Introduction
Percutaneous coronary intervention (PCI) remains a widely utilized, aggressive reperfusion strategy for patients with acute coronary syndromes (ACS) – STEMI, NSTEMI and UA. In this primary research piece, shifts away from focus solely on the EU. For the first time, we provide an in-depth comparison of PCI/stent practices between the US and the 5EU markets.
Scope
*What are the preferred revascularization strategies and how are these affected by geography and diagnosis?
*To what extent are reperfusion therapies, such as PCI (percutaneous coronary intervention) and/or thrombolysis, used?
*Which are the preferred drug classes used as adjunctive therapies to PCI and to what extent are they used?
*What are the current hospital admission and logistics issues?
Highlights
Revascularization patterns vary and are dependent largely on ACS subtype. STEMI patients in all countries showed greater use of thrombolytics compared to NSTEMI and UA patients. PCI represents a more aggressive method to reopen coronary vessels. PCI is widely used in all ACS patients, but is most common in STEMI, particularly in Germany and the US.
Time-to-PCI is very vital for myocardial salvage. Germany, followed by the US, showed the highest proportion of STEMI and NSTEMI patients achieving symptom onset to PCI time and door to PCI times in less than 12 hours. This is a function of Germany’s brilliant PCI infrastructure.
There is wide regional variation in the use of bare metal stents and drug-eluting stents. Germany and France show preference for BMS over DES in all ACS types. Additional data and newly available stents, have powered a shift in practice back towards use of DES, particularly in Italy, Spain, UK and the US.
Reasons to Buy
*Know the PCI market, the driving indications and the drug classes prescribed in PCI patients.
*Gain access to patient records reflecting the current clinical practice in the US and the EU.
*Identify underserved areas in both terms of geography and diagnosis.
Table of Contents :
“ABOUT HEALTHCARE 2
About the Cardiovascular pharmaceutical analysis team 2
CHAPTER 1 EXECUTIVE SUMMARY 3
Scope of the analysis 3
insight into the PCI market 4
Related reports 6
Upcoming related reports 6
CHAPTER 2 PATIENT DEMOGRAPHICS, CO-MORBIDITIES AND RISK FACTORS 8
Methodology 9
Patient demographics 9
Acute coronary syndrome and elective PCI patient ratios 9
US 11
Europe 13
France 16
Germany 16
Italy 16
Spain 17
UK 17
Body mass index 17
Co-morbidities 19
Cardiovascular co-morbidities 19
Diabetes 19
Hypertension 20
Dyslipidemia 21
Atrial fibrillation (AF) 22
Peripheral arterial disease (PAD) 23
Coronary artery disease (CAD) 24
Obesity 26
Chronic heart failure (CHF) 28
Cerebrovascular disease 29
Non-cardiovascular co-morbidities 31
Asthma/COPD 31
Chronic renal insufficiency (CRI) 32
Liver disease 33
Anemia 34
Cancer – active/recent malignancy 35
Risk factors 37
Previous acute events 37
Previous percutaneous coronary intervention (PCI) 37
Previous unstable angina (UA) 39
Previous myocardial infarction (MI) 41
Previous thrombolysis 43
Previous coronary artery bypass graft (CABG) 45
Previous stroke/cerebrovascular attack (CVA) 47
Previous venous thromboembolism (VTE) 49
Previous acute heart failure (AHF) 51
Other risk factors 53
Family history 53
Smoking 54
Ex-smoking 55
Prosthetic heart valve 56
New York Heart Association classification 57
Hospital demographics 59
Hospital size 59
Cardiac catheterization laboratories 59
Coronary care unit (CCU)/intensive care unit (ICU) 61
CHAPTER 3 DIAGNOSIS, PRESENTATION AND REFERRAL OPTIONS 63
Diagnosis 64
Initial systolic blood pressure 64
Electrocardiogram initial findings 65
ST elevation 68
ST depression 70
T-wave inversion 71
Atrial fibrillation (AF) 72
Other abnormal rhythm 73
Left/right bundle branch block (BBB) 74
No electrocardiogram (ECG) change 75
Initial diagnostic tests 76
Troponin tests 76
Creatine kinase-MB 79
Brain natriuretic peptide 80
Imaging tests 83
Diagnostic coronary angiogram 83
Echocardiography 84
Computed tomography (CT) scan 87
Magnetic resonance imaging (MRI) scan 88
Intravascular ultrasound 90
Stress tests 92
Admission patterns 94
US 95
France 97
Germany 98
Italy 100
Spain 101
UK 102
Referral patterns 104
US 104
France 105
Germany 106
Italy 107
Spain 108
UK 109
Outcomes 110
Length of stay in hospital 110
Outcomes for completed acute cardiac episode 113
CHAPTER 4 REVASCULARIZATION PROCEDURES 115
Revascularization procedures 116
Percutaneous coronary intervention (PCI) 116
PCI versus thrombolytics 116
Thrombolytic success 119
Time to PCI 120
PCI with stents 126
Bare metal stents versus drug-eluting stents 127
Repeat PCI 132
PCI and vascular closure devices 134
