Edition 16 | Summer 2015

STENT FOR LIFE INITIATIVE NEWSLETTER Welcome to the 16th edition of the Stent for Life Initiative Newsletter This is an interactive newsletter designed to help you navigate through the content quickly and easily.

PG 2: Second edition of SFL How-to-Guide launched The practical handbook written by SFL experts provides an overview of how to set up a local Stent for Life Initiative. MORE…

Click on MORE… to go directly to an article Click on to go back to the first page

PG 3: STEMINEM Day is training EMS staff in Portugal SFL Portugal’s STEMINEM Day is enhancing the skills and scientific knowledge of Emergency Medical Service staff. Ultimately this should improve the decision making process with clear gains for STEMI patients. MORE…

PG 5: Piloting pre-hospital diagnosis and triage in Greece SFL Greece is running a pre-hospital diagnosis and triage pilot programme with EMS in the Athens area. If system delays are reduced the changes will be extended throughout the country. MORE…

PG 6: Can SFL serve as a best practice example for building stroke networks for acute ischemic stroke patients? EuroPCR 2015 featured a special breaking news session devoted to the rapidly evolving field of mechanical thrombectomy in acute ischaemic stroke. Experts reviewed the recent evidence and discussed the rationale for boosting use of this therapy. MORE…

PG 7: SHARE.INSPIRE.LEARN Welcome to the new section of SFL Newsletter: What can acute stroke interventionalists learn from cardiologists regarding workflow? MORE…

PG 10: Contract4Life educates nurses and patients at selected SFL centres Stent for Life is starting their Contract4Life programme at selected SFL centers in five countries. The objective is to provide standardized education for cardiac nurses and STEMI patients at discharge from a primary PCI hospital. MORE…

Stent for Life Initiative Newsletter | Edition 16 | Summer 2015

Read more country updates in the upcoming editions and send your stories to: [email protected]

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Second edition of SFL How-to-Guide launched

The practical handbook written by SFL experts provides an overview of how to set up a local Stent for Life Initiative. The second edition of the SFL How-to-Guide has been launched. Written by SFL experts, this practical handbook provides an overview of how to set up a local Stent for Life Initiative. SFL’s overall aim is to improve patient access to the life-saving indication of PCI, thereby reducing the mortality and morbidity of patients suffering from acute coronary syndromes. The SFL Initiative is a proven successful model for the implementation of STEMI treatment guidelines. The guide outlines key operational rules to be followed and gives best practice examples from SFL countries. Specifically, the guide outlines how to build the SFL structure with a Country Champion, Steering Committee, Task Force and National Project Coordinator. Guidance is given on how to map and analyse access to primary PCI, identify barriers to the use of PCI and develop a three year long strategic plan. Advice is offered on other important steps including integrating SFL into a government supported programme, setting up a national ACS/AMI registry, engaging stakeholders and publishing findings. Sections are devoted to running a public awareness campaign, budgeting and fundraising, and monitoring systems and measuring success. There are case studies throughout the guide which show how the principles of SFL have been put into practice in different countries and how barriers have been overcome. The Stent for Life How-to-Guide can be downloaded from the SFL website at http://bit.ly/SFLguide. We hope it will inspire the interventional community to follow best practice in STEMI care.

Petr Kala SFL Initiative Chairman

Stent for Life Initiative Newsletter | Edition 16 | Summer 2015

Zuzana Kaifoszova SFL Initiative Project Manager Europe

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STEMINEM Day is training EMS staff in Portugal

SFL Portugal’s STEMINEM Day is enhancing the skills and scientific knowledge of Emergency Medical Service staff. Ultimately this should improve the decision making process with clear gains for STEMI patients. Would it be possible to imagine optimal management of STEMI without considering the Emergency Medical Service (EMS)? The answer to this question is clearly no. In fact, EMS represents the entrance gate for a STEMI patient in the treatment pathway and can be decisive in terms of clinical outcomes for the majority of cases.

