This chapter examines the quality and accessibility of cardiovascular disease (CVD) care, spanning prevention, primary care, emergency response, hospital treatment, and post-acute rehabilitation. While health promotion and self-management support can reduce risks and improve outcomes, confidence in self-management varies widely among EU countries. Primary care plays a pivotal role in prevention and secondary management, yet lifestyle counselling and care planning remain inadequate. Emergency responsiveness varies widely, with delays in ambulance services and gender disparities in help-seeking behaviour. Hospitalisation for CVD remains common, though avoidable admissions are declining. Hospital care shows marked inter-country differences in procedure rates, technology availability, and specialised unit distribution. Finally, post-discharge adherence to medications and participation in rehabilitation programmes are low, impacting long-term outcomes.
The State of Cardiovascular Health in the European Union
Abstract
People living with cardiovascular diseases (CVD) interact with a wide range of settings and levels of the healthcare system, including primary care, emergency responders, hospitals, and rehabilitative care after acute events such as heart attacks or stroke.
Primary care has a critical role in reducing risk factors for CVD and managing CVD. Health promotion initiatives can lower CVD risk in the general population and support those already affected, yet significant opportunities remain to better engage people living with CVD by providing tailored advice that helps them address modifiable risk factors and manage their condition effectively. The extensive uptake of effective and people‑centred primary care approaches across countries is essential. Self-management support, in particular, is key to increase the confidence of patients to manage their own health to control clinical and behavioural risk factors and to be able to manage their conditions. Confidence in self-management among people aged 45 and older with CVD varies more than three‑fold across countries – from 23% in Italy, to 73% in the Netherlands, and up to 84% in France. CVD patients who are confident in managing their own health report higher levels of well-being and are more likely to assess their general health as good or very good, compared to those who lack such confidence.
Eighty per cent of primary care users living with CVD take three or more medications on a regular or ongoing basis – 30% more than primary care users without CVD. Despite demographic changes and evolving CVD risk profiles across Europe, the use of common anti-hypertensive medications has remained stable. In contrast, the use of lipid modifying agents has risen sharply – two‑fold in European countries between 2010 and 2023. However, significant variation in medication use persists across OECD countries, and underuse of well-established first-line therapies – particularly antihypertensives and statins – represents a missed opportunity to improve population health in a cost-effective way. This underuse reflects a mix of access barriers, including poor adherence, clinical inertia, and system-level implementation gaps, inhibiting the delivery of effective CVD care in primary care settings.
Timely access to acute CVD care starts with help-seeking behaviours of the patient and those around them who must recognise the symptoms of potential acute CVD and then be confident to call for help from emergency medical service (EMS). Data from countries suggest that on average only three of four stroke patients (76%) arrive to a dedicated stroke centre by EMS; the other quarter of stroke patients continue to arrive by their own means. Evidence from multiple countries shows that women wait longer than men to call for emergency services following the onset of stroke symptoms and timeliness in accessing high-quality CVD care also varies by people’s socio‑economic background. The pandemic however has significantly impacted ambulance response times in several countries, and average response times have not yet returned to pre‑pandemic levels.
European countries have been making advances in expanding access to time‑sensitive treatments for stroke, reflecting improvements in system capacity and co‑ordination. Time to diagnosis and assessment is modifiable by improvements at every stage in the process from the call for help through to the decision to treat and vary widely between countries. Data from 22 EU countries showed that less than 60% of reporting countries provided intravenous thrombolysis (IVT) to more than 15% of their admitted ischaemic stroke patients in 2023.
Equitable provision of sophisticated, high-quality, acute care across an entire population, following the onset of disease that manifests without warning requires a high degree of integration between the general community, emergency responders, emergency departments (EDs) and the inpatient teams within hospitals. CVD accounts for up to 6% of hospital ED visits. Approximately two‑in-five primary care users over age 45 living with CVD has used the emergency room in the last year – and they are twice as likely to have gone to an ED as those without CVD. Modern healthcare delivery systems generate large quantities of data that may be used to measure the quality of care against evidence based and widely accepted guidelines and targets.
Avoidable hospital admissions due to congestive heart failure and diabetes are trending down across countries – as are hospital discharges for circulatory diseases – but variation in rates between countries indicate these can be reduced through better access to high quality primary care. Despite downward trends, hospitalisation remains a common occurrence for people living with CVD, reflecting difficulties in managing CVD-related conditions. Among people aged 45 and over attending primary care, one‑in-four people with cardiovascular conditions has been hospitalised in the last year, and those with cardiovascular conditions are twice as likely to be hospitalised than those without. Reducing levels of avoidable hospital admissions to the lowest level within the OECD would reduce hospital spending in the EU by EUR 45 billion. Focussing on reducing inequalities in access to effective primary care, countries can further improve health outcomes of overall population and in turn increase cost-saving.
The effectiveness of hospital care varies – and the likelihood of surviving an admission for an acute CVD event varies by geography. The 30‑day AMI mortality rate in 2023 ranged almost five‑fold between the best and worst performing EU country, and 30‑day mortality following ischaemic stroke varied four‑fold. In recent years, Europe has seen increases in the use of intravenous thrombolysis (IVT) as a frontline treatment for acute ischaemic stroke. Rate of IVT varies by a magnitude of 20 between European Countries – from over 75 per 100 000 population in Latvia and Estonia to below 10 in Ireland and Greece. Furthermore, some countries with high mortality rates due to cerebrovascular disease have notably low rates of use of IVT, including Bulgaria and Romania.
Hospital care of CVD is highly dependent on technology including imaging and invasive procedures. For example, countries with fewer hospitals implanting implantable cardioverter defibrillators (ICDs) tend to have lower implantation rates. There remain persistent delays in elective, but time sensitive, cardiovascular services. Data from seven OECD countries shows that a significant share of patients face delays exceeding three months for procedures such as coronary angioplasty and coronary artery bypass grafting (CABG) for chronic coronary disease, highlighting potential challenges insuring access and equality of service provision.
