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Cross-border access to primary angioplasty in the European Union – opportunities, challenges, recommendations European Critical Care Foundation, October 10, 2013.

Optimal organisation of systems and processes to minimize time delays to treatment, and the availability of primary angioplasty as the recommended reperfusion therapy, is key to improving outcomes for acute heart attack (STEMI) patients.  However, access to primary angioplasty can be difficult in national periphery regions where the nearest appropriate facilities may be located across the border.

This report provides a snapshot of the current situation regarding cross-border practices for STEMI patients in 10 member states of the European Union (EU). The Member States studied were Austria, Greece, Latvia, Lithuania, Northern Ireland, Poland, Portugal, Slovenia, Spain, and Sweden. It is based on interviews with leading interventional cardiologists in those countries, and is not intended to be an exhaustive account of STEMI management in border areas in Europe.

The survey revealed limited cross-border collaboration regarding the management of acute heart attack patients in the countries studied, or lack of implementation of existing bilateral agreements. The most commonly mentioned challenges were differing reimbursement systems, the need for joint training programs for healthcare professionals, consistent data registries and the organisation of Emergency Medical Systems (EMS), including use of the common European emergency number, 112. The findings also suggest that despite the ESC guidelines, there are continuing, major variations in treatment utilization. A significant proportion of eligible patients are not receiving any treatment at all, and an estimated 40-50% of European STEMI patients are not currently treated with primary angioplasty. Given the prevalence of acute heart attacks as a cause of death and morbidity in the EU this situation needs to be urgently addressed.

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Barriers to Implementation of Primary Percutaneous Coronary Intervention in Europe

Kristina Grønborg Laut et all. European Cardiology, 2011;7(2):108–12.


Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, only 40–45% of European STEMI patients are currently treated with PPCI and there are large differences in this proportion between different European countries. Several studies have emphasised that PPCI delivery is complex, with multiple potential barriers to implementation, but there is no comprehensive research estimating the significant characteristics, factors and structures that determine the diffusion of PPCI in Europe. The lack of complete implementation and large national and regional differences arise from the interplay between technology, patients, policy makers, culture and resources. Explanations for the variation in treatment access still remain a puzzle and access to valid data is needed.

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Determinants and patterns of utilization of primary percutaneous coronary intervention across 12 European countries: 2003–2008

Kristina Grønborg Laut, Christopher Peter Gale, Timothy L. Lash, Steen Dalby Kristensen International Journal of Cardiology, 2013:03-085.


Background: Important differences exist between European countries in the degree of implementation of primary percutaneous coronary intervention (PPCI) for patients with ST-elevation myocardial infarction (STEMI). To investigate whether health care-associated economic and demographic country-level characteristics were associated with differences in utilization of PPCI, we aimed to examine 5-year trends in the implementation of PPCI for STEMI across 12 EU countries.

Methods: An ecological study of aggregated data from national and international registries. Main outcome was the number of PPCI per 1,000,000 population, collected annually for the years 2003 to 2008. Impact of year on PPCI implementation was modeled using linear regression and mixed effects models used to quantify associations between PPCI use and country-level parameters.

Results: The annual growth in utilization of PPCI was 1.11 (1.03,1.20) per million. Country-level utilization rates varied from 0.82 (95% CI 0.52, 1.30) to 1.38 (95% CI 1.15, 1.64) per million per year. Number of physicians per 100,000 population, number of nurses and midwifes per 100,000 population, number of acute care beds per 100,000 population, population density per km2, and proportion of population under 50 years old were associated with PPCI utilization.

Conclusions: All 12 EU countries demonstrated evidence of PPCI implementation from 2003 to 2008. However, there was substantial variation in the use and rate of uptake of PPCI between countries. Differences in utilization rates of PPCI are associated with supply factors, such as numbers of beds and physicians, rather than healthcare economic characteristics. Further studies are needed to explore the influence of patient-level factors.

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