacement mortality < 7%
(a) < 9% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery
repair mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged
1st CABG (without combined surgery) mortality < 3% (a) < 5%
(b) 1 1 1 A 159 - 161 Staged 1st combined CABG + AVR mortality <
6% (a) < 8% (b) 1 1 1 A 159 - 161 Heart transplant < 15% (a)
(c) 1 1 1 A 161b INCARDIO STEMI mortality 300.000 214 - 216 Patient
services Cardiologist on call / 24 hours Recommended in hospitals
type II and III 199 Rehabilitation program. Recommended in all
hospitals, in house or in a reference hospital 220 - 222
Accreditation External accreditation of specific units 220 - 225
Process of delivery care for diagnosis, treatment, prevention and
patient education Local protocols Local protocols for diagnosis and
treatment for prevalent GRDs based on ESC /AHA-ACC guidelines:
acute coronary syndromes, acute chest pain, chronic stable ischemic
heart disease, valvular heart disease, heart failure, pulmonary
embolism, myocardiopathies, aortic disease, preoperative
cardiovascular evaluation protocols, adult congenital heart
disease, atrial fibrillation, syncope, pulmonary hypertension,
pericardial diseases, cardiovascular disease during pregnancy.
Recommended in all hospitals 104, 105 226 244 Multidisciplinary
protocols Heart Team Multidisciplinary protocols with related
specialties Avoid duplicity of units in the same hospital (e.g.:
heart failure) 103, 104, 245 Regional STEMI protocol 123, 246, 247
Hospital approved protocols for derivation to other hospitals in
case of need for other services: Recommended in hospitals w/out the
required technology 59 Waiting list Waiting list for 1st medical
outpatient visit < 40 days. Recommended in all hospitals <
1,7 / 1000 population covered by hospital 248 - 251 Safety. All
hospitals should identify possible safety problems and organized
local quality programs in a yearly basis. 59 Results Outcomes in
selected populations as described in table # 5 Quality controls:
Adherence to guidelines Adherence to local protocols for diagnosis
and treatment based on ESC / AHA/ACC guidelines Recommended >
90% in all hospitals 11, 103, 104 192 - 194 252-254 Clinical
Cardiology Nurses with Cardiology experience in type II and III h.
Rehabilitation program, all hospitals ICCU: Recommended 4-5
beds/100.000 inhabitants 136. Cardiac imaging Metric Recommendation
References Structure. Resources directly related to patient care
Hospital volumes TTE, TOE, stress echo: recommended: > 1500 and
300 / studies / staff / y) 265, 266 CCT studies (recommended >
250 / year) 267 CMR studies (recommended > 300 / year)* Desired
technology TTE, in all hospitals. TOE and stress echo, in type II
and III hospitals. 3D echo in type III hospitals. CCT, SPECT or PET
Scanner and CMR in-house type II and III hospitals or in reference
hospital. 194, 255 - 264 Staffing Cardiac Imaging certified
cardiologists (recommended 1 per technique: Echo, CMR, CCT), Level
2/3 194, 255 - 264 Certified technicians (recommended 1 per
technique) in all hospitals Nurses with experience in stress
testing and transesophagic ECHO 194, 255 264, 264b Accreditation
Official accreditation (ESC or similar) of Echo lab, CCT lab, CMR
lab 194, 255 - 264 Patient services TT Echocardiography available
24/7/365 in hospitals II and III Process of delivery of care for
diagnosis and treatment Local protocols For indications based on
ESC /AHA.ACC guidelines for each technique 204, 205, 267 - 276
Protocols to reduce radiation from CCT All cases < 15 mSv 273
-275 Waiting list Outpatient, nonurgent, studies, recommended 100%
< 30 days 194 Hospitalized patient, recommended 90%) 264, 282,
285 Report of radiation dose Recommended in 100% of cases (CCT)
272, 286, 287 Waiting list Recommended: < mean value in local
registries Cardiac Imaging Certified technicians (recommended >
1 per technique) Nurses with experience in stress echo and TEE TTE
available 24/7/365 in hospitals II and III 137. Enfermera
Cardiolgica e Imagen Cardiovascular 138. Acute cardiac care /
Intensive cardiac care Metric Recommendation References Structure.
Resources directly related to patient care Hospital volumes 4-5
ICCU beds / 100.000 inhabitants 198 Desired technology Intensive
care environment technology 198 Staffing All nurses with > 1
year cardiology experience. Experience in acute cardiac care 198 At
least 1 cardiologist certified in acute coronary care (optimal: 1 /
3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals
> 300.000) 198 Accreditation At least 1 cardiologist accredited
in acute cardiac care 198 Any accreditation conferred by any
external organizations 198 Patient services Regional network for
STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care
treatment for sudden death (includes temperature management) 14528
Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process
of delivery care for diagnosis, treatment, prevention and patient
education Local protocols based on ESC /AHA- ACC guidelines STEMI
and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments
according to ESC / AHA ACC guidelines 115 - 118 Multidisciplinary
protocols Prehospital systems, emergency department, cardiac unit.
