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Primary PCI use increasing in Europe but huge gaps remain

Stent for Life: optimising primary percutaneous coronary intervention in Europe

The use of primary percutaneous coronary intervention has improved in the 10 Stent for Life Initiative (SFL) countries but there is still large variation in Europe, reported SFL chair Professor Steen Kristensen today at the ESC Congress. New data launched today shows that the number of primary PCI per million inhabitants per year in the ESC countries ranges from 4 to 769.

Stent for Life is an initiative of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), a registered branch of the European Society of Cardiology, and EuroPCR. It brings together interventional cardiologists, government representatives, industry partners, advocacy groups and patients to ensure that the majority of ST-elevation myocardial infarction (STEMI) patients have equal access to the life saving indication of primary percutaneous coronary intervention (pPCI).

Ten countries are involved in Stent for Life Initiative: Bulgaria, France, Greece, Serbia, Spain, Turkey (all since 2009), Egypt, Italy, Romania (since 2010) and Portugal (2011).

Stent for Life objectives include:

  • Increase the use of pPCI to more than 70% among all STEMI patients
  • Achieve PCI rates of more than 600 per one million inhabitants per year
  • Offer 24/7 service for pPCI procedures at invasive facilities to cover the country STEMI population need.

Professor Kristensen said: “In all 10 countries there have been major improvements in access to primary PCI since the initiation of Stent for Life.”

But preliminary data from an unpublished survey performed during 2010/11 in 33 ESC countries (the 10 SFL countries plus 23 others) shows that large gaps in access to pPCI still exist. The survey reveals that the number of primary PCI per million inhabitants per year ranges from 4 to 769.

“This new data from an EAPCI/ESC survey shows huge variation across Europe in the numbers treated with primary PCI,” said Professor Kristensen. “It also stresses that we need to have good national and European registers to monitor the numbers of patients receiving pPCI and to monitor patient outcomes including mortality rate.”

The survey findings are being presented during a Stent for Life symposium at the ESC Congress on Sunday 26 August, at 8:30am. The first Stent for Life chair, Professor Petr Widimsky (Czech Republic), will also present data showing that primary PCI is not just saving lives but is also cost effective. Other presenters will discuss implementation challenges and successes in the Stent for Life countries.

Examples of achievements on the three Stent for Life objectives and remaining challenges in five Stent for Life countries are below:


Romania joined the Stent for Life initiative in August 2010 and for the first time opened 10 pPCI centers organized in a 24/7 system in 5 regions. The total number of pPCI increased from 1,289 in 2010 to 4,200 in 2011. The percentage of STEMI patients receiving pPCI increased from 25% in 2010 to 50% in 2011.

The rate of pPCI increased from 40 pPCI per million inhabitants in 2009 to 64 per million in 2010 and 210 per million in 2011. The Bucharest region achieved 640 pPCI per million in 2011. In 2012 two new 24/7 pPCI centers were opened and there are 8 new centers planned for the next 3 years (2012-2015).

“The impact on mortality was enormous,” said Dr Dan Deleanu, Country Champion of SFL Romania. “In-hospital mortality decreased from 13.6% to 5.2 % during 2009-2011 period, meaning more than 400 lives saved per year.”

What barriers have you experienced and how have these been overcome?
Dr Deleanu said: “The STEMI network was actually built from scratch. Only three years ago, in Romania, STEMI reperfusion therapy was based only on in-hospital thrombolysis. Actually, from the lack of pPCI labs to the insufficient number of interventional cardiologists, everything represented challenges for us. Support and close collaboration with the Ministry of Health and Emergency Medical Services has been critical in achieving our goals.”

