International Circulation: Thank you Dr. Suryapranata for joining us today. I’d like to ask you a few questions today about treating STEMI patients， but first address you talk today speaking about the best reperfusion strategy for the greatest number of patients， a slight different viewpoint from the more often discussed individualized treatment. Can you briefly define some of the characteristics of the “greatest number of patients” as you discussed in your presentation?
Dr. Harry Suryapranata: If you talk about reperfusion therapy I think it is necessary to go back to what it was that caused it. One of the latest breakthroughs in interventional cardiology was back in 1993 when the treatment of acute myocardial infarction (MI) patients changed away from medical therapy. If you look at the mortality rate， lets say in my country， the Netherlands， which is a small country of 60 million inhabitants， in the 1950s the mortality rate was approximately 25%. It later went down dramatically to less than 10%， particularly after the introduction of thrombolytic therapy， one of the reperfusion therapies， and subsequently primary PCI， which is what we are talking about today. It took 10 years after that was first published before these treatments were recommended in guidelines. The problem now is not how to do it. PCI， or coronary intervention， for acute MI can be done by everyone who is skillful in conducting PCI. The key point is organization. How do we bring the greatest number of those patients early enough to undergo that treatment and achieve these positive outcomes. The key point is organization.
There have been three key achievements since the breakthrough in 1993. One is the development of PCI techniques over the past decades. Second is the adjunctive drug therapy. There is currently drug therapy available to us such as an extensive anti-thrombotic arsenal to treat before and after the coronary intervention. Finally， the better organization of CATH which has resulted in an improvement in assessment to PCI centers.
International Circulation: You mentioned that you are in the Netherlands. We know that shortening door-to-balloon time to as short as possible is critical to restore perfusion of STEMI patients. In China， which is a very large country with an extensive portion of the population living in rural areas or remote， it can be difficult to get these patients to receive reperfusion therapy in time. Is there any advice that you could give to your Chinese colleagues of how they could try to solve this problem?
Harry Suryapranata: Again I would like to stress organization. It is just necessary to have a good organization. If you learn from countries in Scandanavia， which has very large， vast countries， and less people. Australia and Eastern Europe are also examples of places who have been able to organize the management of these treatments well. To have certain key PCI centers in certain areas， as well as organize the ambulance services to bring those patients to those PCI centers. Of course， this is the ideal. If you look at Europe who overall have good organization， there still remain rather significant differences between countries. It is sad to see that in some countries too many patients don’t have a form of accessible reperfusion therapy still today. The consciousness to have this organization in mind helps a lot because the implementation of the guidelines of primary PCI has resulted in an enormous increase in the use of reperfusion therapy. Thrombolytic drugs are not a bad idea to have available for those very remote places. A key issue is that it must be distinguished between high-risk infarctions and small-risk infarctions. In high-risk patients with acute MI there are fewer if any concessions， they must be sent to have primary PCI. For all other lower risk patients it is acceptable to think of other modalities. My advice would be to concentrate on those high-risk patients.
International Circulation: Are there any special factors for peri-procedure drug therapy and stent selection that we need to think when we are treating patients with STEMI?
Harry Suryapranata: In the beginning we conduct randomized clinical trials comparing BMS versus balloon angioplasty where you see somewhat of a difference but major difference in terms of mortality. Angioplasty or coronary intervention for acute MI already has brought mortality rates down very low， let’s say less than 5% in the hospital. How can we do better? I think there are numerous potential efforts. The only effort that is key in my opinion is to bring time delay down. Not to bring balloon-stent time down. If you follow the other developments of PCI materials and PCI techniques has increased incredibly. It is all feasible and all effective somewhat. Sometimes you are punished by the fact that there are more stent thromboses in this cohort of patients. Therefore， since 2008， we have used Geni-stent in all cases of STEMI because we believe that it will be safer than other stents because of the feature of antibody coatings that target endothelial progenitor cells from the patients own circulation. We know from experiments that， during acute states of infarction， the production of endothelial progenitor cells is high. There is a three-fold increase in these cells when compared to normal. So， using that concept we have been treating patients since 2008 with Geni-stents and have very good results.
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