Reunion Madeira 2015 Nuevos Retos en la Cardiología Intervencionista.Posición de la Sociedad Española de CardiologíaPrograma INCARDIO

1. Nuevos Retos en la Cardiología Intervencionista.Posición de la Sociedad Española de Cardiología Programa INCARDIO José Ramón González Juanatey Presidente de la Sociedad Española de Cardiología Hospital Clínico Universitario de Santiago de Compostela

2. CV mortality and life-spectancy in Spain 1980 a 2009 García González JM, et al. Rev Esp Cardiol 2013. Women 1980-2009 Men 1980-2009 Lifestyle changes Prevention Health system improvements Treatment RESEARCH INNOVATION

3. Cardiovascular Disease: a complex disease needs integrated solutions Education Raising awareness Adherence to therapy Implementation – Tools – Programs Quality controls – Implementation – Surveys Quality controls – Impact on outcome – Trials Guidelines Recommendations Knowledge/Science (including clinical trials) Refinement

4. ACS. An Extraordinary Journey Innovation Year Impact CCU ¨Blue Code¨. Nurses 60´ & 70´ Mortality B-Blockers 70´ Mortality Thrombolysis 80´ Mortality ASA 80´ Mortality 1º PCI 90´ Mortality Statins Late 90´ Mortality ASA+Clopi Late 90´ Morbidity Better anticoagulation 00´ Morbi-mortality Prasugrel, Ticagrelor 00´ Morbi-mortality Team Work, STEMI code 00´ Mortality? Hypothermia 10´ Mortality? 30% 5%

5. IHD 2ªPrev. An Extraordinary Journey Innovation Year Impact B-Blockers 70´ Mortality ASA 80´ Mortality Life-style changes/Rehab 70-15´ Mortality ACE Ih 80-90´ Morbi-mortality Statins 90´ Mortality Team Work 90´ Mortality Revasc (subgroups) 00´ Morbi-mortality Vorapaxar 13´ Morbi-mortality Rivaroxaban 13´ Morbi-mortality Ticagrelor 15´ Morbi-mortality Ezetimibe 15´ Morbi-mortality 10 %/y 2 %/y

6. Heart Failure. An Extraordinary Journey Innovation Year Impact ACE Inhibitors 80´ Mortality B-Blockers 00´ Mortality Aldosterone Recept Block 00´ Mortality Defibril/Cardiac RT 00´ Mortality Nurses Process 00´ Mortality-morbi Cardiac Transplant 80-00 Mortality Ivabradin 10´ Morbi-mortality? VA Devices 10´ Morbi-mortality LCZ-696 14´ Morbi-mortality Acute HF code 00-15´ Mortality-Morbi? Gene therapy 15´? Mortality? 40% 10%

7. Three priorities. Role SEC •Excellent science •Industrial leadership •Societal challenges • European Research Council • Future and Emerging Technologies • Marie Skłodowska-Curie actions • Research infrastructures • Reserch Grants • Leadership in enabling and industrial technologies • Access to risk finance • Innovation in SMEs Innova-SEC • Health, demographic change and wellbeing • Food security, sustainable agriculture and forestry, marine and maritime and inland water research and the Bioeconomy • Secure, clean and efficient energy • Smart, green and integrated transport • Climate action, environment, resource efficiency and raw materials • Inclusive, innovative and reflective societies • Secure societies • Science with and for society • Spreading excellence and widening participation • RECALCAR/INCA RDIO

8. Diferencias Interterritoriales Existen importantes variaciones interterritoriales en la dotación de recursos, frecuentación, producción y calidad en la atención al paciente cardiológico, así como en la forma de organizar y gestionar la asistencia cardiológica. RECALCAR 2012 Recursos en Cardiología

9. RECALCAR y retos de la cardiología Ha aumentado la representatividad de la muestra. Aportación de información de los registros de las Secciones. Cumplimentar el el registro no es una rutina para todas las UAC del SNS. Se inició en 2013 en el proceso de retroalimentación a las UAC informantes. 1. Mejorar la base de datos de UAC, especialmente en porcentaje de unidades que responden, permitiendo un análisis en todas las Comunidades Autónomas y retroalimentando la información a las UAC que participan. 3. Trabajar en estrecha colaboración con médicos de otras especialidades y unidades que atienden a pacientes con enfermedades cardiológicas y con los equipos de atención primaria. Son minoritarias las UAC que han establecido un cardiólogo como referente de cada equipo de atención primaria de su área de influencia y desarrollado instrumentos de trabajo conjunto.4. Crear redes asistenciales de UAC. 5. Regionalizar unidades de referencia. Sólo el 12% de las UAC refieren estar integradas en una red de ámbito regional (600.000 o más habitantes). 6. Poner el énfasis en el aumento de la calidad (gestión por procesos) y la eficiencia, más que en la dotación de recursos. Baja implantación de una gestión por procesos. Amplias variaciones en el rendimiento de los recursos.Un 28% de UAC con más de 24 camas no tienen asignada guardia de presencia física. Algunas UAC con unidad de hemodinámica o cirugía cardiovascular no tienen camas asignadas. Un 77% de los servicios de cirugía cardiovascular hace menos de 600 intervenciones quirúrgicas mayores. 7. Evitar riesgos potenciales de malas prácticas: ausencia de guardias de presencia física en unidades con más de 1.500 ingresos y/o procedimientos complejos; actividad de hemodinámica y cirugía cardiovascular en centros sin camas asignadas a cardiología; volúmenes de actividad por debajo de los recomendados. 8. Reducir las desigualdades interterritoriales en buenas prácticas vinculadas a resultados (por ejemplo: redes y actividad de ICP-p en IAM). Existen notables diferencias entre Comunidades Autónomas, que probablemente inciden en la calidad asistencial y resultados de la atención a los pacientes con cardiopatía en los distintos territorios

10. CMBD Un 48% de los episodios de ingreso hospitalario con diagnóstico de alta de enfermedad del área del corazón es dado de alta por servicios distintos al de cardiología CMBD_CAR contiene 3,7 millones episodios de hospitalización con diagnóstico principal al alta de “enfermedad del área del corazón” durante el período 2003-2012 La Insuficiencia Cardiaca Crónica es uno de los principales retos del Sistema Nacional de Salud y de la cardiología (escasos progresos en frecuentación, estancia media y reingresos). Existen notables márgenes de mejora en la calidad de la asistencia hospitalaria prestada a los pacientes con enfermedades del área del corazón.

12. SEC quality of care “virtuose circle”

13. Definir los indicadores de calidad asistencial en Cardiología Sociedad de Cirugía Torácica y Cardiovascular S E C T C V

15. Hospital I Low complexity II Intermediate Complexity III High Complexity Volume: Beds · < 200 · 200 to 500 · > 500 Volume: Cardio · < 500 patients / year · 500 to 1000 patients / year · > 1000 patients / year Organization · Cardiology not considered as an independent unit · Cardiology independent unit (own beds) · Cardiology independent unit (own beds) Intensive Cardiac Care Unit · No, or yes but transfers complex patients to other hospitals · Yes, · No dedicated ICCU · Dedicated ICCU Interventional cardiology unit · No · Yes, but complex cases are transferred to other hospitals · PCI not available 24h / 7 days · Yes, including complex cases · PCI available 24h / 7 days Interventional electrophysiology · No, except pacemakers · Yes, but complex cases are transferred to other hospitals · Yes, including ICD / CRT implantation, and treatment of complex arrhythmias Cardiac surgery · No · No · Yes, available 24h / 7 days Transfer of patients · All cases for PCI, complex arrhythmias & Cardiac Surgery · Transfer of complex cases to another hospital including complex PCI, arrhythmias or surgery · Minimal (e.g.: heart transplant) · Receives complex patients from other hospitals INCARDIO. Clasificación de los Hospitales

16. Metric Suggested Reference Value Relevance Difficulty Auditable Evidence References Mortality* STEMI mortality (excluding patients unconscious at admission) < 5% (a) 1 1 1 A 115, 116, 131, 132,, 141 Non STE-ACS mortality (excluding patients unconscious at admission) < 5% (a) 1 1 1 A 117, 118, 131, 132, 141 Staged PCI mortality < 1% (a) 1 1 1 A 140-142 TAVI mortality < 10% (a) 1 1 1 A 147 - 149 VT after AMI and other complex catheter ablation mortality < 3% (a) 1 1 1 A 150 - 152 Pacemaker, ICD, CRT implant mortality < 1% (a) 1 1 1 A 153, 154 Heart Failure mortality < 7% (a) 1 1 1 A 160, 161 Staged 1st Aortic valve surgery replacement mortality (excluding TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery replacement mortality < 7% (a) < 9% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery repair mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined surgery) mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A 159 - 161 Heart transplant < 15% (a) (c) 1 1 1 A 161b INCARDIO STEMI mortality <5% TAVI mortality <10% PM,ICD,CRT implant mortality <1%