The use of implantable devices – such as pacemakers, cardiac resynchronisation therapy (CRT) for heart failure and ICDs – have generally plateaued, but the inter-country variation remains great. The exception is the use of transcatheter aortic valve implantations (TAVI), which has increased in all EU countries and seen expanding populations. Many countries have clinical standards in place for device implantation and follow-up, and many have registries for post-market surveillance and safety monitoring – including tracking device use, complications and reoperation rates. Fewer countries have adopted systems for quality audits, such as professional peer review, compliance checks or have implemented systematic measurement of patient-reported outcomes or experiences related to cardiac implant procedures.
Post acute care is an opportunity to reduce medium to long term mortality and morbidity, but effectively providing such care remains a challenge for many countries. Goals include optimising secondary prevention (medication, risk factor change), rehabilitation after the acute event, and reintegrating with primary care or with ongoing monitoring and self-management programmes. Participation rates in cardiac rehabilitation after hospital discharge remain relatively low across countries. Rates of rehabilitation participation after stroke are generally higher than for cardiac rehabilitation – though overall data coverage and comparability of information related to access to rehabilitation is limited. Data from 14 EU countries shows that, on average, 60% of stroke patients survived without readmission within a year, while 24% were readmitted (5% for stroke‑related causes), and 16% died. For CHF patients, 43% survived without readmission, 33% were readmitted (11% for CHF-related causes), and 24% died within the year.
Discharge from hospital following an acute cardiovascular event requires prescriptions for a combination of medications aimed at preventing another event and managing underlying conditions. Data on prescribing practices shows that care generally conforms to standards. Almost all (97%) of stroke patients receive anticoagulating drugs at discharge in countries that report data, while fewer receive statins (92%) and antihypertensive drugs (82%) Additionally, across countries, most patients were discharged on dual anti-platelet therapy and statins following AMI. However, these prescribing practices need to be sustained – and in most cases there is a steep drop between discharge and prescribing practices more than a year after the event.
The pace and direction of pharmaceutical innovation in CVD is increasingly misaligned with the most pressing public health needs, and investment in cardiovascular R&D has lagged behind other therapeutic areas and focussed on some high-risk population groups where gain is small. While several new therapies have been developed, they demonstrate only modest added clinical value over established treatments for small high-risk population subgroups, raising concerns about alignment between R&D priorities and the most pressing population unmet medical needs. More than half of surveyed countries report placing specific access restrictions to novel CVD medicines such as PCSK9 inhibitors and SGLT2 inhibitors. In addition to be being used to control diabetes treatment, Glucagon-Like Peptide‑1 Receptor Agonists (GLP‑1 RAs), are now authorised to treat obesity in 13 of 17 surveyed OECD countries and have been shown to reduce the occurrence of serious cardiac events in clinical trials. As their indications expand, so too does the potential budgetary impact, raising important questions about cost-effectiveness and long-term system budgetary sustainability.
While significant improvements in cardiovascular health can be addressed through modification of risk factors (Chapter 3), high-quality healthcare (i.e. healthcare that is effective, safe, and person-centred) remains an essential component for mitigating the burden of CVD and related disability. Effective primary care based on clinical practice guidelines for CVD prevention, early detection and cost-effective treatment can reduce the burden of CVDs and the cost associated with treating CVDs significantly. However, most CVD related deaths are caused by acute events, such as heart attack and stroke, and as many as 20‑40% of heart attacks occur in people previously undiagnosed with CVD (McClellan et al., 2019[1]), suggesting opportunities to improve quality of primary care. Moreover, once people enter the care system, there are failures in the provision of proven first line treatments and variation in access to advanced treatments (McClellan et al., 2019[1]). These contribute to high spending by health systems on cardiovascular care and suboptimal health outcomes. Prioritizing high-quality cardiovascular healthcare – through preventive measures, early detection, effective treatment and rehabilitation throughout the care pathway (see Figure 4.1) – can significantly reduce the burden of these conditions.
This chapter discusses trends in the quality of care for CVD across the continuum of prevention, primary care, emergency response, hospital care, and post-acute and rehabilitative care – as well as themes such as timeliness, waiting times, healthcare workforce, and access and use of medicines and medical technologies.
Note: Simplified example.
4.1.1. Engaging patients in secondary prevention in the primary care setting is critical
As the onset of CVD can be prevented or greatly delayed, care of CVD begins with prevention and primary care has a critical role in lowering CVD risk in the population at large. While genetics and age are major, non-modifiable risk factors for CVD, many CVD risk factors are modifiable (see Chapter 3 for additional discussion of primary prevention of CVD and distribution of risk factors). Smoking, a sedentary lifestyle, unmanaged hypercholesterolemia, obesity and diabetes are all amenable to intervention in the primary and secondary prevention of CVD. Moreover, hypertension is often the first manifestation of CVD and if it is detected and effectively managed, the risk of development of other manifestations (ischemic heart disease (IHD), cerebrovascular disease and cardiomyopathy) can all be reduced. Prevention and management of CVD is a major activity of primary care systems, reducing risks of CVD occurrence among people without CVD (i.e. primary prevention), and helping patients with CVD to effectively manage their conditions and address risk factors to improve long-term health outcomes. As primary care providers are often the first point of contact for patients, they play an important role in supporting individuals in making lifestyle changes and adhering to treatment plans.
Primary care providers can introduce measures to prevent progression of disease once a first diagnosis is made (i.e. secondary prevention), including screening for metabolic risk factors, the promotion of healthier lifestyles and behaviours, and commencement of medications that can improve outcomes and reduce the occurrence of an acute event like stroke or heart attack. Findings from the OECD Patient-Reported Indicator Surveys (PaRIS) conducted in 19 countries (including 11 EU member states, as well as Norway, Iceland, Switzerland and Wales) show that among primary care users aged 45 and older, on average only 55% of people with CVD or hypertension reported that their primary care doctor gave them advice on physical activity. This result is 10 percentage points (p.p.) higher than primary care users without CVD or hypertension – but still represents a major gap in counselling for most at risk patients. A similar deficit is found regarding dietary advice where less than two‑in-five (39%) people living with hypertension or CVD reported receiving advice on healthy eating. As with physical activity, rates in dietary counselling are higher for people with CVD and hypertension than those without – but still offer significant potential for better targeting advice and interventions to those who would most benefit (see Figures in Annex 4.A for more detail).