What challenges remain? How do you plan to tackle these?
Dr Deleanu said: “One important challenge is securing the budget for the Stent for Life educational campaign ACT NOW. SAVE A LIFE. In Romania, as our moment zero survey showed, more than half of STEMI patients do not know how to act in case of heart attack. Therefore, we are considering the educational campaign ACT NOW. SAVE A LIFE a critical point in decreasing STEMI mortality. The global economy influences local companies’ spending budgets, so the main funding sources of the entire project are at risk. Under these circumstances, lobby and patient advocacy remains our main weapon.
And the results are promising…. SFL Romania and the National Public Television have agreed upon the broadcasting of our social campaign at no cost.”


Thrombolytic therapy was the dominant reperfusion strategy before Turkey joined the Stent for Life project in 2009. The project was initiated in 18 pilot cities and acceptable progress has been achieved since September 2009.

In the pilot cities, pPCI rates have reached over 90% in three years (2009-2011). An effective mean door-to-balloon time for the pilot cities of 54,72 ± 43,66  minutes was also achieved. Primary PCI has emerged as the preferred reperfusion strategy for patients with acute ST segment elevation myocardial infarction in pilot cities after three years of the Stent for Life project.

Dr Omer Goktekin, Country Champion of SFL Turkey, said: “Unfortunately, we still have many barriers to overcome in Turkey. Insufficient staff (nurses and technicians) is the main obstacle to providing a 24/7 pPCI service. Only 57% of pPCI centers can offer a 24 hour pPCI service seven days a week. Also, the absence of additional payments to cardiologists for primary angioplasty is another obstacle to overcome.”

He added: “Lack of awareness of myocardial infarction increases time from symptom on set to first medical contact. Currently, a local public campaign has been started in two pilot cities. After the implementation of the Stent for Life project in collaboration with our Ministry of Health, direct communication between the Emergency Medical System, ambulances, and the PCI centers prior to admission was achieved.”


Portugal joined Stent for Life in February 2011 and since then has worked with a Task Force that involves people from Emergency Medical Service, hospitals and industry partners. It is a multidisciplinary team with members from intervention cardiology, communication, business, marketing and sales.

Portugal has a national network with 17 cath labs working 24/7, located in most populated regions. In the last several years the rate of pPCI versus fibronolysis has grown. In 2011, 68% of STEMI patients received pPCI compared to 7% treated with fibrinolytics. In 2011 there were 3,192 pPCI procedures performed, which corresponds to 303 pPCI per million inhabitants and is a 13% growth compared to 2010.

The Task Force identified several unmet needs in three main areas of intervention:

  • Long delays in transportation of patients to hospital
  • Different organization of patient flow procedures within and between hospitals
  • Patient awareness of MI symptoms and the need to act quickly.

A national 1-month survey called “Moment Zero” was conducted in 19 Portuguese centers of interventional cardiology that perform primary angioplasty. It revealed that the main barriers to a better performing primary angioplasty programme in Portugal were the low numbers of patients (29%) that contacted Emergency Medical Services (EMS) and the high number of patients (56%) that attended centres without interventional cardiology units, resulting in long periods of time spent in secondary transportation to the institutions with such services.

Dr Helder Pereira, Country Champion of SFL Portugal, said: “The SFL team has worked with the EMS service (INEM) on pre-hospital transportation. A more efficient communication process after an emergency call was implemented in order to reduce system delay. EMS ambulances are equipped with an ECG that is sent by tele-transmission to the cath lab that will receive STEMI patients. Furthermore the SFL team and national EMS agreed that from now on secondary transport will be made by EMS ambulances.”

In the second area of intervention, difference in patient flow procedures, regional meetings are being organized to standardize procedures among all hospitals regarding the flow of STEMI patients and treatment protocols. Dr Pereira said: “At the same time we will train, inform and motivate people in-hospital through local meetings with the EMS and SFL team. In the upcoming months we also plan to provide training for primary care physicians on pPCI guidelines and distribute information about the Stent for Life initiative.”

To tackle the third unmet need, a public awareness campaign on MI symptoms and the need to act quickly and call 112 has been rolled out since December 2011. Stent for Life partners from different industries including medical devices, pharma, energy and telecommunications, have helped to increase the visibility of the campaign in the media.