17. Staged 1st Aortic valve surgery replacement mortality (excluding TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery replacement mortality < 7% (a) < 9% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery repair mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined surgery) mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A 159 - 161 Heart transplant < 15% (a) (c) 1 1 1 A 161b Hospitalization** STEMI number of days in hospital < 10 2 2 1 A 115, 116, 131, 132 Non STE-ACS number of days in hospital < 10 2 2 1 A 117, 118, 131, 132 Heart Failure number of days in hospital < 9 2 2 1 A 155 - 158 Staged 1st CABG, Aortic or Mitral surgery number of days in hospital < 15 2 2 1 A 159 - 161 *** Rehospitalization after ACS, heart failure or surgery as above < mean value in national registries INCARDIO

18. Metric Suggested Reference Value Relevance Difficulty Auditable Evidence References Mortality* STEMI mortality (excluding patients unconscious at admission) < 5% (a) 1 1 1 A 115, 116, 131, 132,, 141 Non STE-ACS mortality (excluding patients unconscious at admission) < 5% (a) 1 1 1 A 117, 118, 131, 132, 141 Staged PCI mortality < 1% (a) 1 1 1 A 140-142 TAVI mortality < 10% (a) 1 1 1 A 147 - 149 VT after AMI and other complex catheter ablation mortality < 3% (a) 1 1 1 A 150 - 152 Pacemaker, ICD, CRT implant mortality < 1% (a) 1 1 1 A 153, 154 Heart Failure mortality < 7% (a) 1 1 1 A 160, 161 Staged 1st Aortic valve surgery replacement mortality (excluding TAVI) < 5% (a) < 7% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery replacement mortality < 7% (a) < 9% (b) 1 1 1 A 159 - 161 Staged 1st Mitral valve surgery repair mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st CABG (without combined surgery) mortality < 3% (a) < 5% (b) 1 1 1 A 159 - 161 Staged 1st combined CABG + AVR mortality < 6% (a) < 8% (b) 1 1 1 A 159 - 161 Heart transplant < 15% (a) (c) 1 1 1 A 161b TAVI mortality <10% PM,ICD,CRT implant mortality <1% Interventional Cardiology STEMI mortality (excluding patients unconscious at admission) < 5% Non STE-ACS mortality (excluding patients unconscious at admission) < 5% (a) Staged PCI Mortality < 1% (a) TAVI Mortality < 10%

19. 5,7 4,1 7,6 6,6 3,9 2,4 8,8 7,8 0 2 4 6 8 10 Todos SCASEST MASCARA 2004-5 DIOCLES 2012 Mortalidad hospitalaria SCACEST Indeterminado

20. Different Mortality rates from AMI in Europe (2009) Crude rates Age-sex standardized rates Suggested reference rate 5%

21. Diferencias entre hospitales. REMAR. 2012 Las variaciones de indicadores entre hospitales son aún mayores que entre Comunidades Autónomas  Desigualdades y notables oportunidades de mejora en la calidad y eficiencia. Promedio 7,43 Mediana 7,19 DS 1,19 Min 5,01 Max 12,22 Hospitales con > 25 IAM en 2012 RECALCAR 2012 STEMI. Risk-adjusted Mortality

22. Andalucía 8,33 7,94 -0,39 Aragón 8,13 7,18 -0,95 Asturias 7,99 7,55 -0,44 Baleares 7,47 6,33 -1,14 Canarias 8,03 7,75 -0,28 Cantabria 8,11 7,56 -0,55 Castilla y León 8,08 7,00 -1,08 Castilla La Mancha 7,28 7,26 -0,02 Cataluña 6,96 6,66 -0,30 Valenciana 9,57 8,49 -1,08 Extremadura 7,98 7,54 -0,44 Galicia 7,64 7,14 -0,50 Madrid 7,73 6,61 -1,12 Murcia 7,78 7,40 -0,38 Navarra 6,06 6,08 0,02 País Vasco 8,71 7,29 -1,42 Rioja 7,34 7,09 -0,25 PROMEDIO 7,84 7,31 -0,53 CCAA Mortalidad IAM (%) Evolución RECALCAR 2012 STEMI. Risk-adjusted Mortality 2011 2012

23. Desigualdades Interterritoriales (IAM. 2012) Límite inferior Límite superior Mortalidad_IAM_esperada ,876 ,003 0,000 ,870 ,881 Mortalidad_IAM_prevista ,882 ,003 0,000 ,876 ,888 Mortalidad_IAM_nulo ,598 ,005 ,000 ,589 ,607 Variables resultado de contraste Área EE p Intervalo de confianza asintótico al 95% OR Sexo (Mujer vs Hombre)1,214 1,116 1,320 Edad (año) 1,069 1,065 1,074 Shock 23,152 20,818 25,748 DM comp 1,608 1,400 1,846 ICC 1,730 1,589 1,883 ECV 2,283 2,003 2,602 Tumor 1,994 1,662 2,395 EAP 2,153 1,599 2,897 IRA 2,631 2,379 2,912 Arritmia 1,749 1,609 1,899 Centro: Identity |0.3431 0,265 0,397 ------------------------------------------------------------------------------ LR test vs. logistic regression: chibar2(01) = 86.73 Prob>=chibar2 = 0.0000 IC95% El ajuste llevado a cabo por la SEC es mas completo. Ajustes por edad y sexo son extraordinariamente limitados

24. Desigualdades Interterritoriales (IAM. 2012) 6 6,5 7 7,5 8 8,5 9 100 150 200 250 300 350 400 450 500 RAMER(%) Tasa ICP-p Millón Hab RECALCAR 2012 STEMI. Risk-adjusted Mortality

26. RECALCAR-2012 Mortalidad Intrahospitalaria de la PCI en Pacientes sin IAM

28. JACC 2015, doi: 10.1016/j.jacc.2015.03.034 German GARY Registry Experiencia con más de 15.000 pacientes

29. Acute cardiac care / Intensive cardiac care Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes 4-5 ICCU beds / 100.000 inhabitants 198 Desired technology Intensive care environment technology 198 Staffing All nurses with > 1 year cardiology experience. Experience in acute cardiac care 198 At least 1 cardiologist certified in acute coronary care (optimal: 1 / 3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals > 300.000) 198 Accreditation At least 1 cardiologist accredited in acute cardiac care 198 Any accreditation conferred by any external organizations 198 Patient services Regional network for STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care treatment for sudden death (includes temperature management) 14528 Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols based on ESC /AHA- ACC guidelines STEMI and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments according to ESC / AHA – ACC guidelines 115 - 118 Multidisciplinary protocols Prehospital systems, emergency department, cardiac unit. 115 - 118 Heart failure: Cardiac unit, internal medicine, emergency department 289, 290 Results Outcomes in selected populations as described in table # 5 Quality controls Adherence to ESC / AHA-ACC guidelines Patients with primary PCI in STEMI: > mean value in national registries Time to call-door-balloon/lytic: < 60 min after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI diagnosis Patients with dual antiplatelet therapy in ACS: > mean value in national registries 115 - 118 Acute Cardiac Care / Intensive Cardiac care ICCU: Recommended 4-5 beds/100.000 inhabitants Cardiologist on call 24 h (recommended in Hospitals > 300.000 inhabitants) All Nurses with > 1 year Cardiology Experience. Experience in Acute Cardiac Care

30. UCAC No UCAC p TBM hosp % 7.57 6.58 0.058 RAMER hosp % 7.78 6.96 0.02 TBM: Tasa bruta de mortalidad. RAMAR: Razón de mortalidad ajustada por riesgo Mortalidad por IAM en España Unidades Cuidados Cardiológicos Agudos Rev Esp Cardiol 2013; 66: 935-942

31. UCAC NO RES. UCAC SI RES. CH TORRECÁRDENAS 2 H UNIVERSITARIO VIRGEN MACARENA 4 H UNIVERSITARIO PUERTA DEL MAR 3 H DE JEREZ DE LA FRONTERA 1 H UNIVERSITARIO DE PUERTO REAL 1 H UNIVERSITARIO REINA SOFIA 3 H UNIVERSITARIO VIRGEN DE LAS NIEVES 3 H JUAN RAMON JIMÉNEZ 2 CH DE JAÉN 1 H REGIONAL UNIVERSITARIO DE MÁLAGA 2 H UNIVERSITARIO VIRGEN DE LA VICTORIA 3 H UNIVERSITARIO VIRGEN DEL ROCÍO 4 H UNIVERSITARIO NTRA SRA. DE VALME 2 H UNIVERSITARIO MIGUEL SERVET 2 H CLÍNICO UNIVERSITARIO LOZANO BLESA 3 CH DOCTOR NEGRIN 3 H UNIVERSITARIO DE CANARIAS 2 HU INSULAR DE G. CANARIAS 2 H UNIVERSITARIO NUESTRA SEÑORA DE LA CANDELARIA 2 H UNIVERSITARIO MARQUÉS DE VADECILLA 2 H GENERAL UNIVERSITARIO DE CIUDAD REAL 2 ÁREA ESPECIALIZADA DE ALBACETE 2 H GENERAL UNIVERSITARIO DE GUADALAJARA 1 CH VIRGEN DE LA SALUD DE TOLEDO 3 CAU DE BURGOS 1 CAU DE LEÓN 3 CAU DE SALAMANCA 3 H. CLÍNICO UNIVERSITARIO DE VALLADOLID 3 CORPORACIÓ SANITARIA PARC TAULÍ 1 H UNIVERSITARI VALL D'HEBRON 3 H CLÍNIC DE BARCELONA 3 H DEL MAR-PARC DE SALUT MAR 2 H DE LA SANTA CREU I SANT PAU 4 H UNIVERSITARI GERMANS TRIAS I PUJOL 3 H UNIVERSITARI DE BELLVITGE 3 H UNIVERSITARI DE GIRONA DR. JOSEP TRUETA 2 H UNIVERSITARI ARNAU DE VILANOVA 1 H UNIVERSITARI JOAN XXIII DE TARRAGONA 2

