Primary and secondary prevention of sudden cardiac death in emerging economies Béla Merkely MD, PhD, DSc, FESC Heart Center Semmelweis University Budapest
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
160 Trends in coronary deaths in men /100 000 Pyrgakis et al. Hellenic J Cardiol 2009 140 120 100 80 60 40 20 0 1979 1989 1999 2005 Europe 90-100, stable EU 40, decreasing Greece 50, stable >100 Hungary France Low and decreasing Czech Rep. Decreasing from high Romania Recent high ceiling
Incidence of sudden cardiac death increases with age Chugh et al., Prog Cardiovasc Dis 2009
Elderly males and females are both affected by SCD Chugh et al., Prog Cardiovasc Dis 2009
EHRA White Book Data 2009 Differences in age distribution Germany Armenia
EHRA White Books: Data on 37-41 ESC member countries, 2006-2008
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 2006-2008 Median: 74 ICD implants 2006-2008 0 100 200 300 400
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
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 0 20000 40000 60000 80000 100000 120000 140000 There are significant differences in GDP among European countries USD
Lubinski et al., 2010 Weak correllation between GDP/capita and number of ICD implants ICD/M pop, 2008 2008 ic d/mln 400 r = 0.60 p < 0.0001 300 200 100 0 0 30000 60000 90000 120000 GDP/capita, $ GDP pc.
Merkely et al. Europace 2010 Weak correlation between GDP and CRT utilization r=0.41
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 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 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
Lubinski et al., 2010 Healthcare spending correlates with number of ICD implants 2008 ic d/mln ICD/M pop, 2008 400 r = 0.58 p < 0.001 300 200 100 0 0 100000 200000 300000 400000 Healthcare spending, thousand Euros GPD on health
Merkely et al. Europace 2010 No correlation between healthcare spending and CRT utilization r=0.47
Lubinski et al., 2010 Life expectancy correlates with number of ICD implants (coincidence) ICD/M pop, 2008 2008 icd/mln 400 r = 0.66 p < 0.0001 300 200 100 0 0 30 60 90 Life expectancy, live years
EHRA White Book Data 2009 Number of ICD centers correlates with number of ICD implants 350 ICD impl/m pop 300 250 200 150 r = 0.68 p < 0.0001 100 50 0 0 1 2 3 4 5 6 7 8 ICD centers/million population
Merkely et al. Europace 2010 Number of ICD implantation correlates with CRT utilization
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
ICD implantation in Italy, 2005-2007 Increasing utilization for primary prevention Very limited similar data on countries with emerging economies Proclemer et al. Europace 2010
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 13500 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
ICD implantations/ 1 million for secondary and primary prevention of SCD in Hungary 100 90 80 70 60 50 40 30 20 10 0 85 77 70 65 55 34 31 2003 2004 2005 2006 2007 2008 2009 Zima, Card Hu 2010 % 2003 2004 2005 2006 2007 2008 2009 VVICD 52.1 53.5 41.,5 49.8 47.8 48,7 49.7 DDDCD 38.1 26.,0 38.4 18.1 16.4 19,1 16.4 CRT-D 9.8 20.5 20.1 32.1 35.8 32,2 33,7
Regional differences in ICD implantation UK, 2005-2007 UK National Survey 2007
Regional differences in Spain Fitch-Warner et al. Rev Esp Cardiol 2006 90/M White Book 2008
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Annual ICD implants per million ICD implants rates continue to diverge between Europe and USA 350 300 250 200 150 100 50 0-50 AVID MADIT 132 105 84 54 63 24 31 37 44 MUSST 180 154 2,5 4 6 8 10 14 18 22 27 31 38 44 208 MADIT II 286 250 56 60 USA Europe 74 2008 S. Priori, 2004, modified
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.
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 $12 1990 1995 2000 2005
The total cost of ICD therapy compared to others European Heart Journal (2007) 28, 392 397
Daily cost of ICD therapy European Heart Journal (2007) 28, 392 397
Annual expenditures on ICDs and other treatment modalities European Heart Journal (2007) 28, 392 397
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
The Device for Life Initiative Fighting against SCD in Emerging Economies