4.1.2. Care co‑ordination and self-management support for people with CVD is key in primary care
While healthcare policy, research, professional training and clinical guidelines have traditionally focussed on single diseases, multimorbidity – people living with two or more chronic conditions – is a major challenge in healthcare, particularly in primary care. Multimorbidity affects the majority of people living with CVD, and imposes numerous management challenges for patients and their care providers, especially to co‑ordinate care and self-management support (Violán et al., 2016[2]). A majority of primary care patients experience sub-optimal care co‑ordination – though, encouragingly, the percentage of patients with care plans is higher in the case of certain co-morbidities.1 PaRIS data shows that only two out of five (44%) of people aged 45 and older with CVD or hypertension report having a care plan, a tool which enhances co‑ordination and can lead to improved outcomes (OECD, 2025[3]). For people living with diabetes, in addition to CVD or hypertension, over half of people (55%) report having a care plan (Annex 4.A).
Individuals with CVD must actively and routinely manage their condition to prevent complications and improve outcomes. Self-management is an important contributor to admission reduction and improvement in patient quality of life (Jaarsma et al., 2021[4]). Effective self-management involves a holistic approach that includes behaviour modification (e.g. exercise, adherence to medication regimens, managing fluid and salt intake), self-monitoring (symptoms, thirst, blood pressure, weight, mood), and practical responses to early signs of deterioration (medication adjustment, clinical review). The proportion of primary care users with CVD reporting confidence to self-manage is similar to that of those without these conditions, 55% and 61%, respectively, see Figure 4.2. Confidence in self-management among people aged 45 and older with CVD varies more than three‑fold across countries – from 23% in Italy, to 73% in the Netherlands, and up to 84% in France. These findings suggest that many people with CVD may be inadequately prepared to handle the demands of their complex health needs.
Percentage of patients that are confident or very confident (compared to somewhat confident or not confident at all) to manage their own health
Note: 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. CVD status is self-reported using the question: “Have you ever been told by a doctor that you have any of the following health conditions?” and answer: “Cardiovascular or heart condition”. Confidence to self-manage; Response to question: “How confident are you that you can manage your own health and well-being?”, response options range from not confident at all (0) to very confident (3). Percentage of patients that are confident or very confident (compared to somewhat confident or not confident at all). Error bars correspond to comparative intervals (84%CI).
Source: OECD PaRIS 2024 Database.
Effective self-management support – particularly when it resonates with and empowers patients – can enhance quality of life and health outcomes. According to OECD PaRIS survey, CVD patients who are confident in managing their own health report higher levels of well-being and are more likely to assess their general health as good or very good, compared to those who lack such confidence. For instance, Figure 4.3 shows that the average WHO (World Health Organization) well-being score among CVD patients that have confidence to self-manage was 62 similar to non-CVD patients (63), but for CVD patients lacking confidence to self-manage it dropped to 48. Similarly, the share of individuals reporting good or better general health was 69% among non-CVD patients, 58% among confident CVD patients, and only 34% among CVD patients lacking confidence to self-manage. These findings suggest that confidence to self-manage may mitigate the adverse effects of CVD on quality of life.
WHO5 Well-being index
Note: 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. CVD status is self-reported using the question: “Have you ever been told by a doctor that you have any of the following health conditions?” and answer: “Cardiovascular or heart condition”. WHO‑5 well-being index; Response to five questions measuring well-being. raw scale 0‑25 converted to 0‑100 scale, higher scores represent higher well-being. General health; response to question: “In general, would you say your health is …” where response options range from poor (1) to excellent (5). Percentage of patients that responded good, very good or excellent (as compared to fair or poor). Error bars correspond to comparative intervals (84%CI).
Source: OECD PaRIS 2024 Database.
Description: MDC is a primary care model for patients with chronic conditions. Patients who access MDC obtain an Individual Medical Care Plan based on a comprehensive assessment by a General Practitioner. Results from the comprehensive assessment are used to stratify patients into risk groups, which helps health professionals proactively manage patient needs. Following the comprehensive assessment, patients receive care by a multidisciplinary care team, which is co‑ordinated through a case manager. MDC resembles a new model of primary care growing increasingly popular amongst OECD countries.
Best practice assessment:
Enhancement options: To enhance the effectiveness of MDC, continued efforts by policymakers are required to promote the use of digital tools across the healthcare sector, including primary care. Digital tools such as electronic health records (EHRs) play an important role in providing co‑ordinated care, which is one of MDC’s key objectives. Sophisticated digital methods to collect patient data can subsequently be used to stratify patients into risk groups, as seen in countries such as Canada and Spain. To enhance the evidence‑base, more robust evaluation methods are necessary, for example, by including data for a control group as well as controlling for confounding factors.
Transferability: New models of primary care, such as MDC, operate in 17 OECD countries, including EU Member States such as Austria, Greece, Ireland, Italy, the Slovak Republic and Slovenia. This indicates that MDC, and the type of care it provides, is highly transferable.
Conclusion: MDC provides patients with patient-centred care delivered by a multidisciplinary care team. This model of care is considered “best practice” and is therefore increasingly popular amongst OECD countries. At present, the real impact of MDC on patient health outcomes and utilisation is unknown given data availability constraints. However, a study looking at similar primary care models in Poland concluded patients reported better experiences and outcomes. To enhance the impact of MDC, policymakers can benefit from policy options outlined in this case study.
Source: OECD (2023[5]), Integrating Care to Prevent and Manage Chronic Diseases: Best Practices in Public Health, https://doi.org/10.1787/9acc1b1d-en.
4.1.3. Hospital avoidable admission can be reduced through better access to high-quality primary care
Congestive heart failure (CHF) and diabetes are common, chronic health conditions with potential for severe complications and rapid deterioration. However, these conditions can also be effectively controlled in primary care using evidence‑based management practices. A well-performing primary care system can reduce acute deterioration of people living with chronic conditions related to CVD such as CHF or diabetes, thereby preventing unwanted and costly avoidable hospital admissions (OECD, 2020[6]).