32. VALLADOLID 3 CORPORACIÓ SANITARIA PARC TAULÍ 1 H UNIVERSITARI VALL D'HEBRON 3 H CLÍNIC DE BARCELONA 3 H DEL MAR-PARC DE SALUT MAR 2 H DE LA SANTA CREU I SANT PAU 4 H UNIVERSITARI GERMANS TRIAS I PUJOL 3 H UNIVERSITARI DE BELLVITGE 3 H UNIVERSITARI DE GIRONA DR. JOSEP TRUETA 2 H UNIVERSITARI ARNAU DE VILANOVA 1 H UNIVERSITARI JOAN XXIII DE TARRAGONA 2 H UNIVERSITARIO 12 DE OCTUBRE 3 H UNIVERSITARIO LA PAZ 3 H UNIVERSITARIO PUERTA DE HIERRO 3 H UNIVERSITARIO RAMÓN Y CAJAL 3 H CLÍNICO SAN CARLOS 4 H GENERAL UNIVERSITARIO GREGORIO MARAÑON 4 H UNIVERSITARIO DE LA PRINCESA 2 H CENTRAL DE LA DEFENSA GOMEZ ULLA 2 FUNDACIÓN JIMENEZ DÍAZ 2 H UNIVERSITARIO FUNDACIÓN DE ALCORCON 1 CLINICA UNIVERSITARIA DE NAVARRA 2 CH DE NAVARRA 2 H GENERAL UNIVERSITARIO DE ALICANTE 2 H GENERAL UNIVERSITARIO DE VALENCIA 2 H GENERAL UNIVERSITARIO DE ELCHE 1 H UNIVERSITARIO DE SANT JOAN 2 H GENERAL DE CASTELLÓN 1 H UNIVERSITARI I POLITÈCNIC LA FE 2 H DOCTOR PESET 2 H CLÍNICO UNIVERSITARIO DE VALENCIA 2 CH DE CÁCERES 1 CH UNIVERSITARIO INFANTA CRISTINA DE BADAJOZ 2 CH UNIVERSITARIO A CORUÑA 3 CH UNIVERSITARIO DE SANTIAGO DE COMPOSTELA 3 CH UNIVERSITARIO DE VIGO (H DO MEIXOEIRO) 2 H. UNIVERSITARIO SON ESPASES 2 H. UNIVERSITARIO ARABA 1 H UNIVERSITARIO CRUCES 2 H GALDAKAO-USANSOLO 1 H UNIVERSITARIO BASURTO 3 H. UNIVERSITARIO CENTRAL DE ASTURIAS 4 H DE CABUEÑES 1 H UNIVERSITARIO VIRGEN DE LA ARRIXACA 2 CH UNIVERSITARIO STA. Mª DEL ROSELL 3

33. Berlin Myocardial Infarction Registry 10 year changes in treatment and outcome Jens-Uwe Röehnisch et al ECC 2011# 5207 Berliner Herzinfarktregister Hospital Mortality for STMI & NSTMI Medications and Reperfusion therapy Year Ptrend<0.001N=9830 Follow Guidelines!

34. Cath Lab Unit Volumes PCI: optimal > 400 year. If < 200 / year cath lab should be part of a larger network PCI per operator > 75 / year Primary PCI > 50 year (PPCI per operator > 11 year) PCI in hospitals without cardiac/vascular surgery: Volumes > 200 / year and protocol for team work with hospital with cardiac surgery Complex PCI cases including coronary and structural interventions only acceptable in hospitals with cardiac/vascular surgery Interventional Cardiology

35. 156 390 90 173 7.8 45.7

36. Cath Lab Unit Technology Reference hospital with cardiac/vascular surgery for high risk PCI or reference in structural interventions Cath labs technology < 10 years old 2 cath labs in hospital with a Primary PCI Program 1 Complete cath lab with clear maintenance protocols. Includes defibrillator, mechanical ventilator, OCT, IVUS and IABP or LVAD in labs performing routine high risk procedures Interventional Cardiology

37. Cath Lab Unit Staffing Certified interventional cardiologists, minimal 1, optimal all Nurses with > 1 year experience in cath lab, minimal 2, desirable 3/lab Nº Interventional Cardiologists > 4 if Primary PCI Program Interventional Cardiology

38. Accreditation Certification of qualification coferred by external organizations Cardiologist with accreditation in PCI highly recommended Interventional Cardiology Patient Services Cath Lab open 24 / 7 /365 days recommended in hospitals > 300.000 (population) Regional Network for STEMI and other ACS

39. Local Protocols (diagnosis and treatment for each technique based on ESC/AHA/ACC guidelines) Risk stratification (GRACE, TIMI, SINTAX, NCDR) HEART TEAM decission in all non-emergency procedures Optimal Medical Treatment according to ESC/AHA/ACC guidelines Renal Protection Protocol Alergic reactions Protocol Diabetic patients Protocols Radial Use > 50% Interventional Cardiology

40. Trends in in-hospital mortality rates after isolated CABG surgery in Ontario 1991-2006 2.95 2.83 3.17 2.83 2.42 2.32 2.2 2.29 2.18 2.32 2.08 1.03 1.23 1.39 1.1 1.17 0 0.5 1 1.5 2 2.5 3 3.5 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Fiscal Year In-HospitalMortalityRate(%) Confidential reporting Public reporting

42. Diferencias Interterritoriales (IAM. 2012) Frec. EM TBM % Reingresos Andalucía 116,9 6,8 8,5% 7,7% Aragón 114,0 9,5 10,0% 5,0% Asturias 156,1 7,1 7,2% 6,3% Baleares 113,7 7,0 5,7% 4,9% Canarias 100,0 9,7 7,0% 3,3% Cantabria 117,8 6,2 8,1% 3,7% Castilla y León 144,5 7,1 8,0% 6,2% Castilla-La Mancha 109,7 7,2 8,6% 3,7% Cataluña 117,8 6,9 6,3% 6,7% Comunidad Valenciana 109,9 6,8 8,6% 4,9% Extremadura 132,0 7,4 7,4% 5,3% Galicia 127,8 8,4 6,8% 5,3% Madrid 86,0 7,5 6,1% 3,5% Murcia 123,3 7,4 6,9% 7,2% Navarra 93,9 9,0 6,2% 6,4% País Vasco 89,1 7,9 7,5% 4,0% Rioja 125,6 8,9 6,9% 5,4% Total general 112,8 7,3 7,5% 5,7% Promedio 116,4 7,7 7,4% 5,3% Mediana 116,9 7,4 7,2% 5,3% DS 18,4 1,0 1,1% 1,3% Max 156,1 9,7 10,0% 7,7% Min 86,0 6,2 5,7% 3,3% RECALCAR 2012 STEMI. Risk-adjusted Mortality

43. RECALCAR-2012 Mortalidad Intrahospitalaria de la PCI en Pacientes sin IAM

44. STEMI Mortality rate 2010-2012 IAMCAT II1 2003 IAMCAT III2 2006 Codi Infart3 2010 Codi Infart3 2011 Codi Infart3 2012 30-day mortality 11,7 % 7,4% 6,8% 6,3% 6,4% 1-year mortality NA NA 9,9 % 10,4 % 8,6 % Catalunya Codi Infart 1. www.catcardio.cat 2. Med Clin (Barc) 2009;133:694 3. Registre Codi Infart. Departament de Salut. Generalitat de Catalunya, 2010-2012

46. Berlin Myocardial Infarction Registry 10 year changes in treatment and outcome Jens-Uwe Röehnisch et al ECC 2011# 5207 Berliner Herzinfarktregister Hospital Mortality for STMI & NSTMI Medications and Reperfusion therapy Year Ptrend<0.001N=9830 Follow Guidelines!

