I have nothing to disclose.

I have nothing to disclose.

Chest Pain Units in Europe Thomas Münzel, Mainz, Germany Clinic Dome Mainz 05

Death Rate Cardiovascular Disease - Europe- About 44% Robert Koch Institut, Gesundheitsbericht Deutschland, Berlin, 2006

Death Rates Myocardial Infarction in Germany

Prognosis: In 2050 a doubling of myocardial infarction infarction rates

Prognosis: Cause of Death Development - 2004 2030 - WHO World Health Report 2008

Improvement of prognosis in patients with acute MI by introducing Coronary Care Units and Reperfusin Therapy

Success Story Concerning the Short Term Mortality of Patients with an Acute MI CPU?

Experiences with Chest Pain Centers Primarily in the US 1981: The first CPC was established in Baltimore Beginning 2000 more than 1500 CPCs Society for CHEST PAIN CENTERS In 2010: More than 500 CPCs are accredited worldwide (www.bohmanmarketing.com) From Bahr: CPCs: Past Present and Future

Reduction of the proportion of patients admitted to the hospital from 54 to 37% Patients wrongly discharged with an ACS from 14% in the ED to 6% in the CPU Reduced costs (saving of 78 /patient) More patient satisfaction BMJ, doi:10.1136/bmj.37956.664236.ee (published 14 January 2004)

The patients like it!

Patient satisfaction with respect to the CPU is also high in Germany Excellent Adequate Inadequate

Development of Chest Pain Units in Europe Number: > 600?

2004 the Spanish Society of Cardiology recommends to set up CPUs in all EDs, to provide fast and efficient care for patients with chest pain Until 2008, 4 CPUs were installed The Cardiology Department is running one CPU 3 are headed by emergency doctors

Are the Europeans unenthusiastic about CPUs?

European Heart Journal (2012) 33, 682 686 doi:10.1093/eurheartj/ehs044

Prerequisits 1: Spatial Requirements

Prequisits 2: Equipment

Prerequisits 3: Minimum Diagnostics

Certified CPUs in Germany:

151 certified CPUs within 4 years!! 32 CPUs already recertified; 35 in the certification process

Own experiences in Mainz since 2005

Patient numbers in Mainz All patients with chest pain in Mainz are getting admitted to the CPU in the University Hospital Patient Numbers

Stiftung ST-Elevation : directly to the Cath Lab

Exercise testing in the CPU: safe and predictive?

Do CPUs have an impact on prognosis?

1-year Kaplan Meier Survival Keller et al Clin Res Cardiol 2010

Effects of implementation of a CPU in an emergency department in Rio de Janeiro

We want to improve patient care: Establishment of the German CPU Registry

Data from the Germany CPU Registry

Leading Diagnoses (2012 Patients ) 60 50 53% 40 30 25,0 20 15% 10 0 7,6% ACS Arrhythmia Stable Angina 2.2% e.g. Aortic Dissection Non Cardiovascular

What has changed in Germany since the introduction of the Chest Pain Unit? ACOS (Classic) - 16812 ACS Patients - 2000-2003 - 159 Clincis (Internal Medicine, Cardiology) - 1J Follow Up German CPU Registry - 5457 ACS Patients - 2008-2011 - 38 Clinics (Certified CPU) - 3 Mo Follow Up

ACS: Classic vs CPU- Diagnosis STEMI / IAP Classic CPU 60% 50% 40% 50% 44% 30% 20% 10% 13% 15% 0% STEMI IAP

STEMI: Classic vs CPU (2) Patient Characteristics Classic CPU Age 66 J 64 J Women 30% 28% Cardiac History (MI, PCI, ACB) 20% 37% Diabetes 27% 22% Renal Insufficiency 3,3% 6,6% History of Stroke 5,9% 3,1% Smoker 36% 42%

CPU ACS First Medical Contact Emergeny Doctor 42,10% Other Hospital 12,80% Family Doctor 23,80% Self-Referrers 21,20%

STEMI: Classic vs CPU Critical Time Intervals 4:00 3:00 3:15 3:55 Classic CPU 2:00 1:15 1:00 0:31 0:00 Pre- Prähospzeit Hospital Time Door to Balloon

minutes Stiftung

We need more awareness campaigns:

5 Effects of different Media Actions on Pre Hospital Time in Patients with STEMI Median in hours. n=217 4 3 2 1 4,2 St 100% -3% -17% -7% 2,1 St -23% All Media -50% 0 Kontrolle 6 9 12 15 Monate Pilot Study The 60 Minutes MI-Project Senges et al.

Awareness Campaigns in Mainz with the 1 Bundesliga Soccer Club Mainz 05

Just the right tactics leads to success in patients with acute AMI

Campaign 2009; woman and atypical chest pain

Campaign 2011: focus on the elderly people with chest pain

Offensive against Chest Pain

Back to registry data:

Treatment of Patients with an ACS STEMI 15% UAP 36% NSTEMI 49%

Primary PCI: 42% CPU Classic

Low MACCE Rate Death Myocardial Infarction Stroke

Better Prognosis STEMI 10% 9,5% 8% 6% 4% 4,2% 2% 0% Classic (hospital) CPU (3 Mo)

First MS published

Summary: Germany establishes a CPU network So far 151 CPUs have been accredited Fundamental goal: Protocol driven systematic approach to the management of patients with acute chest pain and an acute coronary syndrome requiring admission Stratification of a low risk group, who can safely be discharged and managed as outpatients Long prehospital delays: More awareness campaigns required! CPU registry data look promising Switzerland is currently applying for certification Model for a rollout for entire Europe!

Germany Society of Cardiology Informations: http://cpu.dgk.org Task Force Prof. Senges CPU Registry Caroline Grausdies (GSC)

Campaign 2009