Practice of ST-segment elevation myocardial infarction care in the Netherlands during four snapshot weeks with the National Cardiovascular Database Registry for Acute Coronary Syndrome
Practice of ST-segment elevation myocardial infarction care in the Netherlands during four snapshot weeks with the National Cardiovascular Database Registry for Acute Coronary Syndrome
N. P. G. Hoedemaker 0 1 2 3
M. E. ten Haaf 0 1 2 3
J. C. Maas 0 1 2 3
P. Damman 0 1 2 3
Y. Appelman 0 1 2 3
J. G. P. Tijssen 0 1 2 3
R. J. de Winter 0 1 2 3
A. W. J. van 't Hof 0 1 2 3
0 National Cardiovascular Data Registry , Utrecht , The Netherlands
1 Department of Cardiology, VU Medical Centre, VU University Amsterdam , Amsterdam , The Netherlands
2 Department of Cardiology, Academic Medical Centre, University of Amsterdam , Amsterdam , The Netherlands
3 Isala Klinieken Hospital , Zwolle , The Netherlands
Background Clinical registries provide information on the process of care and patient outcomes, with the potential to improve the quality of patient care. A large Dutch national acute coronary syndrome (ACS) registry is currently lacking. Recently, we initiated the National Cardiovascular Database Registry (NCDR) for ACS in the Netherlands. The purpose of this study was to assess the NCDR ACS registry on feasibility and data completeness during a pilot phase of four snapshot weeks. Methods Between 2013 and 2015, we invited all hospitals in the Netherlands to record a predefined dataset for every patient that was admitted to their hospital with ST-segment elevation myocardial infarction (STEMI). Data were entered in an online case report form. All patient-specific data were encrypted to ensure privacy. Results A total of 392 patients were registered in 35 centres. The mean age of the patients was 64 years (SD 13); 8% of patients presented with signs of cardiogenic shock and 11% with an out-of-hospital cardiac arrest. The median time from first medical contact to percutaneous coronary intervention (PCI) was 75 min (IQR 51-108) and this was significantly longer for patients who presented at a non-PCI centre or to a primary care physician. In-hospital and 30day mortality rates were 5.2% and 7.8%, respectively. The amount of completeness varied, with improved completeness over time. Conclusion This report shows that a Dutch ACS registry is feasible with respect to STEMI patients. Data completeness, however, was suboptimal. Improved data completeness is warranted for the future.
ST-elevation myocardial infarction; Registry; Acute coronary syndrome
Within the spectrum of coronary artery disease, acute
coronary syndrome (ACS) is a major cause of death,
hospitalisation, and high rates of acute complications. In the past
decades, there have been improvements in the management
of ACS patients. This resulted in a decrease in mortality
and morbidity of ACS patients, as shown by registry data
[1, 2]. In addition to monitoring outcomes and quality of
care, registries provide the opportunity for hospitals to
evaluate the implementation of clinical guidelines. Furthermore,
benchmarking of hospital performance has the potential to
ultimately improve the quality of care for ACS patients.
Finally, national registries provide information on ACS
patients who are underrepresented in randomised controlled
trials (RCT), for example the elderly and shock patients.
Successful national registration of ACS patients is
performed in Sweden, the United States and the United
Kingdom and more recently in France, Germany, Poland, and
Switzerland [3–9]. In the Netherlands, the National
Cardiovascular Data Registry (NCDR) aims to collect national
data on cardiovascular interventions and device
implantations (http://www.ncdr.nl). In addition to the existing
registries, the NCDR ACS registry was recently initiated.
Hospitals that provide relevant services participate in the
collection of data on ST-segment elevation myocardial infarction
(STEMI) patients. We report the results of the first four
snapshot test weeks of this registry, aiming to assess the
feasibility and data completeness of a Dutch ACS registry.
Source data and study population
We used data that derived from the NCDR ACS registry.
This registry has enrolled consecutive ACS patients
admitted to hospitals in the Netherlands since September 2013.
Information is collected prospectively, and the variables in
the registry comply with the International Cardiology Audit
and Registration Data Standards (CARDS). A description
in Dutch is available at http://www.ncdr.nl/registraties/acs.
The current analysis consists of all patients presenting with
a registered admission diagnosis of STEMI during the four
snapshot test weeks held in September 2013, March and
September 2014, and May 2015. Hospitals that participated
in the data collection are listed in the Appendix. The NCDR
ACS working group approved the registry and the current
analysis. According to Dutch law, no written informed
consent was required.