47. J.R.G. JUANATEY C.H.U.Santiago 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CIBAR. DETERMINANTES DE MUERTE CARDIOVASCULAR GPC: Cumplimiento recomendaciones Guías de Práctica Clínica; DM: diabetes; ICC: insuficiencia cardíaca; IR: insuficiencia renal(TFG<60 ml/min); EF: ejercicio físico 1 100,1 3 5 70,70,3 0,5 GPC ICC DM IR EF 4,4 (2,4-8,1) 0,001 1,9 (1,1-3,5) 0,023 2,4 (1,3-4,5) 0,005 0,43 (0,2-0,8) 0,006 HR (IC-95%) valor-p 0,47 (0,2-0,9) 0,031 Variables

48. Acute cardiac care / Intensive cardiac care Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes 4-5 ICCU beds / 100.000 inhabitants 198 Desired technology Intensive care environment technology 198 Staffing All nurses with > 1 year cardiology experience. Experience in acute cardiac care 198 At least 1 cardiologist certified in acute coronary care (optimal: 1 / 3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals > 300.000) 198 Accreditation At least 1 cardiologist accredited in acute cardiac care 198 Any accreditation conferred by any external organizations 198 Patient services Regional network for STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care treatment for sudden death (includes temperature management) 14528 Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols based on ESC /AHA- ACC guidelines STEMI and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments according to ESC / AHA – ACC guidelines 115 - 118 Multidisciplinary protocols Prehospital systems, emergency department, cardiac unit. 115 - 118 Heart failure: Cardiac unit, internal medicine, emergency department 289, 290 Results Outcomes in selected populations as described in table # 5 Quality controls Adherence to ESC / AHA-ACC guidelines Patients with primary PCI in STEMI: > mean value in national registries Time to call-door-balloon/lytic: < 60 min after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI diagnosis Patients with dual antiplatelet therapy in ACS: > mean value in national registries 115 - 118 Acute Cardiac Care / Intensive Cardiac care ICCU: Recommended 4-5 beds/100.000 inhabitants Cardiologist on call 24 h (recommended in Hospitals > 300.000 inhabitants) All Nurses with > 1 year Cardiology Experience. Experience in Acute Cardiac Care

50. 12,000 22,000 32,000 42,000 52,000 62,000 72,000 82,000 92,000 102,000 112,000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 INSUFICIENCIA CARDIACA INFARTO AGUDO MIOCARDIO ARRITMIAS C. ISQUEMICA CRONICA C. ISQUEMICA AGUDA Hospital admission for Cardiac Diseases RECALCAR 2012

51. Heart Failure Units Metric Recommendation Reference s Structure. Resources directly related to patient care Hospital volumes Nº patients with heart failure discharged from hospital Desired technology Natriuretic peptides 120, 156, 369 Type II and III hospitals: ECHO available 24 hours. Multidisciplinary heart failure outpatient clinic., ICD and CRT therapy 11, 120, 369, 371- 373 Type III hospitals: Intensive CCU, Circulatory assist devices 120, 369 Staffing Type II and III hospitals: Cardiologists assigned to heart failure management 11, 119 Type III hospitals: Accredited cardiologists assigned to advanced heart failure program 11, 119 Type III hospitals: Specialized nurses assigned to heart failure management . Nurse outpatient consult 11, 119, 213, 371- 373 Accreditation Type III hospitals: Accredited multidisciplinary Heart failure program, including cardiologists, internal medicine, oncology, rehabilitation specialists, internal medicine, general physicians, other 120, 369 Type III hospitals: Accredited Advanced heart failure cardiologists 372 Patient services Type III hospitals: Heart failure outpatient clinic 11, 156, 157, 120, 369, 370 Type III hospitals: Heart failure in-hospital management program 156, 157, 120, 369, 370 , All hospitals: On site or access to Rehabilitation, advance heart failure unit, heart transplant, complex pulmonary hypertension units and palliative care units 120, 369, 373 Heart Failure Units Type III hospitals: Specialized nurses assigned to heart failure management. Nurse outpatient clinic. Nº patients with HF discharged from hospital

52. Cardiac imaging Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes TTE, TOE, stress echo: recommended: > 1500 and 300 / studies / staff / y) 265, 266 CCT studies (recommended > 250 / year) 267 CMR studies (recommended > 300 / year)* Desired technology TTE, in all hospitals. TOE and stress echo, in type II and III hospitals. 3D echo in type III hospitals. CCT, SPECT or PET Scanner and CMR in-house type II and III hospitals or in reference hospital. 194, 255 - 264 Staffing Cardiac Imaging certified cardiologists (recommended ³ 1 per technique: Echo, CMR, CCT), Level 2/3 194, 255 - 264 Certified technicians (recommended ³ 1 per technique) in all hospitals Nurses with experience in stress testing and transesophagic ECHO 194, 255 – 264, 264b Accreditation Official accreditation (ESC or similar) of Echo lab, CCT lab, CMR lab 194, 255 - 264 Patient services TT Echocardiography available 24/7/365 in hospitals II and III Process of delivery of care for diagnosis and treatment Local protocols For indications based on ESC /AHA.ACC guidelines for each technique 204, 205, 267 - 276 Protocols to reduce radiation from CCT All cases < 15 mSv 273 -275 Waiting list Outpatient, non–urgent, studies, recommended 100% < 30 days 194 Hospitalized patient, recommended <24h 194 Urgent cases: recommended availability 24/7/365 194 Safety. Quality control programs focussed on safety Complications of stress test requiring specific treatment <10% 264 Notification of contrast induced complications (ECHO, CCT, CMR) in 100% of cases 264 ECHO recommended availability for urgent cases: 24 / 7 / 365 264 Quality controls measures Adherence to local protocols based on ESC / AHA-ACC guidelines Recommended > 90% 270-272 Nº of non interpretable echo studies < 5% 264 Digital archive of studies Recommended 100% of cases 264, 207 Inter-observer variability < 10% recommended 264, 282, 285 Structured report of studies Complete, definitive report, delivery < 24 hours (recommended > 90%) 264, 282, 285 Report of radiation dose Recommended in 100% of cases (CCT) 272, 286, 287 Waiting list Recommended: < mean value in local registries Cardiac Imaging Certified technicians (recommended > 1 per technique) Nurses with experience in stress echo and TEE TTE available 24/7/365 in hospitals II and III

53. Cath Lab Unit Volumes PCI: optimal > 400 year. If < 200 / year cath lab should be part of a larger network PCI per operator > 75 / year Primary PCI > 50 year (PPCI per operator > 11 year) PCI in hospitals without cardiac/vascular surgery: Volumes > 200 / year and protocol for team work with hospital with cardiac surgery Complex PCI cases including coronary and structural interventions only acceptable in hospitals with cardiac/vascular surgery Interventional Cardiology

54. Cath Lab Unit Technology Reference hospital with cardiac/vascular surgery for hogh risk PCI or reference in structural interventions Cath labs technology < 10 years old 2 cath labs in hospital with a Primary PCI Program 1 Complete cath lab with clear maintenance protocols. Includes defibrillator, mechanical ventilator, OCT, IVUS and IABP or LVAD in labs performing routine high risk procedures Interventional Cardiology

55. Cath Lab Unit Staffing Certified interventional cardiologists, minimal 1, optimal all Nurses with > 1 year experience in cath lab, minimal 2, desirable 3/lab Nº Interventional Cardiologists > 4 if Primary PCI Program Interventional Cardiology

56. Accreditation Certification of qualification coferred by external organizations Cardiologist with accreditation in PCI highly recommended Interventional Cardiology Patient Services Cath Lab open 24 / 7 /365 days recommended in hospitals > 300.000 (population) Regional Network for STEMI and other ACS

57. Local Protocols (diagnosis and treatment for each technique based on ESC/AHA/ACC guidelines) Risk stratification (GRACE, TIMI, SINTAX, NCDR) HEART TEAM decission in all non-emergency procedures Optimal Medical Treatment according to ESC/AHA/ACC guidelines Renal Protection Protocol Alergic reactions Protocol Diabetic patients Protocols Radial Use > 50% Interventional Cardiology

58. Interventional Cardiology All nurses with > 1 year experience in cath lab, minimal 2, desirable 3/lab HEART TEAM decision in all non-emergency procedures including nurses PCI: optimal > 400 year: If < 200 year, cath lab should be part of a larger network PCI per operator > 70 year Primary PCI > 36-50 year (PPCI per operator > 11 / year Cath lab open 24/7/365 recommended in hospitals>300000 (population)