However, the effectiveness of primary care varies greatly, and hospital admissions for CHF and diabetes that are largely avoidable through well-performing primary care continue to be high in some countries. Hospital admission rates for CHF varied over four‑fold across EU countries in 2023, averaging 232 per 100 000 population (Figure 4.4). Portugal and Croatia had the lowest rates, while Poland and Lithuania reported rates over twice the EU average. The average CHF admission rate across EU countries fell by 25% between 2013 and 2023 – and over 30% in Austria, Belgium, Estonia, Iceland, Italy and Portugal. Admissions for CHF increased in several countries over this period, including Iceland, Norway and the Slovak Republic. In Germany, high rates of admission may relate to high access to hospital care given its high number of hospital beds, suboptimal functioning of primary care and insufficient care integration due to separation of ambulatory and hospital care. Recognising these challenges, the Government Commission responsible for hospital reform, has proposed a reorganisation of care structures to avoid misdirection of patients who could be treated effectively in primary care to acute care in hospitals and emergency rooms (OECD/European Observatory on Health Systems and Policies, 2023[7]; Regierungskommission, 2022[8]). In the Slovak Republic, high rates of avoidable admissions have led to reforms in primary care, focussing on strengthening the competencies of General Practitioners (GPs) and improving accessibility and availability of GPs based on the General Outpatient Care Strategy to 2030 (OECD/European Observatory on Health Systems and Policies, 2023[9]). Steep reductions in hospital admissions between 2019 and 2021 have been largely attributed to disruptions in hospital services and hesitancy among patients to seek hospital care during the COVID‑19 pandemic and not due to improved quality of primary care, hence pointing to the need to improve its accessibility and resilience. Additional information on avoidable admissions for diabetes can be found in Annex 4.A.
Note: The EU average is unweighted. 1. Latest data from 2021-2022.
Source: OECD Health Statistics 2025.
Reducing avoidable admissions through improvements in primary care and effective delivery can result in significant potential health system savings and improve patient outcomes. According to OECD estimates, EU countries as a whole would have reduced hospital spending by EUR 45 billion, if all countries could reduce hospital admissions for CVD to the lowest level in the OECD (944 per 100 000 population in Canada). The cost-saving was estimated at up to 5.9% of health spending in Poland, 5.2% in Hungary and 4.9% in Lithuania, followed by 4.0% in Latvia and Romania and between 3.6 and 3.8% in Austria, Bulgaria, Germany and the Slovak Republic (see Annex 4.B). Beside cross-country differences, multiple studies also point to disproportionately high avoidable admissions among disadvantaged populations with CVD within countries (Löfqvist et al., 2013[10]; Pongiglione, Torbica and Gusmano, 2020[11]; Sowden et al., 2020[12]), so focussing on reducing inequalities in access to effective primary care, countries can further improve health outcomes of overall population and, in turn, increase cost-saving.
4.1.4. Access to urgent primary care has improved in some countries
For patients with chronic conditions including diabetes requiring urgent care, many OECD countries have developed a wide range of primary care services in the community including 24/7 services for patients in need of urgent care but with low emergency level. In Norway, for example, GPs provide emergency primary care services during and outside of office hours (OOH) and are supported by on-call services provided by specialists. In smaller municipalities, on-call services are also organised in emergency wards in community hospitals, and in very sparsely populated areas, municipal home nursing facilities provide pre‑hospital emergency care, sometimes with the support of telemedicine (OECD/The Health Foundation, 2025[13]). Other countries, such as Belgium, France, Germany and the United Kingdom, have a designated telephone number for medical non-emergency care, which people can call the weekends or if the GP is unavailable (OECD/The Health Foundation, 2025[13]). In Estonia, in addition to family health centres and health centres, Family Doctor’s Helpline (1220) is available for after hour services and 32% of residents used it in 2021 (Kasekamp et al., 2023[14]).
In a number of OECD countries, primary care doctors are required to provide emergency care for people with less acute condition. In Belgium, GPs and specialists are required to maintain a 24‑hour service for ambulatory emergency (Platz, Bey and Walter, 2003[15]) while in Denmark, GPs are required to participate in out-of-hours care, and GP co‑operatives run an advice line (with options for home visit, referral to usual doctor or referral to hospital) in four regions and a municipal 1813 line in Copenhagen is open 24/7 (Kalda et al., 2023[16]). In the Netherlands, all GPs must maintain an emergency phone line that patients may use to contact the GP who will call an ambulance if necessary (Kroneman et al., 2016[17]). In Germany, urgent and out of office hours care is the primary responsibility of the Regional Association of Statutory Health Insurance (SHI) physicians including GPs which provide both office‑based care and home visits (Miriam Blümel et al., 2020[18]). However, the availability of emergency care in the primary care setting is low in some countries. In Spain, primary healthcare centres (PCCs) are encouraged to provide emergency care, but opening hours are not standardised (Bernal et al., 2024[19]).
4.1.5. Affordable, effective medicines have played a key role in driving down CVD mortality in high-income countries
In addition to lifestyle management, which is critical for primary and secondary prevention to reduce CVD risk, medications play a vital role in preventing and controlling CVD. Over recent decades, access to affordable, effective medicines has been central to sharp declines in CVD mortality in high-income countries. In the United States, coronary heart disease (CHD) mortality fell by more than 40% between 1980 and 2000, with approximately 47% of this decrease attributed to medical treatments (Ford et al., 2007[20]). Other studies suggest medical treatments contributed between 23‑46% of CVD mortality reductions across various countries and periods (Hotchkiss et al., 2014[21]; Ford and Capewell, 2011[22]; Laatikainen et al., 2005[23]; Bots and Grobbee, 1996[24]; Capewell et al., 2000[25]). Statins, for instance, are a cornerstone of lipid management, lowering low-density lipoprotein cholesterol (LDL-C) and cutting heart attack and stroke risk. The Scandinavian trial showed a 30% mortality reduction in CHD patients treated with simvastatin (Scandinavian Simvastatin Survival Study Group, 1994[26]). Likewise, antihypertensives – including angiotensin-converting-enzyme (ACE) inhibitors, beta-blockers, calcium channel blockers, and thiazide diuretics – have a pivotal role for controlling blood pressure, a leading modifiable risk factor for CVD. Meta‑analyses indicate that ACE inhibitors alone can reduce mortality by about 10% among patients with hypertension and heart failure (Van Vark et al., 2012[27]; Bangalore et al., 2017[28]).
