Stent for Life Initiative: where are we standing and where are we going?

The first percutaneous coronary angioplasty (PTCA) for acute myocardial infarction was performed nearly 30 years ago in 1983.¹ It took another 10 years before the first randomised trials published in 1993^2–4 had proven that primary PTCA is superior to thrombolysis in the treatment of acute myocardial infarction with ST-segment elevations (STEMI). Despite this evidence, primary angioplasty remained a rare reperfusion method used mostly for patients living near PTCA centres and presenting during working hours. Another 10 years elapsed before two larger multicentre randomised trials^5,6 showed that primary percutaneous coronary intervention (p-PCI) is also the best reperfusion strategy for distant patients who need to be transferred from a small hospital to a tertiary PCI centre during off-hours. The first guidelines defining p-PCI as the default reperfusion strategy were published by the Czech Society of Cardiology,⁷ followed by the European Society of Cardiology⁸ and the American College of Cardiology/American Heart Association.⁹ Thus, it took 20 years from the introduction of primary PTCA and 10 years from the original randomised trials evidence to define p-PCI as the default reperfusion strategy in official guidelines. This is incredibly slow compared to the fast transfer for a new drug, which is usually introduced to the guidelines within 1–2 years after a single large randomised trial has shown its benefit.

Simultaneously, evidence has been accumulating that shows the suboptimal implementation of emergent PCI for acute coronary syndromes.^10,11 On the other hand, the widespread use of PCI for chronic, stable coronary artery disease has had limited or no influence on mortality.¹² Thus, PCI was used far more in symptomatic indications (without significant impact on mortality) than in prognostic indications (where it significantly improves patient outcomes). Thus, in 2008 the European Association for Percutaneous Cardiovascular Interventions (EAPCI) together with the Working Group on Acute Cardiac Care of the European Society of Cardiology (ESC) decided to support the widespread use of acute PCI, and launched the Stent for Life (SFL) Initiative on 13 September 2008.¹³ The first ‘diagnostic‘ step was to map the current situation for reperfusion treatment of acute myocardial infarction in Europe. The survey based on data from 30 countries collected in 2007 revealed extremely large differences in the implementation of reperfusion therapies between European countries.¹⁴

The second step – to actively change the reperfusion to primary pCI – immediately followed. The situation was quickly improving in many countries. In some of these, such as the United Kingdom and Slovakia, this was possible mainly through strategic and financial support from local governments, whereas in other countries (Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey) it was facilitated by national SFL groups. Thus, now – less then 4 years after SFL initiation – primary PCI already is the dominant reperfusion therapy for STEMI in the majority of European countries.

Thus, the question now is: has the SFL Initiative already achieve its goals? Or are we just midway through with a lot of work still ahead? We have to wait for the detailed analysis of the second European SFL survey – carried out in 2011 with results available in late 2012. Irrespective of these results we strongly believe that the Stent for Life Initiative should not only continue, but probably even grow. After the ‘quantitative‘ phase (aimed at increasing primary angioplasty use for reperfusion therapy of STEMI) the SFL Initiative should focus on the ‘qualitative‘ parameters. Our aim should be to systematically record and shorten the time delays and to continue to facilitate the evolution of effective regional STEMI networks. We should open the STEMI networks for other critical situations in acute myocardial infarction (AMI), such as ST-depression myocardial infarction with ongoing ischaemia and AMI with acute heart failure, to facilitate implementation of new technologies and medications as evidence is collected to prove the benefit of these new strategies for patients with AMI. We believe that the Stent for Life Initiative is here to stay for the benefit of all European patients with AMI.