60. Electrophysiology and arrhythmias Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes Complex procedures: Atrial Fibrillation. Recommended > 50 / year 347 - 350 Complex procedures: Ventricular tachycardia. Recommended only in labs with >100 general catheter ablation procedures/y. 133, 350, 351 Non-complex procedures (ablation of paroxysmal supraventricular tachycardia, AV nodal ablation, and common atrial flutter. Recommended >100 procedures/year. 350, 351 Pacemaker implants (>12 implants/y per operator), ICDs (>10 implants/y), and CRTs (>10 implants/y) 352, 353 Desired technology Accredited Arrhythmia Unit in hospitals >100 invasive EP procedures/y 350, 354 Dedicated RX lab 59, 350, 355, 356 Staffing >2 certified cardiologists accredited in arrhythmias 59, 356 – 358 Certified cardiologist accredited in arrhythmias responsible for the unit 356, 357, 359 Nurses with > 1 year experience in arrhythmias, ablation and device implantation and follow-up, minimal 2, desirable 3/ lab Arrhythmias nurse outpatient consult desirable (pacemarker and device follow-up) 356, 356b, 256c Accreditation Accredited Arrhythmia Unit (EHRA, SEA, Certification ISO 9001:2008) 357, 359 Patient services Arrhythmia Ablation, Pacemaker AND ICD, CRT implantation 59, 356 Arrhythmia outpatient clinic 59, 356 Electrophysiology and arrhythmias All nurses with > 1 year experience in arrhythmias, ablation and device implantation and follow-up minimal 2, desirable 3/lab Arrhythmias nurse outpatient consult desirable (PM and device follow-up) Complex procedures: Atrial Fibrillation. Recommended > 50 / year Complex procedures: ventricular Tachy recommended only in labs with > 100 general cath ablation procedures/year Pacemaker implants (<12/y operator), ICD >10 implants/y, CRT> 10 implants/y

61. Radiation dose measure (fluoroscopy time / dose for patient and staff Interventional Cardiology

63. Cardiac Surgery Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes Major cardiac surgery procedures. Recommended: >500 / year or > 70 / cardiac surgeron / year 161, 401 Desired technology Dedicated Cardiac surgery operating rooms, at least 1 full time 161 Fully staffed and equipped Cardiac Surgery Intensive Care Unit 401 Staffing Certified cardiac surgeons Anaesthesiologists, intensivist and cardiac surgeon accredited in post cardiac surgery intensive care Nurses assigned to cardiac surgery, experience > 1 y / operating room Accreditation Accredited cardiac surgery unit Patient services Urgent cardiac surgery Scheduled priority system 161 Prevention of infections protocol 161 Process of delivery care Protocols for evaluation and treatment according to ESC / AHA-ACC Guidelines Risk evaluation using protocols: Euro Score2, SINTAX, other 161 Protocols for indication of cardiac surgery, major procedures 320 HEART TEAM approach for all major surgery indications 161, 345, 346 Scheduled priority system Transfer protocols from hospitals type I and II to III Use of medication for secondary prevention at hospital discharge. Recommended > 90% in all hospitals 115 - 118 161, 377, Results Outcomes in selected populations as described in table # 5 Quality controls ESC / AHA-ACCC / Guideline adherence Prescription of appropriate medication for secondary prevention at hospital discharge Recommended: > 90% in patients without contraindications 115 - 118 161, 377, 398 Other: Waiting list, Infections, Bleeding and other complications, Recommended < mean value in local registries Cardiac Surgery Nurses assigned to cardiac surgery, experience > 1 year / operating room Major cardiac surgery procedures. Recommended > 500 year or > 70 / cardiac surgeron / year HEART TEAM approach for all major surgery indications. Including Nurses

65. UCAC NO RES. UCAC SI RES. CH TORRECÁRDENAS 2 H UNIVERSITARIO VIRGEN MACARENA 4 H UNIVERSITARIO PUERTA DEL MAR 3 H DE JEREZ DE LA FRONTERA 1 H UNIVERSITARIO DE PUERTO REAL 1 H UNIVERSITARIO REINA SOFIA 3 H UNIVERSITARIO VIRGEN DE LAS NIEVES 3 H JUAN RAMON JIMÉNEZ 2 CH DE JAÉN 1 H REGIONAL UNIVERSITARIO DE MÁLAGA 2 H UNIVERSITARIO VIRGEN DE LA VICTORIA 3 H UNIVERSITARIO VIRGEN DEL ROCÍO 4 H UNIVERSITARIO NTRA SRA. DE VALME 2 H UNIVERSITARIO MIGUEL SERVET 2 H CLÍNICO UNIVERSITARIO LOZANO BLESA 3 CH DOCTOR NEGRIN 3 H UNIVERSITARIO DE CANARIAS 2 HU INSULAR DE G. CANARIAS 2 H UNIVERSITARIO NUESTRA SEÑORA DE LA CANDELARIA 2 H UNIVERSITARIO MARQUÉS DE VADECILLA 2 H GENERAL UNIVERSITARIO DE CIUDAD REAL 2 ÁREA ESPECIALIZADA DE ALBACETE 2 H GENERAL UNIVERSITARIO DE GUADALAJARA 1 CH VIRGEN DE LA SALUD DE TOLEDO 3 CAU DE BURGOS 1 CAU DE LEÓN 3 CAU DE SALAMANCA 3 H. CLÍNICO UNIVERSITARIO DE VALLADOLID 3 CORPORACIÓ SANITARIA PARC TAULÍ 1 H UNIVERSITARI VALL D'HEBRON 3 H CLÍNIC DE BARCELONA 3 H DEL MAR-PARC DE SALUT MAR 2 H DE LA SANTA CREU I SANT PAU 4 H UNIVERSITARI GERMANS TRIAS I PUJOL 3 H UNIVERSITARI DE BELLVITGE 3 H UNIVERSITARI DE GIRONA DR. JOSEP TRUETA 2 H UNIVERSITARI ARNAU DE VILANOVA 1 H UNIVERSITARI JOAN XXIII DE TARRAGONA 2

66. VALLADOLID 3 CORPORACIÓ SANITARIA PARC TAULÍ 1 H UNIVERSITARI VALL D'HEBRON 3 H CLÍNIC DE BARCELONA 3 H DEL MAR-PARC DE SALUT MAR 2 H DE LA SANTA CREU I SANT PAU 4 H UNIVERSITARI GERMANS TRIAS I PUJOL 3 H UNIVERSITARI DE BELLVITGE 3 H UNIVERSITARI DE GIRONA DR. JOSEP TRUETA 2 H UNIVERSITARI ARNAU DE VILANOVA 1 H UNIVERSITARI JOAN XXIII DE TARRAGONA 2 H UNIVERSITARIO 12 DE OCTUBRE 3 H UNIVERSITARIO LA PAZ 3 H UNIVERSITARIO PUERTA DE HIERRO 3 H UNIVERSITARIO RAMÓN Y CAJAL 3 H CLÍNICO SAN CARLOS 4 H GENERAL UNIVERSITARIO GREGORIO MARAÑON 4 H UNIVERSITARIO DE LA PRINCESA 2 H CENTRAL DE LA DEFENSA GOMEZ ULLA 2 FUNDACIÓN JIMENEZ DÍAZ 2 H UNIVERSITARIO FUNDACIÓN DE ALCORCON 1 CLINICA UNIVERSITARIA DE NAVARRA 2 CH DE NAVARRA 2 H GENERAL UNIVERSITARIO DE ALICANTE 2 H GENERAL UNIVERSITARIO DE VALENCIA 2 H GENERAL UNIVERSITARIO DE ELCHE 1 H UNIVERSITARIO DE SANT JOAN 2 H GENERAL DE CASTELLÓN 1 H UNIVERSITARI I POLITÈCNIC LA FE 2 H DOCTOR PESET 2 H CLÍNICO UNIVERSITARIO DE VALENCIA 2 CH DE CÁCERES 1 CH UNIVERSITARIO INFANTA CRISTINA DE BADAJOZ 2 CH UNIVERSITARIO A CORUÑA 3 CH UNIVERSITARIO DE SANTIAGO DE COMPOSTELA 3 CH UNIVERSITARIO DE VIGO (H DO MEIXOEIRO) 2 H. UNIVERSITARIO SON ESPASES 2 H. UNIVERSITARIO ARABA 1 H UNIVERSITARIO CRUCES 2 H GALDAKAO-USANSOLO 1 H UNIVERSITARIO BASURTO 3 H. UNIVERSITARIO CENTRAL DE ASTURIAS 4 H DE CABUEÑES 1 H UNIVERSITARIO VIRGEN DE LA ARRIXACA 2 CH UNIVERSITARIO STA. Mª DEL ROSELL 3

67. German GARY Registry Experiencia con más de 15.000 pacientes JACC 2015, doi: 10.1016/j.jacc.2015.03.034

68. JACC 2015, doi: 10.1016/j.jacc.2015.03.034 German GARY Registry Experiencia con más de 15.000 pacientes

69. 92,6% 7,4% MORTALIDAD TOTAL ACUMULADA 1º AÑO 18,7% MORTALIDAD ENTRE EL ALTA Y EL 1º AÑO 11,3% TAVI-Cardio-CHUS. Mortalidad Hospitalaria 43,8 56,3 CV NO CV

70. CCAA Mortalidad Cir. Bypass aislada (%) Núm. Casos Andalucía 3,2% 588 Aragón 4,6% 130 Asturias 4,1% 196 Baleares 3,9% 206 Canarias 7,4% 95 Cantabria 0,0% 66 Castilla y León 2,5% 317 Castilla La Mancha 0,0% 79 Cataluña 2,6% 680 Valenciana 3,6% 779 Extremadura 4,6% 153 Galicia 2,5% 403 Madrid 3,5% 634 Murcia 3,1% 98 Navarra 1,3% 76 País Vasco 4,2% 142 Rioja nd nd PROMEDIO 3,3% 2012

