Stakeholder Insight: Acute Coronary Syndromes Fresh look at ACS in Europe, what is the real picture?

Published by: Datamonitor

Published: Dec. 26, 2007 - 164 Pages

Table of Contents

ABOUT DATAMONITOR HEALTHCARE

About the cardiovascular analysis team

CHAPTER 1 EXECUTIVE SUMMARY

Scope of the analysis

Datamonitor insight into the ACS market

Contributing experts

CHAPTER 2 ACS DEFINITIONS AND PATHOPHYSIOLOGY

Acute coronary syndromes

Definitions

Pathophysiology

Coronary artery disease and atherosclerosis

Vulnerable plaque

Histopathology of atherosclerotic lesions

Remodeling and role of coronary artery inflammation

Thrombosis

Atherosclerotic calcification

Ischemia

Unstable angina (UA)

Variant angina

Non-ST segment elevated myocardial infarction (NSTEMI)

Non-ST segment elevated myocardial infarction (NSTEMI) and ST segment elevated myocardial infarction (STEMI)

New definition of myocardial infarction

CHAPTER 3 EPIDEMIOLOGY

ACS epidemiology specifics and limitations

Ageing population

Male to female ratio and age

Risk factors

Smoking

Obesity and overweight prevalence

Diabetes

Hypertension

Dyslipidemia

Prevalence and incidence of ACS in the 5EU

Incidence of STEMI

Incidence of UA and NSTEMI

CHAPTER 4 DIAGNOSIS AND INVESTIGATION IN ACS

Symptoms

Initial and final diagnosis

Physical examination and chest pain differential

Clinical tests in primary investigation

ECG and ECG Stress testing

Cardiac biomarkers

Cardiac troponins

Creatine Kinase (CK)

Myoglobin

C-reactive protein (CRP)

Neurohormonal activation markers

Novel biomarkers

Multimarker approach

Risk stratification

Role of imaging tests in ACS

Invasive imaging testing

Coronary angiography

Intravascular ultrasound (IVUS)

Intravascular MRI (IVMRI)

Non-invasive imaging testing

Echocardiography and stress echo

Chest X-ray

Nuclear perfusion tests

Role of MRI and CT in coronary heart disease diagnosis

Limitations of early imaging in the emergency department

CHAPTER 5 PHARMACOLOGICAL STRATEGIES

Drug classes in ACS

Anti-ischemic agents

Nitrates

Betablockers

Calcium channel blockers

ACE inhibitors and angiotensin II receptor blockers

Antithrombotics

Anticoagulants

Heparins

Antiplatelet agents

COX-1 inhibitors (aspirin)

ADP receptor antagonists

GPIIb/IIIa receptor inhibitors

Thrombolytics

Fibrinolysis

Pharmacological reperfusion

Statins

CHAPTER 6 REVASCULARIZATION STRATEGIES

Coronary thrombolysis

Pre-hospital thrombolysis

In-hospital thrombolysis

Contraindications to fibrinolytic therapy

Interventions versus thrombolysis

Clinical trial evidence: C-PORT and a meta-analysis

Evidence from registries

Angioplasty

Stenting

In-stent restenosis: the man-made condition

Drug-eluting stents

ESC guidelines on PCI strategy in NSTE-ACS and STEMI

Coronary artery bypass graft (CABG)

CHAPTER 7 HOSPITAL INFRASTRUCTURE AND PATIENT FLOW

Overview

General practitioners and outpatient facilities

Role of ambulance services

Emergency department (ED)

Coronary care and intensive care unit

Cardiac catheterization laboratory (Cathlab)

CHAPTER 8 REVIEW OF CURRENT GUIDELINES

ESC guidelines

Recommendations by the ESC

Guidelines for STEMI patients

CHAPTER 9 KEY FIGURES AND STATISTICAL ANALYSIS

Methodology

Patient demographics

Main diagnosis

ACS age and sex distributions

Co-morbidities and risk factors

Diabetes

Dyslipidemia

Hypertension

Obesity

Smoking

ACS hospital logistics

Mode of admission

Mode of admission for patients with ST-segment elevation

Type of hospital for ACS patient admission.

The importance of cathlabs

Point of entry to hospital

First stage

Second stage

Length of stay in hospital

Hospital transfers

Diagnostic procedures

Cardiac biomarkers

Non-invasive imaging test

Reperfusion therapy

Thrombolytic therapy

Coronary interventions

Pharmacological therapy

Anticoagulants

Unfractionated heparins

Low molecular weight heparins

Antiplatelet agents

COX-1 inhibitors

ADP receptor antagonists

GPIIb/IIIa receptor inhibitors

Anti-ischemic agents

Nitrates

Betablockers

ACE inhibitors

Summary

APPENDIX

References

General sources

Obesity Epidemiology sources

France

Germany

Italy

Spain

UK

About Datamonitor

About Datamonitor Healthcare

About the Cardiovascular Disease analysis team

Disclaimer

List of Tables

Table 1: Prevalence of obesity in the seven major markets (000s), 2006-2015

Table 2: Prevalence of obesity / overweight in the seven major markets (000s), 2006-2015

Table 3: Estimated absolute prevalence of diabetes in the seven major markets (millions), 2006

