EDITORIAL

Interventional cardiology in the Netherlands The Dutch interpretation and adaptation of the European Guidelines for

SInterventional Cardiology or more specifically for ST-elevation myocardial infarction (STEMI) is based on various elements. These are a mixture of professional considerations on quality, and political, emotional considerations. The authors have tried to comply with the European treatment guidelines, and to adjust the guidelines for interventional cardiology to our national situation.' The authors should be commended on the time and energy they have invested in finding a compromise acceptable to the Dutch cardiology community. The guidelines were approved by the national assembly in November 2004. The publication in the Netherlands HeartJournal is thus a formality, and not the appropriate moment for debating the content. The current average waiting time for elective percutaneous coronary intervention (PCI) procedures in the Netherlands is 8.2/18 months (data from the Supervisory Committee for Heart Surgery in the Netherlands (BHN), 18 July 2005). In conclusion the waiting time is less then 0.5 months, showing that there is no formal waiting list anymore. In fact there is probably overcapacity in the current PCI facilities. It is obvious that regarding the current capacity it seems unlikely that new independent centres for interventions will be approved within the next five years. The necessity will depend on the ageing of the baby boom generation and a potential increase in national PCI numbers. Clearly quality should be the most relevant parameter to determine where the patient would be treated most optimally. However, all interventional cardiologists know how difficult it is to define and measure quality. Focusing on complications would lead to conservative patient selection in order to polish the clinical outcome. The number of interventions per cardiologist could be difficult to use as in large centres there is ongoing training of fellows from both the Netherlands and abroad. However, the minimal numbers per operator/centre mentioned in these guidelines seem reasonable and logical. What is more important, however, is the position of guidelines in clinical practice. Crucial are statements on recognition as an interventional cardiologist and the quality control. Although it is nice to have quality commissions and both personal as well as institutional audits, the consequences of disagreement remain unclear. It is also important that we now have guidelines but no legislation. The change from the old situation is that one now has to motivate why the guidelines were not applied in a specific case or centre. But if the motivation is reasonable the guidelines can be easily disregarded. Therefore we have to await the consequences of these guidelines as well as the formal regulation ofcertification as mentioned in the last sentence of the article. Clearly this document provides support for decision-making, but does not pretend to have all the answers and solutions. Emotions are becoming increasingly important as well-established nonPCI cardiology centres gradually loose grip and involvement in the treatment of acute MI patients. Studies show that for the patient direct transfer to,ia PCI centre is preferable. The 'peripheral' centres would be reduced to post-MI treatment facilities, mostly controlling potential bleeding and other post-MI complications and revalidation. For a fully trained cardiologist this is hard to accept and it feels like degradation of the profession. Therefire all large centres would like to provide an around-the-dock PCI service for their region. However, the current geographical position ofall PCI centres 9C

Netherlands Heart Journal, Volume 13, Number 11, November 2005

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shows a well-spread positioning around the country, which gives every patient access to (primary) PCI nearby, within an acceptable time frame. Politics between PCI centres play a role in decision-making and planning. The number ofhospitals with a recognition as cardiology resident training centres has increased considerably in the last few years. This is partly based on increased capacity requirements, but also on consolidation of existing or new collaborations between centres and patient referral. These developments could be compromised in the near future by the fact that the Capaciteitsorgaan is convinced there is an overcapacity and even excess numbers ofresidents currently in training. It is difficult to foresee what the consequences ofthese developments will be on the national level. There is a financial drive in performing PCIs, which is of interest for institutes but also individuals. Moreover, there is a penalty for not delivering production numbers agreed upon within institutes and with insurance companies, induding the academic centres. As a consequence even in academic centres production is equally or even more important then innovation. The application ofthe Netherlands Society ofCardiology (NVVC) guidelines in dinical practice is also discussed by Van Bavel et al. in this journal.2 Here the glidelines for STEMI have been adjusted to the Eindhoven region in an attempt to determine the quality of prehospital triage of acute cardiac patients. They compared the outcome ofearlythrombolysis (intermediate size MI) with primary PCI (large MI) and conduded that results are comparable, but that after one year the outcome is more favourable in the PCI group based on mortality, reocdusion and reinfarction. The ESC guidelines have now been changed and would support primary PCI in all patients, based on less strokes following PCI.3 In their excellent paper, Van Bavel et al. condude that guidelines represent a snapshot in a dynamic process. Their study is a beautiful example of the importance of a guideline for cinical practice. It is important to be informed about the content of new guidelines, preferably in an efficient succinct manner. However, knowledge ofthe guideline never replaces common sense and reasoning. Every physician has the right or maybe even the obligation to disregard the guidelines in individual patients. The bad news is that once a deviant treatment or path is selected it should be motivated, not only verbally to the patient, but in a written justification as well, which is at least as important.

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In condusion the situation for interventional cardiology in the Netherlands is complex and fragile. What we need is a different financial structure for peripheral and academic PCI centres. In the academy the size ofproduction should not be the key issue, but should be based on the combination of quality, time and means for innovative research. This requires sufficient funding for academic research, which brings us back to politics again. The financial consequences for institutes and physicians should be neutralised. These changes would solve emotional, political and also financial issues. Quality ofpatient care would then remain the centre topic in interventional cardiology in the Netherlands. U Refens 1

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Aengevaeren WRM, Laarman GJ, Suttorp MR, ten Berg JM, van Boven AJ, de Boer MJ, et al. Dutch guidelines for interventional cardiology: institutional and operator competence and requirements for training. Neth HeartJ2005;13:416-22. Van Bavel H, Brenninkmeijer V, van Ekelen W, Hendriks D, Hersbach F, Klomp M, et al. Regional implementation of the NVVC guideline on ST-elevation myocardial infarction. Neth HeartJ2005;13:401-7. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. EurHeartJ2005;26:804-47.

P.A. Doevendans, F. de Man, P.R. Stella Heart Lung Centre Utrecht, University Medical Centre Utrecht

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Nethdiands Heart Jounal, Volume 13, Number 11, November 2005

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Interventional cardiology in the Netherlands.

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