71. Trends in in-hospital mortality rates after isolated CABG surgery in Ontario 1991-2006 2.95 2.83 3.17 2.83 2.42 2.32 2.2 2.29 2.18 2.32 2.08 1.03 1.23 1.39 1.1 1.17 0 0.5 1 1.5 2 2.5 3 3.5 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Fiscal Year In-HospitalMortalityRate(%) Confidential reporting Public reporting

72. Exigir exposición pública de resultados ajustados al riesgo por hospital Usar escalas de riesgo que no sobreestimen!!!!! Exigir tasas de mortalidad entre el 0-1%, uso de injertos arteriales y medición de los injertos en quirófano (INDICACION CLASE I) Qué debéis “exigir” a los cirujanos ? Forteza A. SEC-15

73. Exigir exposición pública de resultados ajustados al riesgo por hospital Que se ajusten a las recomendaciones de sus Sociedades científicas !!!!!!!!! Qué debemos “exigir” a los cardiólogos? Forteza A. SEC-15

76. 33.72 32.99 32.81 32.77 31.94 31.57 31.32 30.98 30.71 30.63 30.15 30.14 29.76 29.53 28.18 28.00 27.48 26.30 22.85 Mortalidad CV en España-2013

77. 48,000 50,000 52,000 54,000 56,000 58,000 60,000 62,000 64,000 MUJERES HOMBRES 63,997 53,487 Mortalidad CV en España-2013 ESPAÑA MUJERES HOMBRES BRECHAENTREMUJERESYHOMBRES 35,58% 26,77% 8,81% MORTALIDADCARDIOVASCULARPORCENTUALRESPECTOALASDEMÁSCAUSAS

78. December 14; 2013

79. Liderazgo DOCENCIA Compromiso INVESTIGACÓN ASISTENCIA Integración y Calidad Profesional La Enfermería en el Sistema Nacional de Salud1 Gestión Sanitaria mas allá de las Direcciones de Enfermería

80. EEFF/ Dispositivos La Enfermería Asistencial en Cardiología en Sistema Nacional de Salud Cardiologí a General Imagen CV Rehabilitación / IC Agudos Hemodin/Interv enc.

81. SEC quality of care “virtuose circle” “El Papel Central de la Enfermería” SEC quality of care “virtuose circle”

86. Angioplastia primaria MORTALIDAD 2014. CardioCHUS

87. Clinical cardiology Metric Recommendations References Structure. Resources directly related to patient care Hospital volumes Patient volume (direct and transferred patients) Nº dedicated ICCU beds. Recommended 4-5 beds / 100.000 inhabitants 196 - 203 Desired Technology TTE, in all hospitals. TEE and stress echo, CCT, PET-CT Scanner, NMR, in type II and III hospitals. 3D echo in type III hospitals; 204 - 208 Staffing Certified cardiologist responsible for cardiac unit in hospitals > 300.000 209 - 213 Nurses with cardiology experience. Recommended in type II and III h. Organization Dedicated cardiac unit: Recommended in hospitals with a population > 300.000 214 - 216 Patient services Cardiologist on call / 24 hours Recommended in hospitals type II and III 199 Rehabilitation program. Recommended in all hospitals, in house or in a reference hospital 220 - 222 Accreditation External accreditation of specific units 220 - 225 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols Local protocols for diagnosis and treatment for prevalent GRDs based on ESC /AHA-ACC guidelines: acute coronary syndromes, acute chest pain, chronic stable ischemic heart disease, valvular heart disease, heart failure, pulmonary embolism, myocardiopathies, aortic disease, preoperative cardiovascular evaluation protocols, adult congenital heart disease, atrial fibrillation, syncope, pulmonary hypertension, pericardial diseases, cardiovascular disease during pregnancy. Recommended in all hospitals 104, 105 226 – 244 Multidisciplinary protocols Heart Team Multidisciplinary protocols with related specialties Avoid duplicity of units in the same hospital (e.g.: heart failure) 103, 104, 245 Regional STEMI protocol 123, 246, 247 Hospital approved protocols for derivation to other hospitals in case of need for other services: Recommended in hospitals w/out the required technology 59 Waiting list Waiting list for 1st medical outpatient visit < 40 days. Recommended in all hospitals < 1,7 / 1000 population covered by hospital 248 - 251 Safety. All hospitals should identify possible safety problems and organized local quality programs in a yearly basis. 59 Results Outcomes in selected populations as described in table # 5 Quality controls: Adherence to guidelines Adherence to local protocols for diagnosis and treatment based on ESC / AHA/ACC guidelines Recommended > 90% in all hospitals 11, 103, 104 192 - 194 252-254 Clinical Cardiology Nurses with Cardiology experience in type II and III h. Rehabilitation program, all hospitals ICCU: Recommended 4-5 beds/100.000 inhabitants

88. Cardiac Rehabilitation Metric Recommendation Reference s Structure. Resources directly related to patient care Hospital volumes Recommended 1 unit / 300.000 inhabitants 376, 386 Desired technology Dedicated area related to hospital Appropriate equipment for exercise training, cardiac evaluation, and advanced CV life support equipment 386, 397 Staffing Cardiologist responsible for the rehabilitation unit 386, 397 Nurses with training in cardiac rehabilitation 386, 397 Multidisciplinary team including rehabilitation specialists, physiotherapist, neurologist, psychologist, endocrinologist, general physicians 373, 374, 376, 377, 378 - 381, 383, 386, 397, 399 Accreditation Official accreditation. (No accreditation available yet in Europe or Spain. Accreditation available in US) 397 Patient services Rehabilitation program. Exercise training, life style counselling, and tobacco control. 120, 373, 375, 376, 377, 380, 397, 399, 363, Nurses with training in cardiac rehabilitation 376, 399, 386,396 Long term follow-up for guideline adherence Use of new technologies recommended 376, 377, 389, 397, 399, 363 Cardiac Rehabilitation Nurses with trainning in cardiac rehabilitation Nurse directed Program Recommended 1 unit / 300000 inhabitants

89. Quality controls % of patients admitted to a Rehabilitation program > 50% after AMI? ACS (Ideally all patients should be offered some kind of rehabilitation program) 376, 385, 395, 397 Control of major risk factors and adherence to guideline recommendations for life style Smoking: sustained smoking abstinence >50% in CVD 384 - 386, 392, 393, 395, 397, 399 Hypertension optimal control (< 140/90) > 50%? 376, 386, 393, 397 LDL < 70, recommended target > 70% (1,8 mmml/L) or highest tolerated dose of statins > 50% of patients 376, 385, 394, 397, 400 Adherence to guideline recommendations of lifestyle Exercise, Diet, smoking counselling: Recommended in 100% 376, 387, 390, 397, 399 Adherence to ESC / AHA-ACCC guideline recommendation for 2nd prevention treatment Antiplatelet, Statins, Beta-blockers, ACE-I, aldosterone blockers unless contraindicated. Recommended >90 % unless contraindicated 115 - 118, 376, 397, 398 % of patients admitted in a rehabilitation program after 1st ACS or revascularization Recommended > mean value in local registries Cardiac Rehabilitation. Quality controls Smoking: sustained smoking abstinence > 50% Exercise, diet, smoking counselling: recommended in 100%

91. 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 smoking cessation program, high risk CAD smoking cessation program, low risk CAD Post AMI ACE-inh Cardiac Rehab post AMI BBL post MI Statins (4S) CABG/PCI AAS Thrombolytic th. The cardiologist and smoking cessation. Aboyans, Victor; Thomas, Daniel; Lacroix, Philippe Current Opinion in Cardiology. 25(5):469-477, September 2010. DOI: 10.1097/HCO.0b013e32833cd4f7 Cost € per life year gained Cambios en Estilo de Vida en Prevención Secundaria. “Lo mas coste-efectivo”

92. En 2013: 7434 pacientes rehabilitados 76.666 SCA 85% EC crónica + aguda 64 % fueron SCA 4.757 pacientes con SCA 6,2% 2.Escaso número de pacientes atendidos en las Unidades de Rehabilitación Cardiaca La Rehabilitación Cardíaca uno de los grandes retos de la enfermería en España

93. Proyecto para pacientes y profesionales La Enfermería como el Centro del Proceso

94. Coordinador: Dr. Lorenzo Fácila Dra. Almudena Castro 1. Desarrollo web 2. Paciente experto 1. MimoApp 2. MimoKids 1. MimoFarmacias