Table 4: Prevalence of hypertension in the seven major markets (000s), 2003

Table 5: Estimated prevalent persons with dyslipidemia across the seven major markets, 2005

Table 6: Incidence of ST-segment elevation myocardial infarction (000s)

Table 7: Incidence of unstable angina and non-ST segment elevation myocardial infarction (000s)

Table 8: Types of chest pain

Table 9: Risk stratification summary for ACS, 2006

Table 10: Number of PCI procedures performed in the 5EU, 2005

Table 11: CABG procedures performed in the 5EU, 2005

Table 12: ESC guidelines for the management of STEMI, 2002

List of Figures

Figure 1: Development and progression of atherosclerosis

Figure 2: Pathogenesis of a plaque leading to rupture

Figure 3: ACS pathophysiology cycle

Figure 4: The 10 leading causes of death in high-income countries (%),2005 projections

Figure 5: Deaths attributed to specific cardiovascular diseases, 2006

Figure 6: Major causes of death in the 5EU, 2006

Figure 7: Distribution of the population in Europe by age, 2004

Figure 8: Distribution of the population in Europe by age, 2050

Figure 9: Basic diagnostic flow in ACS

Figure 10: Antiplatelet therapy in ACS

Figure 11: Ancrod acts indirectly on the thrombolytic pathways

Figure 12: Contraindications to fibrinolytic therapy

Figure 13: PCI procedures carried out by indication in the 5EU, 2005

Figure 14: Management of ACS without ST-elevation (NSTE-ACS)

Figure 15: Management of ACS in STEMI

Figure 16: Typical patient flow in case of acute chest pain

Figure 17: Delays in patients with acute chest pain

Figure 18: Proportion of patients presented with and without ST-segment elevation on initial ECG, 5EU, 2007

Figure 19: Ratio of main ACS diagnoses in 5EU

Figure 20: Overall ACS age distribution in the ACV analyzer sample

Figure 21: ACS age distribution split by country and sex

Figure 22: Changes in main diagnosis ratio in age distribution

Figure 23: Changes in main diagnosis ratio by age and sex, MALE

Figure 24: Changes in main diagnosis ratio by age and sex, FEMALE

Figure 25: Age-related variations in male:female ratio of ACS patients in the 5EU

Figure 26: Diabetes distribution among ACS patients in the 5EU

Figure 27: Dyslipidemia distribution among ACS patients in the 5EU

Figure 28: Hypertension distribution among ACS patients in the 5EU

Figure 29: BMI distribution among ACS patients in the 5EU

Figure 30: Percentage of patients who smoke in the ACS analyzer sample per country

Figure 31: Hospital admission mode for ACS patients

Figure 32: Mode of hospital admission for patients with ST-segment elevation

Figure 33: Patients admitted via ambulance to hospitals with or without cathlabs - all patients versus those with ST-segment elevation

Figure 34: Proportion of ACS patients admitted to hospitals with or without cathlab by all modes of admission - all patients versus those with ST-segment elevation

Figure 35: First stop in hospital after admission - all patients versus those with ST-segment elevation

Figure 36: Second stop in hospital after admission - all patients versus those with ST-segment elevation

Figure 37: Diagnostic challenge: Second stop in hospital after admission for patients without ST-segment elevation and with negative troponin

Figure 38: Length of in-hospital stay for ACS patients, UA

Figure 39: Length of in-hospital stay for ACS patients, NSTEMI

Figure 40: Length of in-hospital stay for ACS patients, STEMI

Figure 41: Percentage of all ACS patients who have been transferred or referred to hospitals and transferred from hospitals for further PCI or CABG or other treatment

Figure 42: Distribution of troponin test

Figure 43: Distribution of Echo and Nuclear perfusion tests

Figure 44: Distribution of CT and MRI tests

Figure 45: Distribution of stress test

Figure 46: Distribution of IVUS (%) in angiography cases only

Figure 47: Distribution of thrombolytic therapy in all ACS patients and in patients presented with ST-segment elevation

Figure 48: Country distribution of thrombolytic therapy in patients presented with ST-segment elevation only

Figure 49: Country distribution of success rate of thrombolytic therapy in patients presented with ST-segment elevation

Figure 50: Specific thrombolytic molecules use distribution in 5 European countries

Figure 51: % of all ACS patients receiving Diagnostic Angiography test then PCI and then Stenting

Figure 52: Door to PCI time, percentage of patients who received PCI <12h from hospital admission vs. >12h from hospital admission

Figure 53: Distribution of STENT implantations by type

Figure 54: % of CABG

Figure 55: Early reperfusion therapy (< 12 h after onset of symptoms) distribution in STEMI patients

Figure 56: Use of unfractionated heparins in the treatment of ACS patients

Figure 57: Use of low molecular weight heparins (LMWH) in the treatment of ACS patients

Figure 58: Use of COX-1 Inhibitors (aspirin) in the treatment of ACS patients

Figure 59: Use of ADP receptor antagonists in the treatment of ACS patients

Figure 60: Use of GPIIb/IIIa receptor inhibitors in the treatment of ACS patients

Figure 61: Use of nitrates in the treatment of ACS patients

Figure 62: Use of betablockers in the treatment of ACS patients

Abstract

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