The recommended first-line treatment has changed for the following conditions in the last 5 years
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OCED Cardiovascular Policy and Data Survey.
High systolic blood pressure and LDL-C are two of the most significant modifiable CVD risk factors (see Chapter 3). Guidelines support managing these risks with antihypertensive and lipid-lowering medications (Heart Protection Study Collaborative Group, 2002[29]; Adler et al., 2021[30]; ESC Guidelines, 2019[31]; ESC Guidelines, 2024[32]). Strong evidence confirms these treatments significantly reduce the risk of major cardiovascular events – including stroke, heart failure, and ischaemic heart disease – and lower CVD mortality, making them the cornerstone of CVD care (Cholesterol Treatment Trialists’ (CTT) Collaboration, 2010[33]; Rahimi et al., 2021[34]; Thompson, 2011[35]). As a result, few countries have altered first-line therapies for hypertension (3/18) or high cholesterol (5/18) in recent years (Figure 4.5). Implementation of such affordable, effective, standard treatment is a key. However, over 60% of surveyed countries reported recent updates in heart failure management, reflecting the introduction of new pharmacological treatments (see Section 4.9 and Box 4.2).
Anti-hypertensive drug classes with robust evidence of efficacy in reducing CVD events include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), diuretics, and beta-blockers (see Table 4.1). Among these, the first four classes are recommended as first-line therapies for hypertension management, either as monotherapy or in combination (Ettehad et al., 2016[36]). The ESC (European Society of Cardiology) guidelines recommend low-dose combination therapy as the preferred initial approach. Monotherapy is generally indicated for individuals with mildly elevated blood pressure (120/70 to 139/89 mmHg), moderate to severe frailty, orthostatic hypotension, or those over 85 years of age (ESC Guidelines, 2024[32]). Importantly, anti-hypertensive medications are also frequently prescribed for other indications, such as certain arrhythmias, cardiac failure, left ventricular dysfunction, and certain renal conditions (Jackson and Bellamy, 2015[37]). While these drug classes are central to hypertension management, they are also used to treat a range of other cardiovascular and renal conditions. Moreover, patients are often prescribed two or more anti-hypertensive agents concurrently. As a result, drug consumption data – such as the number of defined daily doses (DDDs) – do not provide an accurate estimate of hypertension treatment coverage at the population level.
Source: ESC Scientific Document Grou (2023[38]), 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes, https://doi.org/10.1093/eurheartj/ehad192; Developed with the special contribution of: European Association for Cardiovascular Prevention & Rehabilitation et al. (2011[39]), ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS), https://doi.org/10.1093/eurheartj/ehr158; ESC Guidelines (2024[32]), 2024 ESC Guidelines for the management of elevated blood pressure and hypertension, https://doi.org/10.1093/eurheartj/ehae178.
For lipid modifying therapy, the primary treatment option is hydroxy-methylglutaryl-Coenzyme A (HMG-CoA) reductase inhibitors, commonly known as statins. Statins are classified as high-intensity or moderate‑intensity based on their capacity to reduce LDL-C. However, there is significant inter-individual variability in LDL-C reduction, even when the same drug and dosage are administered (Boekholdt et al., 2014[40]). For patients who cannot tolerate the recommended statin intensity due to adverse effects or fail to achieve target LDL-C levels, adding a non-statin lipid-modifying agent – such as ezetimibe, bile acid sequestrants, or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors – to the maximally tolerated statin is recommended (See Section 4.9 for more detail) (Moriarty et al., 2015[41]). Unlike antihypertensive medications, which are often prescribed in combination or for indications other than hypertension, lipid modifying agents specifically target dyslipidaemia and treatment usually begins with statin monotherapy (Preiss et al., 2020[42]). New oral anticoagulants are discussed in Box 4.3.
Source: Excerpted from OECD (forthcoming[43]), Benchmarking Medicine Utilisation to Improve Health Outcomes.
CVD patients often require complex medication regimens involving multiple drugs, which can make it challenging to accurately interpret prescribing patterns when analysing consumption data from individual therapeutic classes. Almost 80% of primary care users with CVDs surveyed though the OECD PaRIS survey reported taking three or more medications – compared to 50% of all other primary care users (Figure 4.6). OECD data on post-discharge care after ischaemic stroke (see Section 4.7) also reveals inappropriate prescribing across a regimen that includes antihypertensives, antiplatelets, anticoagulants, and relevant combinations of cardiac or lipid-lowering agents containing aspirin. International guidelines highlight the complexity of tailoring treatment to specific CVD patient subpopulations. For instance, recommended post-discharge regimens for patients with heart failure with reduced ejection fraction (HFrEF) include RAAS2 inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter‑2 inhibitors (SGLT2i) (Heidenreich et al., 2022[44]; Haydock and Flett, 2022[45]).
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. Sorted by people living with CVD. Differences between people living with CVD and people living without CVD are statistically significant (p<0.05) for all countries.
Source: OECD PaRIS Database, 2024.
4.1.6. Established, low-cost cardiovascular medicines remain underused in some EU countries – better prescribing could deliver substantial population health gains
The underuse of evidence‑based cardiovascular medications – such as antihypertensives, lipid lowering agents, and anticoagulants – is a persistent and well documented gap in care, and represents a missed opportunity to improve population health. These treatments, along with lifestyle and behavioural changes, are proven to reduce the risk of major cardiovascular events such as heart attacks, strokes, and other major events. Yet large segments of at-risk populations remain untreated or undertreated (Bansilal et al., 2016[46]). For example, in Germany, 69% of older patients at high CVD risk were not prescribed at least one recommended medication – more than half lacked statins or antiplatelet agents, with further substantial gaps in beta-blockers and antihypertensives (Meid et al., 2015[47]). Closing this treatment gap could yield substantial gains in life expectancy and quality-adjusted life years, while reducing the overall burden on health systems.