96. Enfermería Cardiológica e Imagen Cardiovascular

98. Acute cardiac care / Intensive cardiac care Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes 4-5 ICCU beds / 100.000 inhabitants 198 Desired technology Intensive care environment technology 198 Staffing All nurses with > 1 year cardiology experience. Experience in acute cardiac care 198 At least 1 cardiologist certified in acute coronary care (optimal: 1 / 3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals > 300.000) 198 Accreditation At least 1 cardiologist accredited in acute cardiac care 198 Any accreditation conferred by any external organizations 198 Patient services Regional network for STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care treatment for sudden death (includes temperature management) 14528 Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols based on ESC /AHA- ACC guidelines STEMI and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments according to ESC / AHA – ACC guidelines 115 - 118 Multidisciplinary protocols Prehospital systems, emergency department, cardiac unit. 115 - 118 Heart failure: Cardiac unit, internal medicine, emergency department 289, 290 Results Outcomes in selected populations as described in table # 5 Quality controls Adherence to ESC / AHA-ACC guidelines Patients with primary PCI in STEMI: > mean value in national registries Time to call-door-balloon/lytic: < 60 min after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI diagnosis Patients with dual antiplatelet therapy in ACS: > mean value in national registries Patients with statins at discharge: > mean value in national registries Aspirin at admission: > mean value in national registries 115 - 118 Safety Infections: Recommended < mean value in national registries Transfusions: Recommended < mean value in national registries 115 - 118 291 Acute cardiac care / Intensive cardiac care All nurses with > 1 year cardiology experience. Experience in acute cardiac care Cardiologist on call 24 h (recommended in hospitals > 300.000)

102. 12,000 22,000 32,000 42,000 52,000 62,000 72,000 82,000 92,000 102,000 112,000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 INSUFICIENCIA CARDIACA INFARTO AGUDO MIOCARDIO ARRITMIAS C. ISQUEMICA CRONICA C. ISQUEMICA AGUDA Hospital admission for Cardiac Diseases RECALCAR 2012

104. Roccaforte, et al. Eur J Heart Fail 2005; 7: 1133-44 Metaanálisis de Programas Asistenciales en IC. Papel Central de la Enfermería Enfermería asistencial

105. Interventional Cardiology All nurses with > 1 year experience in cath lab, minimal 2, desirable 3/lab HEART TEAM decision in all non-emergency procedures including nurses PCI: optimal > 400 year: If < 200 year, cath lab should be part of a larger network PCI per operator > 70 year Primary PCI > 36-50 year (PPCI per operator > 11 / year Cath lab open 24/7/365 recommended in hospitals>300000 (population)

106. La Enfermería en Cardiología Intervencionista Atención Paciente Intrumentación Control Técnico Control Material

107. Andalucía 8,33 7,94 -0,39 Aragón 8,13 7,18 -0,95 Asturias 7,99 7,55 -0,44 Baleares 7,47 6,33 -1,14 Canarias 8,03 7,75 -0,28 Cantabria 8,11 7,56 -0,55 Castilla y León 8,08 7,00 -1,08 Castilla La Mancha 7,28 7,26 -0,02 Cataluña 6,96 6,66 -0,30 Valenciana 9,57 8,49 -1,08 Extremadura 7,98 7,54 -0,44 Galicia 7,64 7,14 -0,50 Madrid 7,73 6,61 -1,12 Murcia 7,78 7,40 -0,38 Navarra 6,06 6,08 0,02 País Vasco 8,71 7,29 -1,42 Rioja 7,34 7,09 -0,25 PROMEDIO 7,84 7,31 -0,53 CCAA Mortalidad IAM (%) Evolución RECALCAR 2012 STEMI. Risk-adjusted Mortality 2011 2012

111. Radiation dose measure (fluoroscopy time / dose for patient and staff Electrophysiology and arrhythmias Interventional Cardiology

112. Cardiac Surgery Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes Major cardiac surgery procedures. Recommended: >500 / year or > 70 / cardiac surgeron / year 161, 401 Desired technology Dedicated Cardiac surgery operating rooms, at least 1 full time 161 Fully staffed and equipped Cardiac Surgery Intensive Care Unit 401 Staffing Certified cardiac surgeons Anaesthesiologists, intensivist and cardiac surgeon accredited in post cardiac surgery intensive care Nurses assigned to cardiac surgery, experience > 1 y / operating room Accreditation Accredited cardiac surgery unit Patient services Urgent cardiac surgery Scheduled priority system 161 Prevention of infections protocol 161 Process of delivery care Protocols for evaluation and treatment according to ESC / AHA-ACC Guidelines Risk evaluation using protocols: Euro Score2, SINTAX, other 161 Protocols for indication of cardiac surgery, major procedures 320 HEART TEAM approach for all major surgery indications 161, 345, 346 Scheduled priority system Transfer protocols from hospitals type I and II to III Use of medication for secondary prevention at hospital discharge. Recommended > 90% in all hospitals 115 - 118 161, 377, Results Outcomes in selected populations as described in table # 5 Quality controls ESC / AHA-ACCC / Guideline adherence Prescription of appropriate medication for secondary prevention at hospital discharge Recommended: > 90% in patients without contraindications 115 - 118 161, 377, 398 Other: Waiting list, Infections, Bleeding and other complications, Recommended < mean value in local registries Cardiac Surgery Nurses assigned to cardiac surgery, experience > 1 year / operating room Major cardiac surgery procedures. Recommended > 500 year or > 70 / cardiac surgeron / year HEART TEAM approach for all major surgery indications. Including Nurses

113. A B Predicted Mortality Observed Mortality Trends in outcomes for mortality after AVR

114. La Enfermería Investigadora en Cardiología en Sistema Nacional de Salud La Misión: “Se que me voy a curar y, sobre todo, que ME VAN A CUIDAR”

116. Master propio de Tecnicos en Ecocardiografia

117. 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 smoking cessation program, high risk CAD smoking cessation program, low risk CAD Post AMI ACE-inh Cardiac Rehab post AMI BBL post MI Statins (4S) CABG/PCI AAS Thrombolytic th. The cardiologist and smoking cessation. Aboyans, Victor; Thomas, Daniel; Lacroix, Philippe Current Opinion in Cardiology. 25(5):469-477, September 2010. DOI: 10.1097/HCO.0b013e32833cd4f7 Cost € per life year gained Cambios en Estilo de Vida en Prevención Secundaria. “Lo mas coste-efectivo”

118. R- EUReCa- Participación Mapa por provincias de centros que participan en el registro según dependencia funcional (n=91) 1 1 2 4 1 1 2 3 2 1 1 1 1 11 2 4 1 2 3 1 1 4 2 1 1 5 3 2 4 1 1 2 Privados (n=29) Públicos (n=54) 1 1 1 1 2 1 1 2 1 1 1 1 1 1 Mutuas (n=8) 1 1 1

119. 80.2 8.8 2.2 2.21.1 1.1 1.1 2.2 1.1 Cardiología Medicina física y rehabilitación Medicina Interna Cardiología y Rehabilitación Cuidados intensivos INEF Fisioterápia Medicina y fisiología del deporte No contestan R- EUReCa ESPECIALIDAD y DEDICACIÓN del director/coordinador/responsable del Programa de Rehabilitación Cardiaca (PRC) Papel Central ENFERMERÍAESPECIALIDAD DEDICACIÓN n=91 n=91 27.5 72.5 Tiempo completo Tiempo parcial Fisioterapi a

120. R- EUReCa- Participación Mapa por provincias de centros que participan en el registro según dependencia funcional (n=91) 1 1 2 4 1 1 2 3 2 1 1 1 1 11 2 4 1 2 3 1 1 4 2 1 1 5 3 2 4 1 1 2 Privados (n=29) Públicos (n=54) 1 1 1 1 2 1 1 2 1 1 1 1 1 1 Mutuas (n=8) 1 1 1

121. R- EUReCa % de centros n=91 ¿Cuáles son las patologías más frecuentes en el PRC en Fase II en el año 2013? Porcentaje de centros. *En el caso de SCA con cirugía de By-pass, el porcentaje se corresponde con ésta última 95.6 63.7 48.4 37.4 35.2 34.1 15.4 14.3 8.8 8.8 6.6 4.4 0 20 40 60 80 100 SCA con o sin EST Cirugía de By-pass aortocoronario ICP en angina estable Cirugía de recambio valvular Enfermedad coronaria crónica Insuficiencia Cardiaca Por implantación de DAI Pacientes de alto riesgo cardiovascular Trasplante cardiaco Por implantación de marcapasos Enfermedad Arterial Periférica Corrección de cardiopatía congénita

122. En 2013: 7434 pacientes rehabilitados 76.666 SCA 85% EC crónica + aguda 64 % fueron SCA 4.757 pacientes con SCA 6,2% 2.Escaso número de pacientes atendidos en las Unidades de Rehabilitación Cardiaca La Rehabilitación Cardíaca uno de los grandes retos de la enfermería en España

123. Proyecto para pacientes y profesionales La Enfermería como el Centro del Proceso

124. Coordinador: Dr. Lorenzo Fácila Dra. Almudena Castro 1. Desarrollo web 2. Paciente experto 1. MimoApp 2. MimoKids 1. MimoFarmacias

125. Integrating therapies Ibanez et al. JACC 2015 (In Press) 12/13

126. STEMI Heart Failure Heart Failure a “nurse process” •Figure 1: Projected cumulative (2011 to 2025) economic losses from all non-communicable diseases worldwide. Adapted from ref 3. •Figure 2: 1/16