The numbers of pPCI per million inhabitants in Bulgaria has risen over the past five years, from 88 per million inhabitants in 2007 to 130 in 2008, 376 in 2009, 530 in 2010 and 650 in 2011.

The progress of the SFL initiative led to an increased number of AMI patients undergoing pPCI, with a significant decrease of total AMI mortality from 16.3% to 12.7 % during 2007-2011, while pPCI AMI mortality remains unchanged at around 5%.

Dr Julia Jorgova, Country Champion of SFL Bulgaria, said: “Despite the great progress made in pPCI network development, there are still some issues to be resolved. The decreasing payment for PCI procedures is an unfavourable trend, originating from budget cuts caused by the global worldwide financial crisis. This makes working with top shelf materials harder which further decreases motivation.”

She added: “The negative campaign in the Bulgarian media towards interventional cardiology is a dangerous pitfall, as it discourages a lot of patients from undergoing PCI during STEMI. The patients’ poor awareness of STEMI symptoms still hinders the timely first medical contact and prolongs the onset-to-door times.”

She concluded: “These are perhaps the main reasons for the slight increase in the mortality rate from 10.4% to 12.77% in 2011 compared to 2010.”


Greece started the Stent for Life initiative in 2009 with a rate of 9% pPCI. In 2011 the percentage rose to 32% for the whole of Greece and almost 59% for the area of Αthens.

The number of pPCIs has increased from 95 per million in 2009 to 346 per million per year in 2011.

Currently, in the Athens pPCI network, only the hospitals with an on duty service can provide pPCI facilities 24/7. The northwestern Greece pPCI network has a 24/7 pPCI service. Dr John Kanakakis, Country Champion of SFL Greece, said: “Offering 24/7 pPCI services throughout the area of Athens and in other Greek cities requires central government decisions and financial support.”
What barriers have you experienced and how have these been overcome?
Dr Kanakakis said: “In Athens, the main barrier was the organization of the Emergency Medical System (EMS) to support the immediate transfer of acute chest pain patients to hospitals with pPCI facilities.”

The following comprehensive EMS actions to facilitate the transfer of the patients with STEMI to pPCI centers have been recently applied:

  • Priority transfer is given for chest pain patients. The nearest fully equipped ambulance transfers the patient to the nearest pPCI hospital
  • Time delays >5 minutes for the patient pick-up is considered an alarm code. In this case, the chief EMS doctor is alerted and is responsible for organizing the immediate transfer of the chest pain patient
  • Non-PCI hospitals are bypassed and the patient is directly transferred to a pPCI hospital.

What challenges remain? How do you plan to tackle these?
Dr Kanakakis said: “The big challenges that remain are first the expansion of the network to other cities in Greece with PCI centers (the network already exists in the area of Athens and in the area of Patras) and second to organise and equip the EMS system with ECGs. A meeting with the Minister of Health is scheduled for September.”

Which patients still do not have access to stents in Greece?
Dr Kanakakis said: “There are many people in Greece that live in the islands and in small villages in the mountains with very difficult access to the PCI hospitals. These people are currently transferred by helicopter to the closest big city but it is not always done fast enough.”

Notes to editor

About the Stent for Life Initiative

The Stent for Life Initiative aims to improve the delivery of care and patient access to the life saving indications of primary percutaneous coronary intervention (p-PCI), thereby reducing mortality and morbidity in patients suffering from acute coronary syndromes (ACS). More info at this session.

About the European Association of Percutaneous Cardiovascular Interventions
The European Association of Percutaneous Cardiovascular Interventions (EAPCI) is a registered branch of the ESC. Its aim is to reduce the burden of cardiovascular disease in Europe through

About the European Society of Cardiology
The European Society of Cardiology (ESC) represents more than 75,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

About ESC Congress 2012
ESC Congress 2012 will take place from 25 to 29 August at the Messe München centre in Munich, Germany. Information on the scientific programme is available here. More information on ESC Congress 2012 is available from the ESC Press Office or contact us at