115 - 118 Heart failure: Cardiac unit, internal medicine, emergency
department 289, 290 Results Outcomes in selected populations as
described in table # 5 Quality controls Adherence to ESC / AHA-ACC
guidelines Patients with primary PCI in STEMI: > mean value in
national registries Time to call-door-balloon/lytic: < 60 min
after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI
diagnosis Patients with dual antiplatelet therapy in ACS: > mean
value in national registries Patients with statins at discharge:
> mean value in national registries Aspirin at admission: >
mean value in national registries 115 - 118 Safety Infections:
Recommended < mean value in national registries Transfusions:
Recommended < mean value in national registries 115 - 118 291
Acute cardiac care / Intensive cardiac care All nurses with > 1
year cardiology experience. Experience in acute cardiac care
Cardiologist on call 24 h (recommended in hospitals > 300.000)
139. Interventional Cardiology All nurses with > 1 year
experience in cath lab, minimal 2, desirable 3/lab HEART TEAM
decision in all non-emergency procedures including nurses PCI:
optimal > 400 year: If < 200 year, cath lab should be part of
a larger network PCI per operator > 70 year Primary PCI >
36-50 year (PPCI per operator > 11 / year 140. Desigualdades
Interterritoriales (IAM. 2012) 6 6,5 7 7,5 8 8,5 9 100 150 200 250
300 350 400 450 500 RAMER(%) Tasa ICP-p Milln Hab RECALCAR 2012
STEMI. Risk-adjusted Mortality 141. Desigualdades
Interterritoriales (IAM. 2012) Lmite inferior Lmite superior
Mortalidad_IAM_esperada ,876 ,003 0,000 ,870 ,881
Mortalidad_IAM_prevista ,882 ,003 0,000 ,876 ,888
Mortalidad_IAM_nulo ,598 ,005 ,000 ,589 ,607 Variables resultado de
contraste rea EE p Intervalo de confianza asinttico al 95% OR Sexo
(Mujer vs Hombre)1,214 1,116 1,320 Edad (ao) 1,069 1,065 1,074
Shock 23,152 20,818 25,748 DM comp 1,608 1,400 1,846 ICC 1,730
1,589 1,883 ECV 2,283 2,003 2,602 Tumor 1,994 1,662 2,395 EAP 2,153
1,599 2,897 IRA 2,631 2,379 2,912 Arritmia 1,749 1,609 1,899
Centro: Identity |0.3431 0,265 0,397
------------------------------------------------------------------------------
LR test vs. logistic regression: chibar2(01) = 86.73
Prob>=chibar2 = 0.0000 IC95% El ajuste llevado a cabo por la SEC
es mas completo. Ajustes por edad y sexo son extraordinariamente
limitados 142. Radiation dose measure (fluoroscopy time / dose for
patient and staff Electrophysiology and arrhythmias Interventional
Cardiology 143. Electrophysiology and arrhythmias Metric
Recommendation References Structure. Resources directly related to
patient care Hospital volumes Complex procedures: Atrial
Fibrillation. Recommended > 50 / year 347 - 350 Complex
procedures: Ventricular tachycardia. Recommended only in labs with
>100 general catheter ablation procedures/y. 133, 350, 351
Non-complex procedures (ablation of paroxysmal supraventricular
tachycardia, AV nodal ablation, and common atrial flutter.
Recommended >100 procedures/year. 350, 351 Pacemaker implants
(>12 implants/y per operator), ICDs (>10 implants/y), and
CRTs (>10 implants/y) 352, 353 Desired technology Accredited
Arrhythmia Unit in hospitals >100 invasive EP procedures/y 350,
354 Dedicated RX lab 59, 350, 355, 356 Staffing >2 certified
cardiologists accredited in arrhythmias 59, 356 358 Certified
cardiologist accredited in arrhythmias responsible for the unit
356, 357, 359 Nurses with > 1 year experience in arrhythmias,
ablation and device implantation and follow-up, minimal 2,
desirable 3/ lab Arrhythmias nurse outpatient consult desirable
(pacemarker and device follow-up) 356, 356b, 256c Accreditation
Accredited Arrhythmia Unit (EHRA, SEA, Certification ISO 9001:2008)
357, 359 Patient services Arrhythmia Ablation, Pacemaker AND ICD,
CRT implantation 59, 356 Arrhythmia outpatient clinic 59, 356
Electrophysiology and arrhythmias All nurses with > 1 year
experience in arrhythmias, ablation and device implantation and
follow-up minimal 2, desirable 3/lab Arrhythmias nurse outpatient
consult desirable (PM and device follow-up) Complex procedures:
Atrial Fibrillation. Recommended > 50 / year Complex procedures:
ventricular Tachy recommended only in labs with > 100 general
cath ablation procedures/year Pacemaker implants (10 implants/y,
CRT> 10 implants/y 144. Heart Failure Units Metric
Recommendation Reference s Structure. Resources directly related to
patient care Hospital volumes N patients with heart failure
discharged from hospital Desired technology Natriuretic peptides
120, 156, 369 Type II and III hospitals: ECHO available 24 hours.
Multidisciplinary heart failure outpatient clinic., ICD and CRT
therapy 11, 120, 369, 371- 373 Type III hospitals: Intensive CCU,
Circulatory assist devices 120, 369 Staffing Type II and III
hospitals: Cardiologists assigned to heart failure management 11,
119 Type III hospitals: Accredited cardiologists assigned to
advanced heart failure program 11, 119 Type III hospitals:
Specialized nurses assigned to heart failure management . Nurse
outpatient consult 11, 119, 213, 371- 373 Accreditation Type III
hospitals: Accredited multidisciplinary Heart failure program,
including cardiologists, internal medicine, oncology,
rehabilitation specialists, internal medicine, general physicians,
other 120, 369 Type III hospitals: Accredited Advanced heart
failure cardiologists 372 Patient services Type III hospitals:
Heart failure outpatient clinic 11, 156, 157, 120, 369, 370 Type
III hospitals: Heart failure in-hospital management program 156,
157, 120, 369, 370 , All hospitals: On site or access to
Rehabilitation, advance heart failure unit, heart transplant,
complex pulmonary hypertension units and palliative care units 120,
369, 373 Heart Failure Units Type III hospitals: Specialized nurses
assigned to heart failure management. Nurse outpatient clinic. N
patients with HF discharged from hospital
