The Euro Heart Survey program was launched by the European Society of Cardiology (ESC) around the year 2000 to assess variations in management and treatment of cardiovascular disease (CVD) across Europe, particularly with regard to diagnostic procedures and treatments. Both the incidence of CVD and access to medical care are highly variable throughout Europe. Reports have shown that for a given age group, the risk of dying from CVD was five times higher in eastern European countries as compared with western European countries such as France, Italy, or Spain ( Fig. 4-1 ). This huge difference in the prevalence of CVD is linked to several factors, including the higher prevalence of risk factors such as smoking, hypertension, obesity, and diabetes in eastern compared with western European populations. The common denominator of this higher incidence of risk factors and CVD is probably unfavorable economic conditions. As a result, the countries where the incidence of CVD is highest are also those that offer the least adequate health care to their citizens. Differences in the rate of CVD and the dynamics of this rate over time have been recorded in several reports coordinated by the ESC. , These reports have consistently shown that as the European population ages, more people are surviving a first manifestation of CVD, particularly coronary artery disease (CAD). Similarly, the number of people suffering from CVD and requiring treatment is increasing steadily over time. If the rate of hospital discharge with a primary diagnosis of CVD, ischemic heart disease, or cerebrovascular disease is taken as an indicator of the burden of CVD in Europe, it seems that there has been a gradual and steady increase since the early 1990s. The standardized rate of CVD mortality is decreasing in men and women in Europe, but there is a trend toward an increase in the countries of the Commonwealth of Independent States (CIS; see Fig. 4-1 ). (The CIS is made up of former Soviet republics.)
Since 1990, the number of hospital discharges for CVD in the European population has increased by 26%, from 20.8 to 26.3/1000. This increase was more marked in eastern European countries and, to a lesser extent, in countries from the European Union (12 members, or the new enlarged EU, with 15 members). Over the same period, the number of hospital discharges for ischemic heart disease increased by 29% and for cerebrovascular disease by 41%. *
* These data are from the World Health Organization (WHO) European Health for All database (HFA-DB) http://data.euro.who.int.easyaccess2.lib.cuhk.edu.hk/hfadb , the WHO Mortality database (WHOMDB) http://data.euro.who.int.easyaccess2.lib.cuhk.edu.hk/dmdb , the Eurostat databases http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/home , and the U.S. Census Bureau International database http://www.census.gov/ipc/www/idb .
The Euro Heart Survey program collects data all over Europe in many cardiology fields (e.g., acute coronary syndrome [ACS], heart failure, percutaneous coronary intervention [PCI], revascularization, atrial fibrillation, valvular heart disease, congenital heart disease). Participation in the surveys is voluntary, and there are no financial incentives for the participating centers or investigators. Ideally, the Euro Heart Survey program would be representative of the whole of Europe, but it is clear that in many countries, only the best hospitals participate, with the result that the data may portray a more optimistic picture than reality. With each subsequent survey, the logistics have gradually been modernized and improved, moving from paper case report forms (CRFs) in the first surveys to electronic CRFs online, an online data collection system that provides each center with access to its own data, and comparisons to peer centers.This chapter presents data collected in three consecutive surveys carried out in early 2000, 2004, and 2007. The first two surveys were done over a fixed period of time. The last survey is still underway and is being transformed into a permanent registry.
Euro Heart Surveys: Acute Coronary Syndromes I and II
In 2000, the ESC encompassed 47 countries across Europe and the Mediterranean basin. To delineate the characteristics, treatments, and outcomes of ACS patients treated in representative ESC member countries, and particularly to examine the adherence to current practice guidelines, the ESC sponsored the large-scale Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS; EHS ACS-I), a prospective survey of 25 ESC member countries. The enrollment period was planned from September 4 to December 31, 2000, but it was extended to May 15, 2001, with data collection beginning in early 2001 in some countries.
During the study period, 14,271 patients were screened, of whom 10,484 were finally diagnosed with ACS. The initial diagnosis for these patients was ACS with ST elevation in 42.3%, ACS without ST elevation in 51.2%, and ACS with an undetermined electrocardiographic pattern in 6.5%. Altogether, 32.8% of patients had a final diagnosis of Q-wave acute myocardial infarction (AMI), 25.3% non–Q-wave AMI, and 41.9% unstable angina (UA).
The patients were enrolled in 65 clusters (103 hospitals)—65% in academic hospitals, 77% in hospitals with catheterization laboratories, and 57% in hospitals with cardiac surgery facilities. The vast majority of patients with ST-elevation ACS were originally admitted to coronary care units or a general cardiology ward, with only a minority of patients admitted to internal medicine wards. ACS patients with other electrocardiographic patterns were more than twice as likely to be admitted to internal medicine wards. The median (25th, 75th percentiles) duration of hospitalization was 8 (5, 12) days for all patients, 8 (5, 12) for ST-elevation patients, 7 (4, 12) days for non–ST-elevation patients, and 8 days (5, 13) for patients with an undetermined electrocardiographic pattern. When analyzed based on the final diagnosis, the duration of hospitalization was 7 (4, 12) days for patients with UA, 7 (5, 11) days for patients with non–Q-wave AMI, and 8 (5, 13) days for patients with Q-wave AMI.
Coronary angiography was performed in approximately half of the survey cohort during the initial hospitalization. PCIs were performed more commonly for patients with ST-elevation ACS.