EMS in Portugal (INEM – National Institute of Medical Emergency) plays several crucial roles in STEMI management. Apart from ensuring initial medical support and patient transportation to hospital units, EMS teams are also responsible for the referral/interpretation of the ECG. Additionally, EMS assures transportation of STEMI patients from health units without a cath lab to hospitals with the capacity to perform primary angioplasty 24/7.

ADVANCED TRAINING IN STEMI MANAGEMENT Scientific Programme Acute Coronary Syndrome: Diagnose and Initial Approach. ECG Interpretation STEMI: Myocardial Reperfusion Strategies Antithrombotic therapy Prevention and Treatment of the Main Electrical Complications Cardiogenic shock: Prevention, Recognition and Initial Treatment. Scientific Programme

The majority of people who work for EMS do it under a part-time contract with a hospital or other health unit as their main employer. Most of these people have responsibilities within the emergency room, putting them in the front seat of another main health system entrance gate. This is an important fact in Portugal, where there is still a high percentage of STEMI patients who do not activate EMS but instead access health units by their own means. EMS teams are prepared to deal with many critical situations but there is no specific and comprehensive training on how to manage STEMI patients. The system delay (first medical contact to primary angioplasty) in STEMI management in Portugal is very well documented. There is clear room to improve STEMI decision making at prehospital/emergency room level and that can only be achieved by enhancing the scientific knowledge of EMS teams.

Stent for Life Initiative Newsletter | Edition 16 | Summer 2015

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STEMINEM Day is training EMS staff in Portugal

An educative initiative – STEMINEM Day - has been set up to address three main areas of disease management: diagnosis, treatment and complications. This initiative is a half day programme composed of lectures and case report discussion. It is 100% focused on STEMI management and all case report discussions are adapted to the region of the country where the course takes place. A customised strategy ensures the coverage of all situations that can occur in the field such as indirect transportation, cardiogenic shock, need for fibrinolysis, etc.

Picture from the first STEMINEM Day

The STEMINEM Day programme was built together with the EMS education department to fulfil the real needs of trainees. All of the speakers are cardiologists who have extensive experience and a strong relationship with the emergency room. STEMINEM Day has no registration fee and is open to all EMS staff. In its second phase, the project aims to reach all emergency room teams at country level. So far three courses have been completed with 112 participants. The feedback obtained through an online questionnaire has been truly amazing and five additional courses are already scheduled for 2015. SFL Portugal strongly believes that empowering EMS teams with scientific knowledge will improve the decision making process with clear gains for STEMI patients.

João Sousa Ferreira Executive Secretary APIC (Associação Portuguesa de Intervenção Cardiovascular) Hélder Pereira SFL Portugal Country Champion

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Piloting pre-hospital diagnosis and triage in Greece

SFL Greece is running a pre-hospital diagnosis and triage pilot programme with EMS in the Athens area. If system delays are reduced the changes will be extended throughout the country. Emergency Medical Services (EMS) play a critical role in STEMI networks. EMS crews must arrive quickly, assess the patient’s condition and offer first aid, and then transfer the patient to the nearest PCI centre if needed. EMS is a key partner in SFL Greece and despite infrastructure problems EMS managers are motivated to contribute to STEMI networks. One major barrier to the optimal performance of EMS in Greece is the lack of 12-lead ECGs in ambulances. The result of this deficit is that pre-hospital diagnosis and triage is nonexistent. Pre-hospital diagnosis and triage is of extreme importance in STEMI care because it reduces system delays by transferring patients to the nearest cath lab and bypassing non-PCI hospitals. SFL Greece has started a pre-hospital diagnosis and triage pilot programme in the Athens area in which ten ambulances are equipped with 12-lead ECGs that automatically generate a diagnosis. Teletransmission is used to send ECG results to the attending physician in the dispatch centre to initiate triage and direct referral. The pilot programme began in June and will run for six months. To start the pilot programme SFL Greece secured approvals from the Ministry of Health and EMS, selected equipment and raised the required funds. The next step was to train EMS personnel. The training programme for EMS doctors featured a presentation from SFL Greece Country Champion Dr John Kanakakis, who explained the objectives and structure of SFL. He also outlined how to best care for STEMI patients, including how to recognise the symptoms of STEMI, read the ECG and take the necessary actions. Paramedics have received training on how to perform and transmit an ECG, how to interpret the automatic diagnosis, and what to do when STEMI is found. A transportation protocol for STEMI patients has been agreed and is being tested, along with the ECG transmission, in a single ambulance for the first month of the pilot. The remaining nine ambulances will then join the pilot programme. Results of the pilot are expected at the beginning of 2016. If system delays are reduced, all ambulances in Greece will be equipped with 12-lead ECGs. SFL Greece is enthusiastic about this collaboration with EMS and is optimistic that it will improve care for STEMI patients.

