Market Report Source

Overview

Introduction

The face of ACS is changing. The ageing population and pressure of growing risk factors have made a significant impact on the management strategies in ACS. This report unveils the true picture through in-depth analysis of data on over 21,000 ACS patient records in the 5 major European pharmaceutical markets (5EU; France, Germany, Italy, Spain and the UK).

Scope

What are the current definitions, diagnostic methods and treatment approaches of the disease? To what extent are reperfusion therapies, such as PCI (percutaneous coronary intervention) and/or thrombolysis, used? What is the current role of pre-hospital thrombolysis and how is this likely to change in the future? What are the current hospital admission and logistics issues?

Highlights

Costs are no longer the restraining or dominant driver of a specific pharmacological strategy. Datamonitor’s findings show that the routine use of troponins as cardiac markers has aided this development, with almost 90% of all ACS patients receiving tests for either troponin I or troponin T across the 5EU. A new definition for myocardial infarction has shifted a significant number of patients from unclear diagnosis of unstable angina to myocardial infarction moving from an essentially conservative and observational approach to an increase in more aggressive treatment strategies. Advances in novel imaging techniques provide opportunities to diagnose and treat the most complex ACS cases, however, inter-hospital logistics, necessary specialist training and cost constraints continue to prevent hospitals and clinicians from regular use of those diagnostic methods.

Reasons to Purchase

Understand current definitions, diagnostic methods and treatment approaches in ACS Quantify current dynamics of hospital logistics, conservative therapies and reperfusion therapies, such as PCI and thrombolysis Unveil the in-depth influencing factors leading to selection of specific pharmacological and interventional strategies.

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
Definitions
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)
Variant angina
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
Heparins
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
First stage
Second stage
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