127. Enfermería e Intervencionismo

128. Enfermería e Intervencionismo

129. La Enfermería en Cardiología Intervencionista Atención Paciente Intrumentación Control Técnico Control Material

135. Metric Relevance Difficulty Auditable Evidence Comments All cause Mortality 1 1 1 A · Self-evident. Reliable only in well organized, auditable registries / databases Cardiovascular Mortality 1 2 2 A · Difficult to ascertain. Needs adjudication. Number of days in hospital 1 2 2 A · Reason for hospitalization dependent of health care systems and individual preferences · Number of days in any hospital 30 days after index hospitalization preferred to days in hospital until discharge if feasible Stroke 1 2 2 A · Difficult to ascertain. Needs adjudication · No reliable risk scores for corrections of results in different hospitals Re-infarction 1 2 2 A · Difficult to ascertain. Needs adjudication Safety (Major bleeding, severe infections, medical errors, etc.) 1 2 2 A · Difficult to ascertain. Needs adjudication and audits

138. Type of correction Pros Cons None · Real figures · Good to compare global results in very large populations, especially when no selection bias is expected (e.g.: benchmarking between countries or in same country through different periods of time) · Different risk profiles impact the results, especially in not very large populations or biased population · Hospitals admitting the worst cases have the worst results Age and gender · Classic when comparing global results in large populations when no population selection bias is expected · Generally accepted; used in many statistical reports of large populations · Incomplete refinement of population risk · May be unreliable in relatively small populations Hospital clusters · Corrects for bias of patient admissions in different types of hospitals · Insufficient for risk correction · Hospitals admitting the worst cases have the worst results General risk correction · Some scores were validated (e.g.: ICES (155)) and used in quality benchmarking · Not compare and validated against disease specific risk scores · No universal risk score for all clinical settings with different risk factors for outcomes Disease specific risk scores (e.g.: Euro score II, GRACE, TIMI, SYNTAX, HAS-BLED, Stroke, · Validated for specific populations · Recommended in guidelines for risk stratification and therapeutic strategies in clinical practice · Best for specific registries; probably the best if universally accepted for risk correction in benchmarking · No universally accepted / used for quality benchmarking · Some risk scores include data not available in large populations (e.g.: heart failure) Risk standardized mortality ratios · Difficult to understand by non- professional observers · Not universally used · Predicted mortality may be inaccurately calculated Risk score calculated in study populations used for benchmarking · Probably the best correction for benchmarking in a single study (e.g.: specific registry) · Impossible to apply universally · Unreliable to compare very different populations (different registries, databases, countries)

139. Type of report Pros Cons Selected populations e.g.: STEMI excluding prehospital cardiac arrest unconscious at hospital arrival e.g.: exclusion of low prevalence and very high risk populations (trauma, endocarditis, non-cardiac surgery · More uniform populations for benchmarking · Corrects for confounders · More uniform results without need for other corrections · Not real figures for the complete population · No universal selection criteria accepted · Benchmarking between different registries etc. unreliable due to difficulties in selecting appropriate populations Crude observed values (Number or %) · Represent the real problem · Easy to understand · Good for large populations · Unreliable for smaller populations because of lack of risk correction Risk corrected figures · Corrects for risk population between clusters · More reliable · No universal risk correction accepted Observed vs. predicted (expected) ratios · Better describe performance for benchmarking · More difficult to understand than crude or percent values when reporting for non- professional readers · No universally validated algorithms to calculate expected values · Usually, expected figures are higher than observed (e.g. euroscore) Reporting for benchmarking

142. A B Predicted Mortality Observed Mortality Trends in outcomes for mortality after AVR

143. STEMI Time from Hospital Arrival to Primary PCI Site Cluster World Year Median edianac Rehabilitationded > 50 prt failure or surgery as aboveght ate quality 0 50 100 150 200

145. Clinical cardiology Metric Recommendations References Structure. Resources directly related to patient care Hospital volumes Patient volume (direct and transferred patients) Nº dedicated ICCU beds. Recommended 4-5 beds / 100.000 inhabitants 196 - 203 Desired Technology TTE, in all hospitals. TEE and stress echo, CCT, PET-CT Scanner, NMR, in type II and III hospitals. 3D echo in type III hospitals; 204 - 208 Staffing Certified cardiologist responsible for cardiac unit in hospitals > 300.000 209 - 213 Nurses with cardiology experience. Recommended in type II and III h. Organization Dedicated cardiac unit: Recommended in hospitals with a population > 300.000 214 - 216 Patient services Cardiologist on call / 24 hours Recommended in hospitals type II and III 199 Rehabilitation program. Recommended in all hospitals, in house or in a reference hospital 220 - 222 Accreditation External accreditation of specific units 220 - 225 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols Local protocols for diagnosis and treatment for prevalent GRDs based on ESC /AHA-ACC guidelines: acute coronary syndromes, acute chest pain, chronic stable ischemic heart disease, valvular heart disease, heart failure, pulmonary embolism, myocardiopathies, aortic disease, preoperative cardiovascular evaluation protocols, adult congenital heart disease, atrial fibrillation, syncope, pulmonary hypertension, pericardial diseases, cardiovascular disease during pregnancy. Recommended in all hospitals 104, 105 226 – 244 Multidisciplinary protocols Heart Team Multidisciplinary protocols with related specialties Avoid duplicity of units in the same hospital (e.g.: heart failure) 103, 104, 245 Regional STEMI protocol 123, 246, 247 Hospital approved protocols for derivation to other hospitals in case of need for other services: Recommended in hospitals w/out the required technology 59 Waiting list Waiting list for 1st medical outpatient visit < 40 days. Recommended in all hospitals < 1,7 / 1000 population covered by hospital 248 - 251 Safety. All hospitals should identify possible safety problems and organized local quality programs in a yearly basis. 59 Results Outcomes in selected populations as described in table # 5 Quality controls: Adherence to guidelines Adherence to local protocols for diagnosis and treatment based on ESC / AHA/ACC guidelines Recommended > 90% in all hospitals 11, 103, 104 192 - 194 252-254 Clinical Cardiology Nurses with Cardiology experience in type II and III h. Rehabilitation program, all hospitals ICCU: Recommended 4-5 beds/100.000 inhabitants

147. Enfermería Cardiológica e Imagen Cardiovascular

148. Acute cardiac care / Intensive cardiac care Metric Recommendation References Structure. Resources directly related to patient care Hospital volumes 4-5 ICCU beds / 100.000 inhabitants 198 Desired technology Intensive care environment technology 198 Staffing All nurses with > 1 year cardiology experience. Experience in acute cardiac care 198 At least 1 cardiologist certified in acute coronary care (optimal: 1 / 3-4 beds) 198 Cardiologist on call 24/h (recommended in hospitals > 300.000) 198 Accreditation At least 1 cardiologist accredited in acute cardiac care 198 Any accreditation conferred by any external organizations 198 Patient services Regional network for STEMI and other ACS 115 Cath lab available 2/7 115 Bundle of care treatment for sudden death (includes temperature management) 14528 Risk stratification (GRACE, TIMI, CRUSADE) 115 - 118, 223 Process of delivery care for diagnosis, treatment, prevention and patient education Local protocols based on ESC /AHA- ACC guidelines STEMI and Non-STEMI protocols 115 - 118, 145 Optimal medical treatments according to ESC / AHA – ACC guidelines 115 - 118 Multidisciplinary protocols Prehospital systems, emergency department, cardiac unit. 115 - 118 Heart failure: Cardiac unit, internal medicine, emergency department 289, 290 Results Outcomes in selected populations as described in table # 5 Quality controls Adherence to ESC / AHA-ACC guidelines Patients with primary PCI in STEMI: > mean value in national registries Time to call-door-balloon/lytic: < 60 min after STEMI diagnosis Fibrinolytic therapy < 30 min after STEMI diagnosis Patients with dual antiplatelet therapy in ACS: > mean value in national registries Patients with statins at discharge: > mean value in national registries Aspirin at admission: > mean value in national registries 115 - 118 Safety Infections: Recommended < mean value in national registries Transfusions: Recommended < mean value in national registries 115 - 118 291 Acute cardiac care / Intensive cardiac care All nurses with > 1 year cardiology experience. Experience in acute cardiac care Cardiologist on call 24 h (recommended in hospitals > 300.000)

149. Interventional Cardiology All nurses with > 1 year experience in cath lab, minimal 2, desirable 3/lab HEART TEAM decision in all non-emergency procedures including nurses PCI: optimal > 400 year: If < 200 year, cath lab should be part of a larger network PCI per operator > 70 year Primary PCI > 36-50 year (PPCI per operator > 11 / year

150. Desigualdades Interterritoriales (IAM. 2012) 6 6,5 7 7,5 8 8,5 9 100 150 200 250 300 350 400 450 500 RAMER(%) Tasa ICP-p Millón Hab RECALCAR 2012 STEMI. Risk-adjusted Mortality

152. Radiation dose measure (fluoroscopy time / dose for patient and staff Electrophysiology and arrhythmias Interventional Cardiology

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