Organisation and funding
NCDR is an independent organisation that was founded by
the Netherlands Society of Cardiology. The NCDR provides
multiple clinical registries, including the ACS registry. This
registry is managed by a steering group which includes
members of the ACS working committee of the
Netherlands Society of Cardiology. The steering group takes care
of project management, monitoring, quality and statistical
reports. The NCDR ACS registry is self-funded by the
participating hospitals and independent from commercial
funding. The participating hospitals retain ownership of the
patient data they provide.
Data are stored on an externally located server and
managed by NCDR and Reports BV (Almere, the Netherlands).
NCDR is NEN 7510:2011 (a Dutch institute supporting
standardisation for data protection) certified for
information security in Dutch healthcare. A trusted third party
(Zorg TTP, Houten, the Netherlands) encrypts all
confidential patient information before it is stored. Independent
researchers do not have access to the decryption key. The
NCDR ACS dataset includes patient demographics and risk
factors, time to treatment, details of reperfusion treatment,
and outcomes up to 30 days. The NCDR ACS registry has
automatic error-checking routines, including range and
consistency checks. For this paper, data were exported from the
database on 24 August 2015.
First medical contact (FMC) was defined as the first patient
contact with a medical care giver. FMC was subdivided
into 1) ambulance (emergency service call), 2) emergency
room at a centre performing percutaneous coronary
interventions (PCI), 3) emergency room at a non-PCI centre
and 4) primary care physician. FMC time was defined as
the time of the first diagnostic ECG. PCI time was defined
as the time of arrival at the PCI centre. Total ischaemic time
was defined as the time from symptom onset until arrival
at the PCI centre. Cardiogenic shock was defined as signs
of shock (systolic blood pressure <90 mm Hg, tachycardia,
decreased peripheral circulation, cold extremities, and
Killip class 3 or 4) during admission at the PCI centre.
Outof-hospital-cardiac arrest (OHCA) was defined as cardiac
resuscitation initiated before admission to the hospital.
Continuous variables are presented as the mean with
standard deviation or median with interquartile range depending
on their distribution. Categorical variables are presented as
the number with percentage. Comparison of time between
different first FMC categories and time of PCI was
performed with the Kruskal-Wallis test and Dunn’s multiple
comparison test. P-values <0.05 were considered
Baseline characteristics, time delay, and treatment
The baseline characteristics and treatment strategies are
presented in Table 1. In September 2013, March and September
2014, and May 2015, a total of 329 patients with a STEMI
were included in 35 centres. The mean age was 64 years
(SD 13) and approximately one-third of the patients were
women. At the time of admission, half of the patients were
smokers. Of the patients, 8% presented with signs of
cardiogenic shock and 11% with an OHCA.
The median FMC-to-PCI time was 75 min (IQR 51–108).
A total of 66.2% of the patients first presented in an
ambuTable 1 Baseline characteristics of the patients and treatments
Week 1 Week 2
N = 120
N = 123
N = 78
N = 71
n = 392
Na number of missing values filled in on the case report form, N number of completed case report forms available, STEMI ST-segment elevation
myocardial infarction, SD standard deviation, OHCA out-of-hospital cardiac arrest, ER emergency room, PCI percutaneous coronary intervention,
IQR interquartile range, FMC first medical contact, CAG coronary angiography
Time is in minutes
Table 2 Time of first medical contact to percutaneous coronary intervention
First medical contact N Percentage
Time to PCI (min)
ER emergency room, PCI percutaneous coronary intervention, NS not significant, * compared with ambulance
Time displayed as mean with interquartile range
lance and these patients had the lowest FMC-to-PCI time
(69 min, IQR 50–92). Patients presenting in an ambulance
also had a significantly lower FMC-to-PCI time compared
with those who presented at a non-PCI centre or a primary
care physician, as is displayed in Table 2.
Catheterisation was performed via the radial artery in
60.4% of the patients and thrombus aspiration was used in
39.8%. There was an increase in the use of radial access
and a decrease in the use thrombus aspiration in 2015,
compared with 2013. Primary PCI was performed in 95.0% of
patients, of which 98.8% was successful.