General pharmacological management 136
Anticoagulants 137
Use of heparins in combination with PCI 137
Antiplatelet agents 140
ADP antagonists 140
GPIIb/IIIa inhibitors 143
Other drug classes 145
ACE inhibitors 145
Statins 146
BIBLIOGRAPHY 148
Journal papers 148
Websites 151
reports 152
APPENDIX A 153
Contributing experts 153
APPENDIX B 154
About154
About Healthcare 154
About the Cardiovascular Disease analysis team 155
Disclaimer 157
List of Tables
Table 1: Median time delays in reperfusion therapy across the five major EU countries, 2009 125
List of Figures
Figure 1: Ratio of elective PCI patients to ACS patients, split by STEMI, NSTEMI and UA, in the combined US and five major EU markets 10
Figure 2: Death rates, split by age, for the leading 10 causes of death in the US, 2006 12
Figure 3: Proportion of patients, split by age and sex, undergoing elective PCI or diagnosed with NSTEMI, STEMI or UA in the US, 2009 13
Figure 4: Proportion of patients, split by age and sex, undergoing elective PCI or diagnosed with NSTEMI, STEMI or UA in the five major EU markets, 2008 15
Figure 5: Body mass index (BMI) distribution among elective PCI, NSTEMI, STEMI and UA patients in the US (2009) and five major EU markets (2008) 18
Figure 6: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have diabetes in the US (2009) and five major EU markets (2008) 19
Figure 7: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have hypertension in the US (2009) and five major EU markets (2008) 21
Figure 8: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have dyslipidemia in the US (2009) and five major EU markets (2008) 22
Figure 9: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have atrial fibrillation (AF) in the US (2009) and five major EU markets (2008) 23
Figure 10: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have peripheral arterial disease (PAD) in the US (2009) and five major EU markets (2008) 24
Figure 11: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have coronary artery disease (CAD)in the US (2009) and five major EU markets (2008) 25
Figure 12: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have obesity in the US (2009) and five major EU markets (2008) 27
Figure 13: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have chronic heart failure (CHF)in the US (2009) and five major EU markets (2008) 28
Figure 14: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have cerebrovascular disease in the US (2009) and five major EU markets (2008) 30
Figure 15: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have asthma/COPD in the US (2009) and five major EU markets (2008) 32
Figure 16: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have chronic renal insufficiency in the US (2009) and five major EU markets (2008) 33
Figure 17: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have liver disease in the US (2009) and five major EU markets (2008) 34
Figure 18: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have anemia in the US (2009) and five major EU markets (2008) 35
Figure 19: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have cancer (active/recent malignancy) in the US (2009) and five major EU markets (2008) 36
Figure 20: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had a previous percutaneous coronary intervention (PCI) in the US (2009) and five major EU markets (2008) 38
Figure 21: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had previous unstable angina (UA) in the US (2009) and five major EU markets (2008) 40
Figure 22: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had a previous myocardial infarction (MI) in the US (2009) and five major EU markets (2008) 42
Figure 23: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had previous thrombolysis in the US (2009) and five major EU markets (2008) 44
Figure 24: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had a previous coronary artery bypass graft (CABG) in the US (2009) and five major EU markets (2008) 46
Figure 25: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had a previous stroke/cerebrovascular attack (CVA) in the US (2009) and five major EU markets (2008) 48
Figure 26: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had a previous venous thromboembolism (VTE) in the US (2009) and five major EU markets (2008) 50
Figure 27: Proportion of elective PCI, NSTEMI, STEMI and UA patients who had previous acute heart failure (AHF) in the US (2009) and five major EU markets (2008) 52
Figure 28: Proportion of elective PCI, NSTEMI, STEMI and UA patients who have a family history of cardiovascular disease in the U
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