Direct oral anticoagulants (DOACs) have demonstrated modest clinical added benefit when compared with standard of care – warfarin. DOACs offer important cardiovascular benefits, particularly for patients with non-valvular atrial fibrillation (AF) and venous thromboembolism (VTE). In stroke prevention for patients with AF, several DOACs have demonstrated non-inferior or superior efficacy compared to warfarin. For example, a consistent benefit of DOACs across trials is the lower risk of intracranial haemorrhage, often cited as one of their key safety advantages. Reductions in this risk typically range between 50‑70% compared to warfarin, as seen in multiple large‑scale studies. For instance, apixaban was associated with a 58% lower risk of intracranial bleeding in the ARISTOTLE trial (Rao, Lopes and Granger, 2013[48]). Reflecting these benefits, current American and European guidelines recommend DOACs over VKAs (vitamin K antagonists) as first-line therapy for non-valvular AF and pulmonary embolism (ESC Guidelines, 2020[49]).1
However, evidence regarding cardiovascular mortality is more nuanced. While some individual trials and pooled analyses suggest modest reductions – such as a 10% relative reduction in cardiovascular death observed in a meta‑analysis of four major trials (RE‑LY, ROCKET-AF, ARISTOTLE, and ENGAGE AF-TIMI 48) – the overall effect appears limited and varies by drug and patient subgroup (Ruff et al., 2014[50]).
1. In Singapore, DOACs are now also favored over warfarin due to their more favorable benefit-risk profile, fewer drug interactions, and the convenience of not requiring routine coagulation monitoring (2025 OECD Cardiovascular Policy and Data Survey).
Despite evolving demographics and CVD risk profile across Europe (see chapter 3), the use of many common anti-hypertensive drugs – such as diuretics, beta-blockers, and calcium channel blockers – has remained stable in recent years (Figure 4.7). In contrast, the use of lipid modifying agents has seen an over two‑fold (103%) increase between 2010 and 2024, suggesting changing treatment patterns. OECD Health Statistics confirm growing use of these medications overall but reveal large variations across OECD countries.
OECD analysis attributes much of this variation to underuse of core therapies like antihypertensive and statins (OECD, forthcoming[43]). Underuse reflects varying barriers to access by therapy type: older, off-patent medications often face poor adherence, clinical inertia, and system-level implementation gaps (AHA/AMA, 2023[51]; OECD, forthcoming[43]). Meanwhile, access to newer, high-cost treatments – such as PCSK9 inhibitors, SGLT2 inhibitors, and GLP‑1 receptor agonists – is often limited by health technology assessments and cost-effectiveness. These newer therapies are not always clinically superior to established standard of care, except in select high-risk subpopulation groups (see Section 4.9).
Average pharmaceutical consumption (DDD/1 000 population/day) of indicated drug classes between 2010 and 2023 across EU countries
Note: Bulgaria, Cyprus, Ireland, Malta and Romania are not included as data were unavailable. Data for 2024 is only represented by 12 countries. Antihypertensives refer to for the annual average of consumption of antihypertensives, agents acting on the renin-angiotensin system, calcium channel blockers, beta-blocking agents and diuretics.
Source: OECD Health Statistics, 2025.
Primary care users with CVD report having visited the Emergency Department (ED) almost twice as much as those without CVD (40% and 26% respectively, Figure 4.8). The higher share of CVD patient visits to ED is observed across all countries participating in the PaRIS survey: in the Netherlands, where fewer than a third (29%) of primary care users with CVD reported having visited the ED, it is still 14 p.p. higher than those without CVD. Self-management support can play an important role in how people with CVD manage their health concerns (Section 4.1.2). In the Netherlands and France, where primary care users with CVD report lower rates of ED visits (29% and 32%, respectively), more than 70% of them report feeling confident that they can manage their own health (Figure 4.2).
Percentage of primary care users aged 45 and older that report having been to the ED in the past 12 months
Note: The EU11 average is unweighted 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to the questions: “In the last 12 months, have you been to a hospital ED for your own medical care?” (Yes). * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. Hence, they are expected to have higher risk levels than the patient sample of other countries who had contact with primary care. ** the United States sample only includes people aged 65 years or older. All within country differences are statistically significant.
Source: OECD PaRIS 2024 Database.
Acute CVD refers to those manifestations that develop or deteriorate suddenly, which have the potential to become rapidly worse, but which may be reversed or significantly mitigated by timely, short-term treatment. Three of the most important acute manifestations of acute CVD – stroke, AMI/ACS, and cardiac arrest – occur extremely suddenly and have treatment windows measured in minutes to hours (in the case of cardiac arrest, minutes only). Provision of sophisticated, high-quality, emergency and acute care equitably across people in need, responsively following the onset of a disease process that manifests without warning, requires integration of patient and citizen first aid response, co‑ordinated ambulance dispatch, acuity identification and treatment initiation in the field, distribution of patients to hospitals most capable of providing the required diagnostics and treatments, and smooth transition through ED, interventional care and admission to specialist wards (see Figure 4.9).
4.2.1. Speeding up access to lifesaving care starts with patients and bystanders. Much has been achieved but there are gains to be made
Women often wait longer to call for emergency services than men
Women often wait longer than men after experiencing symptoms to call for help. The Irish National Heart Attack Audit (IHAA, 2024[52]) has shown steady improvement in the proportion of patients with STEMI3 who call for help within 60 minutes of symptoms between 2017 and 2020. However, since this data has been disaggregated by sex (starting in 2021), it has become apparent that improvements have been entirely among men, with fewer women calling within 60 minutes each year. Likewise, an analysis of the e‑MUST register, which captures data from STEMI patients cared for by the SAMU (Service d’Aide Médicale Urgente) units in the greater Paris area, has shown that older age, female sex, and symptom onset at night are all associated with a longer delay to call EMS and that these are synergistic, with a much greater delay at night, for older, female patients than for younger females, or for males of any age, and a greater effect of age on time for call for female patients than male patients (Lapostolle et al., 2021[53]). A similar phenomenon has been reported from the STEMI registry of a major Swiss hospital, persistent for over 15 years, with patient delays 21‑53% longer (25‑50 minutes) for women during the three periods studied (Meyer et al., 2019[54]) and in a Swedish study in which women were found to have a delay to first healthcare contact of 90 minutes compared to 66 minutes for men, as well as the first health contact for women being the nursing advice line rather than primary care, EMS or ED in 28% of cases compared to 18% for men (Sederholm Lawesson et al., 2018[55]). Outside of Europe, the phenomenon is noted in Korea, where, in 2019, 22.9% of men and 15.7% of women with AMI had an onset to arrival time of under one hour and 37.1% of men and 48.6% of women had a prolonged onset to arrival time of over six hours (Kim, Kim and Hwang, 2022[56]). These are likely related, at least in part, to the fact that living alone is more common among women than men.