Among patients with ST-elevation ACS, 55.8% received any form of reperfusion therapy, 20.7% received primary PCI, and 35.1% had fibrinolytic therapy. Among patients with ST-elevation ACS who underwent reperfusion therapy, the median time (25th, 75th percentiles) from symptom onset to arrival in the emergency room was 176 minutes (90, 465) and the median time from arrival to the emergency room to reperfusion therapy was 59 minutes (30, 109)—40 minutes (25, 70) to the initiation of fibrinolytic therapy and 93 minutes (60, 170) to the first balloon inflation. Among patients undergoing primary PCI in this subgroup, 45.4% received a platelet glycoprotein IIb/IIIa inhibitor and 70.7% received an intracoronary stent.
While in hospital, a substantial proportion (7% to 17%) of patients with ACS did not receive aspirin, especially if they had an initially undetermined electrocardiographic pattern (results are presented as ranges for the different forms of ACS). Unfractionated heparin was more commonly used among patients with ST-elevation ACS, whereas low-molecular-weight heparin (LMWH) was more commonly used in the other subgroups. Altogether, platelet glycoprotein IIb/IIIa inhibitors were not commonly used in this survey cohort (8.9% to 19.6% for the different types of ACS), and if they were used it was more common in the ST-elevation ACS group. Although β-adrenergic blockers were commonly used in all subgroups, their intravenous use was low, 5.9% to 13.5% for the different types of ACS).
A substantial proportion of patients did not receive aspirin at discharge (11.5% to 16.9% for the different types of ACS), only partially explained by the widespread use of anticoagulation agents or the other antiplatelet agents, ticlopidine and clopidogrel. Although β-adrenergic blockers were commonly prescribed (67.4% to 76.9% for the different types of ACS), the use of agents blocking the angiotensin axis was less common (55.7% to 64.1% for the different types of ACS). Over 50% of patients received lipid-lowering treatment with statins at discharge; most of them began receiving this treatment during the hospitalization.
Patients with ST-elevation ACS were more likely to undergo PCI in the interim between hospital discharge and the 30-day follow-up, whereas patients with non–ST-elevation ACS were more likely to undergo coronary bypass surgery.
In-hospital survival status was available for all patients, with a mean in-hospital death rate of 4.9% for the entire survey cohort. The in-hospital death rate for patients with ST-elevation ACS was 7.0%, for patients without ST-elevation ACS 2.4%, and for patients with an undetermined initial electrocardiographic pattern 11.8%. At 30 days, the death rates were 8.4%, 3.5%, and 13.3%, respectively (with 30-day survival status available for 90.7%, 88.8%, and 88.6%, respectively), resulting in a mean 30-day death rate for the entire cohort of 6.3%.
To examine the management and implementation of more contemporary guidelines, we conducted the second Euro Heart Survey of ACS during 2004 in 190 medical centers from 32 countries in Europe and the Mediterranean basin. Of the 190 centers, 91 that participated in the survey were affiliated with academic institutions, 123 had catheterization laboratories, and 61 had cardiac surgery facilities. Of the patients who were hospitalized, 53% were in medical centers affiliated with academic institutions and 46% were hospitalized in tertiary care centers. Seventy-three percent of the patients were treated in hospitals that had on-site catheterization laboratories and 37% in centers that had facilities for cardiovascular surgery. Among the centers participating in EHS ACS-II were 34 centers that had also participated in the first Euro Heart Survey on ACS.
The EHS ACS-II cohort included 6385 patients with a final diagnosis of ACS. The proportion of patients with an initial diagnosis of ACS with ST elevation rose from 42% in EHS ACS-I to 47% in EHS ACS-II, whereas non–ST-elevation ACS patients comprised 51% of the ACS-I participants and 48% of those included in ACS-II. Five percent and 6.5% of the patients in ACS-II and ACS-I, respectively, presented with an undetermined electrocardiographic pattern.
Examination of the characteristics of all patients included in the first and second EHS surveys of ACS showed a considerable degree of similarity with respect to mean age (65.2 vs. 64.7 years in ACS-I vs. ACS-II), proportion of men (67.5% in ACS-I vs. 70.1% in ACS-II), and the proportion of patients with risk factors. Comparison of the characteristics of the patients in the 34 centers participating in both surveys showed much similarity in the two periods.
In the second survey, more patients were hospitalized in coronary care units (70% vs. 62.4%), whereas fewer were treated in cardiology wards (19.1% vs. 22%) and in internal medicine wards (7% vs. 13.8%). The proportion of patients hospitalized in other wards was 3.9% in ACS-II versus 1.8% in ACS-I.
Coronary angiography, PCIs, and intracoronary stents were used more frequently in ACS-II than in ACS-I, including primary PCI for ST-elevation ACS. The increase in the proportion of patients undergoing coronary angiography, PCIs, and stent implantation among those hospitalized in the 34 centers was higher than in the full ACS-I and ACS-II cohorts (from 60.5% to 82.3%, 45.9% to 69.9%, and 34.1% to 63.6% for patients with ST-elevation ACS, respectively, and from 54.3% to 72.1%, 27.3% to 46.7%, and 19.6% to 43.6% for non–ST-elevation patients, respectively). In addition, a greater proportion of patients received evidence-based medications during their hospitalization and at discharge in ACS-II compared with ACS-I, irrespective of their initial electrocardiographic diagnosis ( Fig. 4-2 ).