Lina Hourdaki SFL Greece Project Manager

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Can SFL serve as a best practice example for building stroke networks for acute ischemic stroke patients?

EuroPCR 2015 featured a special breaking news session devoted to the rapidly evolving field of mechanical thrombectomy in acute ischaemic stroke. Experts reviewed the recent evidence and discussed the rationale for boosting use of this therapy. Seven clinical trials in the past six months have demonstrated that intracranial thrombus retrieval or lysis is feasible and safe, and leads to significant improvements in neurological function on top of best medical therapy (including intravenous thrombolysis, when indicated), as compared to best medical therapy alone. These seven trials are REVASCAT, THRACE, MR CLEAN, ESCAPE, EXTEND-1A, SWIFT PRIME and THERAPY. “Acute ischaemic stroke is as common as acute coronary syndrome, but the prognosis is still very grave,” commented Petr Widimsky, one of the breaking news session panelists. “With conservative treatment following a moderate or severe stroke, only 10% of patients will recover to the state of functional independence.” He added: “So, 90% of patients who are not treated die or are severely disabled. Thrombolysis increases the rate of people who return to functional independence from 10% to 20%–25%, but that still leaves 75% disabled or dead.” According to Widimsky, the accumulated evidence from the various clot retrieval trials published or presented in the past few months suggests that the number of moderate/severe stroke patients who regain full or near-full neurological function rises to 40% to 50% with this novel therapy. He stated: “With good patient selection, that may increase to 60%.” “We are highlighting the new data here at EuroPCR 2015 in order to spread the message that this therapy shows great promise,” said Widimsky. “We need to build healthcare systems and train physicians to be able to offer this effective method to as many patients with acute ischaemic stroke as possible.” Experts agreed that there are far too few qualified interventional neuroradiologists in Europe to offer such services 24/7 to the existing numbers of stroke patients. “To offer this intervention rapidly, the question becomes whether cardiologists can help,” said Kenneth Snyder, from the State University of New York in Buffalo. The panelists concluded that interventional cardiologists may have the basic skill set, which with additional training could maintain 24/7 coverage for this time-critical procedure. “Stent for Life (SFL), which is an initiative of the EAPCI and EuroPCR, can serve as a best practice example to support the development of regional stroke networks for patients with acute ischaemic stroke,” said Zuzana Kaifoszova, SFL project manager. “SFL will share our experience with stroke organisations to help speed up the process of improving access to mechanical thrombectomy.”

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SHARE.INSPIRE.LEARN

What can acute stroke interventionalists learn from cardiologists regarding workflow? Four randomised trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME) published during the last few months have convincingly demonstrated the benefits of percutaneous interventions in acute ischaemic stroke. This led to a joint statement from the European Stroke Organisation (ESO), the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the European Society of Neuroradiology (ESNR). The trials found that rapid mechanical thrombectomy improves patient function after acute ischaemic stroke. To achieve this benefit, patients were treated by interventional neuroradiologists in stroke centres with multidisciplinary stroke teams. The treatment should be performed as rapidly as possible in conjunction with standard intravenous thrombolysis. ESO, ESMINT and ESNR stated that they strongly support the application of this treatment in appropriately selected patients in well equipped stroke centres by properly trained neurointerventionists. Thus, the task for health care providers is to offer this effective therapy to all suitable patients with acute ischaemic stroke (estimated at 10-15% of all acute strokes). The experience of the cardiology community in the logistics of STEMI networks can be used when building and organising networks for the interventional treatment of acute stroke (ref. 1). In some regions, where interventional treatment of acute stroke is not readily available, interventional cardiologists can (after appropriate training focused on acute stroke interventions and carotid stenting) help to cover this medical service for the given population. In most countries (Czech Republic, Germany, US and others) treatment of all suitable patients with reperfusion by intervention would require a five to 10-fold increase in the number of interventional procedures compared to current rates. The involvement of interventional cardiologists may help to cover this unmet medical need. Median imaging-to-groin puncture time

