Table of Contents
- ABOUT DATAMONITOR HEALTHCARE
- About the cardiovascular analysis team
- CHAPTER 1 EXECUTIVE SUMMARY
- Scope of the analysis
- Datamonitor insight into the ACS market
- Contributing experts
- CHAPTER 2 ACS DEFINITIONS AND PATHOPHYSIOLOGY
- Acute coronary syndromes
- Pathophysiology
- Coronary artery disease and atherosclerosis
- Vulnerable plaque
- Histopathology of atherosclerotic lesions
- Remodeling and role of coronary artery inflammation
- Thrombosis
- Atherosclerotic calcification
- Ischemia
- Unstable angina (UA)
- Non-ST segment elevated myocardial infarction (NSTEMI)
- Non-ST segment elevated myocardial infarction (NSTEMI) and ST segment
elevated myocardial infarction (STEMI)
- New definition of myocardial infarction
- CHAPTER 3 EPIDEMIOLOGY
- ACS epidemiology specifics and limitations
- Ageing population
- Male to female ratio and age
- Risk factors
- Smoking
- Obesity and overweight prevalence
- Diabetes
- Hypertension
- Dyslipidemia
- Prevalence and incidence of ACS in the 5EU
- Incidence of STEMI
- Incidence of UA and NSTEMI
- CHAPTER 4 DIAGNOSIS AND INVESTIGATION IN ACS
- Symptoms
- Initial and final diagnosis
- Physical examination and chest pain differential
- Clinical tests in primary investigation
- ECG and ECG Stress testing
- Cardiac biomarkers
- Cardiac troponins
- Creatine Kinase (CK)
- Myoglobin
- C-reactive protein (CRP)
- Neurohormonal activation markers
- Novel biomarkers
- Multimarker approach
- Risk stratification
- Role of imaging tests in ACS
- Invasive imaging testing
- Coronary angiography
- Intravascular ultrasound (IVUS)
- Intravascular MRI (IVMRI)
- Non-invasive imaging testing
- Echocardiography and stress echo
- Chest X-ray
- Nuclear perfusion tests
- Role of MRI and CT in coronary heart disease diagnosis
- Limitations of early imaging in the emergency department
- CHAPTER 5 PHARMACOLOGICAL STRATEGIES
- Drug classes in ACS
- Anti-ischemic agents
- Nitrates
- Betablockers
- Calcium channel blockers
- ACE inhibitors and angiotensin II receptor blockers
- Antithrombotics
- Anticoagulants
- Antiplatelet agents
- COX-1 inhibitors (aspirin)
- ADP receptor antagonists
- GPIIb/IIIa receptor inhibitors
- Thrombolytics
- Fibrinolysis
- Pharmacological reperfusion
- Statins
- CHAPTER 6 REVASCULARIZATION STRATEGIES
- Coronary thrombolysis
- Pre-hospital thrombolysis
- In-hospital thrombolysis
- Contraindications to fibrinolytic therapy
- Interventions versus thrombolysis
- Clinical trial evidence: C-PORT and a meta-analysis
- Evidence from registries
- Angioplasty
- Stenting
- In-stent restenosis: the man-made condition
- Drug-eluting stents
- ESC guidelines on PCI strategy in NSTE-ACS and STEMI
- Coronary artery bypass graft (CABG)
- CHAPTER 7 HOSPITAL INFRASTRUCTURE AND PATIENT FLOW
- Overview
- General practitioners and outpatient facilities
- Role of ambulance services
- Emergency department (ED)
- Coronary care and intensive care unit
- Cardiac catheterization laboratory (Cathlab)
- CHAPTER 8 REVIEW OF CURRENT GUIDELINES
- ESC guidelines
- Recommendations by the ESC
- Guidelines for STEMI patients
- CHAPTER 9 KEY FIGURES AND STATISTICAL ANALYSIS
- Methodology
- Patient demographics
- Main diagnosis
- ACS age and sex distributions
- Co-morbidities and risk factors
- Diabetes
- Dyslipidemia
- Hypertension
- Obesity
- Smoking
- ACS hospital logistics
- Mode of admission
- Mode of admission for patients with ST-segment elevation
- Type of hospital for ACS patient admission.