Health decision-makers should understand that living with cardiovascular disease—especially alongside multiple chronic conditions—is not just a medical challenge, but a full-time personal and emotional burden. It means managing complex symptoms, medications, side effects, and appointments with multiple specialists, all while trying to maintain some quality of life.
As a woman, I often feel that I have to fight to be heard—sometimes even scream—just to have my symptoms taken seriously or to get clear answers... Patients like me need coordinated, personalised care that considers the full picture—not just isolated diagnoses. We need faster access to disability support, better communication between specialists, and more investment in gender-aware, preventive, and mental health care. Without these changes, people like me are left to navigate a fragmented system—often alone and unheard.
Angela, 53, mother, in menopause and living with multiple chronic conditions.
Citizen engagement can help facilitate an early response during acute events
Some countries, including Austria, Hungary, Italy, Germany and the United Kingdom, have implemented policies to encourage the engagement of citizen first responders for cardiac arrest as a pre‑hospital care resource. Citizen first responders are trained citizens and provide first assistance at the emergency scene (Fredman, Berglund and Dardel[57]; for the ESCAPE-NET Investigators, 2019[58]). Several European countries have app-based notification systems for first responders and many of which are integrated with automated external defibrillators (AED) registration and mapping systems (see Box 4.4).
In Denmark, when a bystander witnesses someone collapse, they call 112, the Europe‑wide toll-free number that routes automatically to an operator with the Danish police. The operator quickly clarifies the nature of the emergency and connects them with the regional Emergency control centre (ECC) where a nurse or paramedic operator identifies a potential cardiac arrest, if needed. The operator then sets in trained ambulance logistics to dispatch the nearest ambulance resource and also a mobile emergency care unit. A signal goes to the national first responder organisation Trygfonden which automatically sends out notifications to nearby citizens who have completed mandatory cardiopulmonary resuscitation (CPR) training as part of drivers licencing and are registered as basic life support (BLS) trained first responders. Trygfonden also maintains the national automated external defibrillators (AED) register and the first responder receives details of the location of nearby AEDs also. Meanwhile the ECC is providing telephone CPR guidance to the original caller, including by video connection. Rates of bystander CPR provision have increased from 19.3% in 2001 to 76% in 2023, AED use has increased from 1.4% to 23% over the same period, and survival rates from 1.4% to 23%.
Source: Dansk Hjertestopregister (2024[59]), Danish Cardiac Arrest Registry.
Access to automated external defibrillators (AEDs) plays a critical role in improving survival rates after out-of-hospital cardiac arrest (Baldi et al., 2021[60]) Early defibrillation has been consistently associated with higher rates of return of spontaneous circulation and favourable neurological outcomes at the time of hospital discharge – meaning the patient is admitted, treated, and ultimately discharged alive (Weisfeldt et al., 2010[61]; Kishimori et al., 2020[62]). A meta‑analysis of six observational studies without critical risk of bias showed that bystander AED use significantly increases the rate of survival to hospital discharge (Holmberg et al., 2017[63]). Importantly, the technical skills required to operate an AED are minimal since modern AEDs are designed for layperson use, with clear audio and visual instructions, and their use poses no risk to rescuers (Baldi et al., 2021[60]). Since 2015, international guidelines have explicitly encouraged AED use by untrained laypersons (Perkins et al., 2015[64]).
However, despite these recommendations, AED use rates remain heterogeneous across countries – with especially low uptake observed in parts of Europe. Survey results show that the percentage of AED use before emergency medical services arrival remain highly variable, with only five countries reporting pre‑EMS AED use exceeding 10%, with large variation between them: France 72%, the Netherlands 46%, Switzerland 23%, Sweden, 20%, and Norway 12% (Baldi et al., 2021[60]).
Publicly Accessible Defibrillators (PAD) play a vital role in enabling early intervention. Since 2015, guidelines have recommended PADs be publicly registered and integrated into emergency dispatch systems so that first responders and bystanders can be directed to the nearest AED quickly (Perkins et al., 2015[64])). Yet, research continues to show significant gaps in AED registration, mapping, and integration into emergency response frameworks. According to the 2021 ENSURE survey, an AED mapping system was only available in a little over half of countries surveyed – with some countries having a nation-wide AED mapping available: Finland, Italy, Luxembourg, Norway, the Slovak Republic and Slovenia, Sweden, and Switzerland, and others with AED mapping available in certain regions – France, Germany and the Netherlands (Baldi et al., 2021[60]).
Legislation can support AED usage. In countries where legal restrictions require a certification for AED use, utilisation rates remain low (around 2.4% to 5%). In contrast, countries that have adopted “Good Samaritan” laws – allowing any citizen to use an AED without prior training – report much higher usage rates (15‑20%) before emergency medical services arrive. According to the 2021 ENSURE survey, 80% of responding European countries allowed unrestricted AED use by all citizens, with only Greece, Italy and Spain requiring a certificate (Baldi et al., 2021[60]).
4.2.2. Pre‑hospital emergency care organisation varies across countries and some countries provide more highly specialised ambulance care
Ambulance systems are critical to delivery of emergency CVD care, both through bringing lifesaving care to the patient, and through moving patients efficiently to hospitals capable of providing advanced interventions. Ambulance operations include a wide spectrum of medical rescue and critical care but also routine patient transport, and countries have different systems of both prioritising allocation of ambulance resources and of labelling different types of cases. Data collected from OECD countries show that circulatory diseases (defined as AMI and other acute coronary syndrome (ACS), stroke, and cardiac arrest) account for a significant share of emergency (high priority) ambulance transports, but with wide variation across countries, ranging from 1% in Belgium, to 6% in Poland, 18.5% in Estonia and over 30% in Canada (OECD, 2024[65]).
