Primary and secondary prevention of sudden cardiac death in emerging economies

Transcription

1 Primary and secondary prevention of sudden cardiac death in emerging economies Béla Merkely MD, PhD, DSc, FESC Heart Center Semmelweis University Budapest

2 Common risk factors for sudden cardiac death Increasing age Male gender Family history of coronary artery disease Increased LDL cholesterol Hypertension Smoking Diabetes mellitus Heavy alcohol consumption Mostly these are the risk factors for CAD, which is especially prevalent in Central-Eastern European countries with emerging economies ESC SCD guideline, 2001

3 160 Trends in coronary deaths in men / Pyrgakis et al. Hellenic J Cardiol Europe , stable EU 40, decreasing Greece 50, stable >100 Hungary France Low and decreasing Czech Rep. Decreasing from high Romania Recent high ceiling

4 Incidence of sudden cardiac death increases with age Chugh et al., Prog Cardiovasc Dis 2009

5 Elderly males and females are both affected by SCD Chugh et al., Prog Cardiovasc Dis 2009

6

7 EHRA White Book Data 2009 Differences in age distribution Germany Armenia

8 EHRA White Books: Data on ESC member countries,

9 Italy Germany Denmark Czech Republic Netherlands Finland Switzerland Austria France Israel Slovakia Greece Poland Spain Luxembourg Sweden United Kingdom Portugal Hungary Slovenia Armenia Serbia Lebanon Croatia Latvia Lithuania Estonia Romania Georgia Macedonia ICD/M pop, 2006 Change Median: 74 ICD implants

10 Lubinski et al., 2010 Factors affecting the number of ICD implantations: ICD impl/m pop, 2008 Gross domestic product (GDP) (r) = 0,55 P = 0,0006 Gross domestic product (GDP) per (r) = 0,60 capita P < 0,0001 Total healthcare spending (r) = 0,58 P = 0,0004 Live expectancy at birth (r) = 0,66 P = 0,0002 Number of implanting centers (r) = 0,64 P < 0,0001 CRT-D impl/ M pop, 2008 (r) = 0,63 P < 0,0001 (r) = 0,34 P = 0,0428 (r) = 0,62 P < 0,0001 (r) = 0,61 P = 0,0002 (r) = 0,78 P < 0,0001 Density of physicians ns ns Density of nurses ns ns Hospitals ns ns Beds ns ns Population over 65 years old ns ns

11 Luxembourg Denmark Switzerland Sweden Finland Netherlands Austria France Germany United Kingdom Italy Spain Greece Slovenia Israel Portugal Czech Republic Estonia Slovakia Hungary Latvia Poland Lithuania Croatia Romania Lebanon Serbia Macedonia Armenia Georgia GDP/capita There are significant differences in GDP among European countries USD

12 Lubinski et al., 2010 Weak correllation between GDP/capita and number of ICD implants ICD/M pop, ic d/mln 400 r = 0.60 p < GDP/capita, $ GDP pc.

13 Merkely et al. Europace 2010 Weak correlation between GDP and CRT utilization r=0.41

14 Luxembourg Denmark Switzerland Sweden Finland Netherlands Austria France Germany United Kingdom Italy Spain Greece Slovenia Israel Portugal Czech Republic Estonia Slovakia Hungary Latvia Poland Lithuania Croatia Romania Lebanon Serbia Macedonia Armenia Georgia Healtcare spending/capita The differences in healthcare spendings are similar to the total GDP The general portion of healthcare spending is 7-11% of the GDP in Europe

15 Lubinski et al., 2010 Healthcare spending correlates with number of ICD implants 2008 ic d/mln ICD/M pop, r = 0.58 p < Healthcare spending, thousand Euros GPD on health

16 Merkely et al. Europace 2010 No correlation between healthcare spending and CRT utilization r=0.47

17 Lubinski et al., 2010 Life expectancy correlates with number of ICD implants (coincidence) ICD/M pop, icd/mln 400 r = 0.66 p < Life expectancy, live years

18 EHRA White Book Data 2009 Number of ICD centers correlates with number of ICD implants 350 ICD impl/m pop r = 0.68 p < ICD centers/million population

19 Merkely et al. Europace 2010 Number of ICD implantation correlates with CRT utilization

20 0% 20% 40% 60% 80% 100% Armenia Greece Israel Sweden Belarus Estonia Latvia Switzerland United Kingdom Austria Denmark Iceland Belgium Egypt Germany Finland Slovakia Lithuania Czech Republic Hungary Spain Poland Serbia Slovenia Luxembourg Portugal Lebanon Bulgaria Georgia Macedonia Single chamber vs. dual chamber ICDs Single chamber ICD Dual chamber ICD Lubinski et al., 2010

21 ICD implantation in Italy, Increasing utilization for primary prevention Very limited similar data on countries with emerging economies Proclemer et al. Europace 2010

22 ICD utilization in the Netherlands Patients with secondary prevention indication ICD implanted in 91% Patients with primary prevention indication ICD implanted in 7% Backlog of ICD implantations exists Implantation rate 125/million/year (2006) 200/million/year (2008-White Book) Needs to be increased to 510/million/year after eliminating backlog

23 ICD implantations/ 1 million for secondary and primary prevention of SCD in Hungary Zima, Card Hu 2010 % VVICD , , DDDCD , , CRT-D ,2 33,7

24 Regional differences in ICD implantation UK, UK National Survey 2007

25 Regional differences in Spain Fitch-Warner et al. Rev Esp Cardiol /M White Book 2008

26 Annual ICD implants per million ICD implants rates continue to diverge between Europe and USA AVID MADIT MUSST , MADIT II USA Europe S. Priori, 2004, modified

27 Factors Contributing to Low ICD Utilization Rates in countries with emerging economics Healthcare budgets and policies don t favor highcost therapies without immediate benefit # EPs, support staff and implant centers Acceptance of ICD clinical results is not universal Low physician referral practices ICD cost-effectiveness results not incorporated JCE 2002;13:38-43.

28 ICD Therapy Cost/D Increasing Cost Effectiveness Daily cost of ICD Therapy The cost/day of ICD therapy has dropped dramatically due to reduced procedure costs, reduced LOS (less invasive implant procedure) and increased battery life. $100 $90 $80 $70 $60 $50 $40 $30 $20 $10 $0 $91 Major increase in functionality $40 $14 $

29 The total cost of ICD therapy compared to others European Heart Journal (2007) 28,

30 Daily cost of ICD therapy European Heart Journal (2007) 28,

31 Annual expenditures on ICDs and other treatment modalities European Heart Journal (2007) 28,

32 Conclusions Healthcare budgets significantly affect ICD utilization in European countries with emerging economies Hopefully the favorable cost-effectiveness data will increase utilization More data needed regarding factors affecting local, regional differences, such as the inadequancies of: Referral system Staffing and training of EP labs

33 The Device for Life Initiative Fighting against SCD in Emerging Economies