Fig. 1 shows a comparison of time delays from initial imaging (CT or MR) to the beginning of intervention (sheath insertion) in five randomised trials and at the Cardiocenter, University Hospital Kralovske Vinohrady, Prague.

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SHARE.INSPIRE.LEARN

Fig. 2 shows the optimal workflow in STEMI and acute ischaemic stroke with possible time savings when the emergency room and intensive care unit are skipped en route to the cath lab. Thrombolysis (whenever indicated) should be given in the CT suite and should not delay transfer to the cath lab.

Fig. 3 shows the optimal workflow for acute stroke in more detail.

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SHARE.INSPIRE.LEARN

There are still many unanswered questions in interventional treatment for acute stroke. From the population perspective the most important question is whether acute stroke patients can benefit from long distance (interhospital) transport to a similar extent as STEMI patients. There is no answer to this question yet but some observational data (ref. 2) suggest that due to longer delays the benefit of transferring patients is much smaller than the benefit observed in patients directly (primarily) admitted to interventional stroke centres. Thus, it is likely that future networks of interventional acute stroke centres should be at least as dense as networks of STEMI centres. Given the global shortage of fully trained health care professionals it may be wise for all interventional specialties (radiology, cardiology, neurosurgery, neurology, angiology, etc.) to cooperate in this field rather than fight against each other.

Petr Widimsky Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Czech Republic L. Nelson Hopkins Gates Vascular Institute, Department of Neurosurgery, University at Buffalo, United States

References: 1. Widimský P, Kožnar B, Štětkářová I. Modern treatment of acute ischemic stroke. Vnitr Lek. 2014; 60: 1086-1089. 2. Sonig A, Lin N, Krishna C, Natarajan SK, Mokin M, Hopkins LN, Snyder KV, Levy EI, Siddiqui AH. Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US. J Neurointerv Surg, in press 2015.

Petr Widimsky

L. Nelson Hopkins

Stent for Life Initiative Newsletter | Edition 16 | Summer 2015

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Contract4Life educates nurses and patients at selected SFL centres

Stent for Life is starting their Contract4Life programme at selected SFL centers in five countries. The objective is to provide standardized education for cardiac nurses and STEMI patients at discharge from a primary PCI hospital. In the present era of primary PCI, the proportion of STEMI patients who survive to hospital discharge has improved dramatically. These patients are at risk of early post discharge hospital readmission. Predictors of 30-day readmission for STEMI patients have not been well studied. However, research has shown that readmissions are heterogeneous in nature and some issues can be resolved, not with more medical procedures, but with education and standardised communication. Patients who have a clear understanding of their after-hospital care instructions including how to take their medication, signs and symptoms of the disease, and diet and lifestyle requirements are 30% less likely to be readmitted or visit the emergency department than those who lack this information. SFL is bstarting a new project called Contract4Life. Selected SFL countries will participate in the pilot phase of the programme. The major objective is to ensure that a dedicated certified nurse education specialist is a member of the heart team at each 24/7 SFL centre to provide clear discharge instructions to post-STEMI patients. Barriers will be identified and strategies adopted to make patient education activities part of the work flow of SFL centre employees. The post-MI patient journey will be mapped, and discharge educational programmes currently in place will be analysed. Based on a needs assessment, a standardised post-MI education toolkit for SFL centre discharge nurses, rehabilitation specialists and patients, including a patient information sheet, patient discharge contract and nurse checklist will be designed and tailored to country specific needs. Educational sessions will then be documented to track patients’ learning progress. The first phase of the project, which involved mapping and analysing the current situation in respective countries, was launched in May at EuroPCR 2015.

Zuzana Kaifoszova SFL Initiative Project Manager Europe

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