The rate of in-hospital complications was 13.5%, as is
displayed in Table 3. The rates of in-hospital and 30-day
mortality were 5.2% and 7.8% respectively. The use of dual
antiplatelet therapy, beta-blockers and statins was slightly
under 90% and anticoagulants were prescribed in 18.5%.
Of the patients, 87.7% were offered a place in a cardiac
rehabilitation program of whom 80.9% are known to have
Table 3 Outcomes, medication at discharge and cardiac rehabilitation
N = 120
N = 123
N = 78
N = 71
Na number of missing values filled in on the case report form, N number of completed case report forms available
STEMI ST-segment elevation myocardial infarction
N = 392
Information on missing data can be found in Table 1 and 3.
The data completeness of patient characteristics and
information on FMC and intervention improved over the course
of the four weeks. Data completeness for these categories
generally increased by 50% or more. The percentage of
missing data on time delay indicators decreased slightly.
The amount of missing data on in-hospital outcome was
lower in 2015 compared with 2013, whereas missing data
on 30-day mortality increased. In addition, an increase in
missing data was also found for information on discharge
medication and cardiac rehabilitation.
The current report describes the first results of the Dutch
NCDR ACS registry with respect to STEMI patients. The
first data were collected during four snapshot test weeks
between 2013 and 2015 and show that a national registry
for STEMI patients is feasible. However, with suboptimal
data completeness, improvement is of upmost importance.
Outcomes of an unselected population
This registry showed in-hospital and 30-day mortality rates
of 5.2% and 7.8%, respectively. To put this into context,
30-day mortality rates of STEMI patients enrolled in
various major RCTs conducted from 2009 to 2013 ranged from
2.0–3.3% [10–13]. For this registry no patients were
excluded and we aimed to collect data that reflect real-world
practice. Almost 10% of patients presented after an OHCA
and 8% presented in cardiogenic shock. In addition, 5% of
patients did not receive reperfusion therapy, mainly because
of late presentation or frailty. This may explain the higher
mortality rate. A higher in-hospital mortality rate was also
found in Denmark (10.9%, 95% CI 7.0–14.7) and in a
snapshot of Western European countries (6.3%) [14, 15]. In
addition, the Swedish and the British registries show 30-day
mortality rates of 8.6% (95% CI 8.3–8.8) and 11.2% (95%
CI 11.1–11.4) respectively . The results from our registry
showed lower mortality rates; however, these derived from
a small sample size and thus, comparison with results from
other registries should be done with care.
Trends in practice
Registries can help to identify trends in practice of care over
the years. Our results show an increase in the use of radial
access and a decrease in the use of thrombus aspiration in
2015, compared with the first snapshot test week in 2013.
These results may reflect the impact of the latest trials that
were conducted in these areas and follow recommendations
of guidelines [16–20].
Clinical registries are necessary in order to monitor
outcomes and ultimately help improve the quality of care.
Examples of successful national registries include the
Myocardial Ischaemia National Audit Project (MINAP) from the
United Kingdom, the American NCDR CathPCI registry,
and the Swedish Web-system for Enhancement and
Development of Evidence-based care in Heart disease
Evaluated According to Recommended Therapies
(SWEDEHEART) [7–9]. The SWEDEHEART registry has
demonstrated the positive impact of evidence-based treatments on
outcomes. In a report that included STEMI patients
between 1996–2007, an increase in the use of evidence-based
treatments was associated with a sustained decrease in
30day and 1-year mortality during the same period of time
. In addition, registries have expanded their roles and
are also used for multi-centre observational research and
more recently, registry-based RCTs . Furthermore,
international collaborations can be initiated, potentially
giving insight into differences in patient characteristics and
treatments among countries [23, 24].
At a national level, the NCDR ACS registry can be used
as an instrument for quality improvements in hospitals. A
retrospective study showed that Dutch hospitals use
dissimilar definitions to determine performance indicators for
STEMI patients . The use of predefined key
performance and quality indicators, which correspond with those
required by the Dutch Health Inspectorate and the Dutch
Safety Management System, can solve this problem and
offers a universal method to compare hospitals at a national
level. This can potentially create opportunities to reduce
complications, and reveal targets for improvement.
This report shows the first test on feasibility and data
completeness of a national Dutch ACS registry. A total of
35 centres have participated at least once, and have thereby
been introduced to be part of the NCDR ACS registry and
the process of providing data to NCDR. In order to catch
up with registries from surrounding countries, we need to
further develop the Dutch registration.