- The importance of cathlabs
- Point of entry to hospital
- Length of stay in hospital
- Hospital transfers
- Diagnostic procedures
- Cardiac biomarkers
- Non-invasive imaging test
- Reperfusion therapy
- Thrombolytic therapy
- Coronary interventions
- Pharmacological therapy
- Anticoagulants
- Unfractionated heparins
- Low molecular weight heparins
- Antiplatelet agents
- COX-1 inhibitors
- ADP receptor antagonists
- GPIIb/IIIa receptor inhibitors
- Anti-ischemic agents
- Nitrates
- Betablockers
- ACE inhibitors
- Summary
- APPENDIX
- References
- General sources
- Obesity Epidemiology sources
- France
- Germany
- Italy
- Spain
- UK
- About Datamonitor
- About Datamonitor Healthcare
- About the Cardiovascular Disease analysis team
- Disclaimer
- List of Tables
- Table 1: Prevalence of obesity in the seven major markets (000s),
2006-2015
- Table 2: Prevalence of obesity / overweight in the seven major markets
(000s), 2006-2015
- Table 3: Estimated absolute prevalence of diabetes in the seven major
markets (millions), 2006
- Table 4: Prevalence of hypertension in the seven major markets (000s),
2003
- Table 5: Estimated prevalent persons with dyslipidemia across the
seven major markets, 2005
- Table 6: Incidence of ST-segment elevation myocardial infarction (000s)
- Table 7: Incidence of unstable angina and non-ST segment elevation
myocardial infarction (000s)
- Table 8: Types of chest pain
- Table 9: Risk stratification summary for ACS, 2006
- Table 10: Number of PCI procedures performed in the 5EU, 2005
- Table 11: CABG procedures performed in the 5EU, 2005
- Table 12: ESC guidelines for the management of STEMI, 2002
- List of Figures
- Figure 1: Development and progression of atherosclerosis
- Figure 2: Pathogenesis of a plaque leading to rupture
- Figure 3: ACS pathophysiology cycle
- Figure 4: The 10 leading causes of death in high-income countries
(%),2005 projections
- Figure 5: Deaths attributed to specific cardiovascular diseases, 2006
- Figure 6: Major causes of death in the 5EU, 2006
- Figure 7: Distribution of the population in Europe by age, 2004
- Figure 8: Distribution of the population in Europe by age, 2050
- Figure 9: Basic diagnostic flow in ACS
- Figure 10: Antiplatelet therapy in ACS
- Figure 11: Ancrod acts indirectly on the thrombolytic pathways
- Figure 12: Contraindications to fibrinolytic therapy
- Figure 13: PCI procedures carried out by indication in the 5EU, 2005
- Figure 14: Management of ACS without ST-elevation (NSTE-ACS)
- Figure 15: Management of ACS in STEMI
- Figure 16: Typical patient flow in case of acute chest pain
- Figure 17: Delays in patients with acute chest pain
- Figure 18: Proportion of patients presented with and without
ST-segment elevation on initial ECG, 5EU, 2007
- Figure 19: Ratio of main ACS diagnoses in 5EU
- Figure 20: Overall ACS age distribution in the ACV analyzer sample
- Figure 21: ACS age distribution split by country and sex
- Figure 22: Changes in main diagnosis ratio in age distribution
- Figure 23: Changes in main diagnosis ratio by age and sex, MALE
- Figure 24: Changes in main diagnosis ratio by age and sex, FEMALE
- Figure 25: Age-related variations in male:female ratio of ACS patients
in the 5EU
- Figure 26: Diabetes distribution among ACS patients in the 5EU
- Figure 27: Dyslipidemia distribution among ACS patients in the 5EU
- Figure 28: Hypertension distribution among ACS patients in the 5EU
- Figure 29: BMI distribution among ACS patients in the 5EU
- Figure 30: Percentage of patients who smoke in the ACS analyzer sample
per country
- Figure 31: Hospital admission mode for ACS patients
- Figure 32: Mode of hospital admission for patients with ST-segment
elevation
- Figure 33: Patients admitted via ambulance to hospitals with or
without cathlabs - all patients versus those with ST-segment elevation
- Figure 34: Proportion of ACS patients admitted to hospitals with or
without cathlab by all modes of admission - all patients versus those with
ST-segment elevation
- Figure 35: First stop in hospital after admission - all patients
versus those with ST-segment elevation
- Figure 36: Second stop in hospital after admission - all patients
versus those with ST-segment elevation
- Figure 37: Diagnostic challenge: Second stop in hospital after
admission for patients without ST-segment elevation and with negative
troponin
- Figure 38: Length of in-hospital stay for ACS patients, UA
- Figure 39: Length of in-hospital stay for ACS patients, NSTEMI
- Figure 40: Length of in-hospital stay for ACS patients, STEMI
- Figure 41: Percentage of all ACS patients who have been transferred or
referred to hospitals and transferred from hospitals for further PCI or
CABG or other treatment
- Figure 42: Distribution of troponin test
- Figure 43: Distribution of Echo and Nuclear perfusion tests
- Figure 44: Distribution of CT and MRI tests
- Figure 45: Distribution of stress test
- Figure 46: Distribution of IVUS (%) in angiography cases only
- Figure 47: Distribution of thrombolytic therapy in all ACS patients
and in patients presented with ST-segment elevation
- Figure 48: Country distribution of thrombolytic therapy in patients
presented with ST-segment elevation only
- Figure 49: Country distribution of success rate of thrombolytic
therapy in patients presented with ST-segment elevation
- Figure 50: Specific thrombolytic molecules use distribution in 5
European countries
- Figure 51: % of all ACS patients receiving Diagnostic Angiography test
then PCI and then Stenting
- Figure 52: Door to PCI time, percentage of patients who received PCI
<12h from hospital admission vs. >12h from hospital admission
- Figure 53: Distribution of STENT implantations by type
- Figure 54: % of CABG
- Figure 55: Early reperfusion therapy (< 12 h after onset of
symptoms) distribution in STEMI patients
- Figure 56: Use of unfractionated heparins in the treatment of ACS
patients
- Figure 57: Use of low molecular weight heparins (LMWH) in the
treatment of ACS patients
- Figure 58: Use of COX-1 Inhibitors (aspirin) in the treatment of ACS
patients
- Figure 59: Use of ADP receptor antagonists in the treatment of ACS
patients
- Figure 60: Use of GPIIb/IIIa receptor inhibitors in the treatment of
ACS patients
- Figure 61: Use of nitrates in the treatment of ACS patients
- Figure 62: Use of betablockers in the treatment of ACS patients
- Figure 63: Use of ACE inhibitors in the treatment of ACS patients
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