Firstly, our main goal is to involve all Dutch hospitals
in the registry and start continuous inclusion of all ACS
patients. However, a common problem for hospitals is the
workload of the registration, which is needed to
guarantee the quality and completeness of the data. Currently, not
every Dutch hospital has a registration nurse, which may
cause hospitals to provide an incomplete dataset or to
withdraw from the national registry. Therefore, we encourage
all Dutch hospitals to recruit a dedicated registration nurse.
Possibly, this could be supported by Dutch government
institutions or health insurance companies, since a successful
registry can contribute to improving the quality of care.
In addition, we want to develop ways to link the national
registry to insurance, pharmacy, and hospital databases, in
order to collect follow-up data beyond 30 days after
Secondly, we aim to expand the ACS registry to include
patients with non-ST-elevation-ACS (NSTE-ACS).
Registration of NSTE-ACS can be challenging because of the
heterogeneity of the population; however, it will provide
further insight into the use of antiplatelet and antithrombotic
therapy or differences between PCI and non-PCI centres
regarding timing of intervention in NSTE-ACS [26–28].
For the future, we want to integrate and link different
electronic patient records (EPRs) in order to allow direct
data capture from the patient records, which will minimise
the extra work associated with data entry. The first
experiences with direct registration from existing EPRs are
encouraging. As mentioned previously, the NCDR ACS
registry will serve as a platform for national quality
improvement efforts. Beyond this primary goal, international
collaborations and research will be important other goals.
Several limitations must be taken into account. Our results
are based on registry data and may be subject to some
selection bias. We invited all hospitals in the Netherlands
to report consecutive STEMI cases; however, participation
in the registry was voluntary. Overall, 18 of 55 non-PCI
(32%) and 17 of the 30 PCI (57%) centres participated and
therefore our results may not fully reflect the whole STEMI
population in the Netherlands. Despite this limited
participation and patient numbers, our results seem to provide
an adequate representation of an unselected Dutch STEMI
The NCDR ACS registry is a national program that aims
to enrol consecutive ACS patients presenting to hospitals
in the Netherlands. The results from four snapshot test
weeks show that a Dutch national ACS registry is
feasible. Data completeness, however, was suboptimal.
Improved data completeness, is warranted for the future.
Acknowledgements We thank all the participating hospitals and
patients contributing to the NCDR ACS registry. Special
acknowledgement to Esther Zwaan and Ineke Stam.
Conflict of interest N.P.G. Hoedemaker, M.E. ten Haaf, J.C. Maas,
P. Damman, Y. Appelman, J.G.P. Tijssen, R.J. de Winter and A.W.J. van
’t Hof declare, that they have no competing interests.
Open Access This article is distributed under the terms of the
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creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
NVVC ACS working group
NCDR ACS steering committee
A.W.J. van ’t Hof (chair), J.M. ten Berg, P. Damman,
J.G.P.Tijssen, V.A.W.M. Umans, T.W. Galema
NCDR PCI steering committee
W.R.M. Aengevaeren, Y. Appelman, A.W.J. van ’t Hof,
M. Meuwissen, A.A.C.M. Heestermans, J.G.P. Tijssen,
VA.W.M. Umans, T.W. Galema
List of participating centres
Academic Medical Center – University of Amsterdam,
Albert Schweitzer Hospital, Alrijne Hospital Leiderdorp,
Amphia Hospital, Antonius Hospital, Bethesda Hospital,
BovenIJ Hospital, Bronovo Hospital, Catharina Hospital,
Deventer Hospital, Sint Franciscus Gasthuis Hospital, Gelre
Hospital Apeldoorn, Gemini Hospital, Groene Hart
Hospital, Haga Hospital Leyweg, Isala Hospital, Jeroen Bosch
Hospital , Leiden University Medical Center, Maasstad
Hospital, Medical Center Alkmaar, Rijnstate Hospital,
Rode Kruis Hospital, St. Antonius Hospital, TweeSteden
Hospital, University Medical Center Groningen, Münster
University Hospital, University Medical Center St
Radboud, VU Medical Center Westfries Gasthuis Hospital,
Hospital Rivierenland, Hospital St Jansdal,
Ziekenhuisgroep Twente Hospital (Hengelo), Zorggroep
Noorderbreedte Hospital, ZorgSaam Zeeuws-Vlaanderen Hospital,
Zuyderland Medical Center Heerlen
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