The first step to effective ambulance care is prioritisation and distribution of resources in response to emergency calls. In some countries (e.g. Norway and Denmark), trained nurses at an Emergency Control Centre triage calls based on structured questionnaires. In other countries, a non-clinical operator applies a tool with support from nurses, paramedics or doctors available as needed (the United Kingdom, Ireland, Australia and Estonia). In France, calls to SAMU15 (Service d’Aide Médicale Urgente) emergency number are first assessed by a trained medical assistant who then routes the call to either a generalist physician (for low acuity cases) or an emergency physician (for high acuity cases). Each of these systems has significantly different workforce requirements. Despite this variation, there are commonalities. For example, the pre-hospital triage systems employed in Norway, Denmark, Slovenia, Estonia, Sweden and Israel are all adapted from the Seattle/King County EMS Criteria Based Medical Dispatch System and all applications of it separate cases into those for immediate response, those for urgent response, and those that can wait or be scheduled, with what variation there is occurring in the handling of the low acuity cases (OECD, forthcoming[66]).
High-quality pre‑hospital care for CVD emergencies depends on effective integration with hospital care to minimise delays to delivery of time critical, high-complexity interventions (like revascularisation for STEMI and stroke) and ensure a prompt and guideline compliant response to cardiac arrest (Figure 4.10). Diagnosis and prescription and administration of medicines in many countries are protected activities belonging to the scope of physicians (and in the case of administration, nurses). Countries may have to overcome regulatory hurdles to allow non-medical pre‑hospital staff to perform these tasks as ensuring a doctor and nurse are at the scene of every critical case in the time required is proving very difficult. In some countries (e.g. Australia), EMS/ambulance officers began administering medications under according to protocols many decades ago. These protocols have progressively increased in scope as has the sophistication of the training of the workforce. The first bachelor’s degree programme in paramedicine started in Australia in 1994 and the British NHS has required a degree for entry into the profession since 2013 (Makrides et al., 2022[67]). Currently, most ambulance providers in these countries are paramedics or above. Many EU countries are creating paramedic qualifications also, for example in Germany, a federal law was passed in 2014 (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, 2018[68]) to create the role of Notfallsanitäter (Paramedic) and to define educational standards and a scope of practice including administration of key medications and therapies. These changes are allowing countries to redirect the physician workforce to activities where they are more needed.
Pre‑hospital diagnosis and treatment contribute to higher survival of patients. Pre‑hospital decision support and electrocardiogram (ECG) transmission to the receiving facility can be associated with significant reductions in door-to-balloon times (Nelson et al., 2025[69]). Similarly, pre‑hospital screening tools can assist with identification of potential ischaemic stroke and of large vessel occlusion stroke and allow for hospital selection and prenotification by EMS teams (Zhao et al., 2018[70]). Aspirin administration reduces death from AMI as much as revascularisation does, and is additive in effect to those more invasive therapies, making its prompt use on suspicion of acute coronary syndrome essential.
Some countries are employing specialised vehicles and teams to deliver high-level care to patients with specific conditions. Norway, Poland, and several non-EU countries are employing Mobile Stroke Ambulances with on-board CT (computed tomography) scanners and the ability to diagnose and treat acute ischaemic stroke in field (Navi et al., 2022[71]). Norway also utilises pre‑hospital thrombolysis of STEMI in rural areas where transport times can be long. In smaller countries with shorter transport times, priorities are different. Denmark is moving away from use of physicians on board of ambulances and delegating more authority to paramedics and teams are typically composed of a paramedic and an emergency medical technician. Estonia has extended significant autonomy to pre‑hospital nurses and is trying to reduce physician use in ambulances.
The staffing model approach for bringing high level critical care to the patient varies between countries (Figure 4.11). According to the OECD Cardiovascular Policy and Data Survey, seven countries (Healthcare quality and outcomes) have a physician on board in the ambulance when possible for high acuity cases like stroke and STEMI. Three of these countries and three others utilised physician telehealth support to EMS crew members treating these cases. In four countries, there was a system for telehealth consultation between EMS and specialty staff (cardiology or stroke clinicians). Seven countries reported using paramedics or nurses trained to Advanced Life Support (ALS) level and three using nurses or paramedics trained to a higher level than that. It should be noted that some larger countries have significant local variation in models of service delivery and identified more than one of these models as being in use.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Ambulance response time targets are introduced in many countries in Europe to promote timely and effective emergency care
Many European countries have introduced ambulance response time targets (examples in Annex 4.C), which act both as a driver of responsiveness in the EMS system and as a measure of adequacy of resourcing and organisation. Some are maximum acceptable times, but most are targets for mean, median or a specific centile of responses. There are also differences between countries in the degree of complexity of targets. In England, for example, there is an 8‑minute target for the most urgent (cardiac arrest or immediate risk of cardiac arrest) cases and an 18‑minute target for the next category (which includes potential stroke and STEMI) while some other countries set a single target time for all emergency transports. Using different targets for rural and urban environments is another consideration, for example as Norway and Estonia do. In Singapore, ambulance response time is monitored primarily for internal reporting purposes, with specific measures implemented to address the root causes of delayed responses.
The pandemic significantly impacted ambulance response times in several countries (Figure 4.12) and recovery seems to be starting, but progress is slow. In England, the mean and 90th centile response times for Category 1 (potential cardiac arrest) cases peaked in 2022 at 31% and 30% above the 2019 figure respectively. Category 2 response times (for potentially serious cases like heart attack and stroke symptoms) were even more impacted, peaking the same year at 150% and 130% above the 2019 figures (not shown in figure). Data prior to the pandemic had demonstrated consistent performance close to targets for at least 2 years. In other countries, peaks relative to the 2019 results occurred in 2022 in Ireland (36%), the Netherlands (6%), Latvia (13%), Australia (32%), Türkiye (29%) and Japan (18%) and in Sweden in 2023 (11%). Sweden and Australia also had very little variation reported in the years before the pandemic. Data from Norway on the other hand shows a consistent response time from 2019 and Danish data (only available from 2020) has also been consistent.
Response times presented as percentage change in average response time. Reference year 2019
Note: Ireland, the Netherlands, Sweden, Latvia and Türkiye report median response times, Japan reports the mean. Australian data represents the weighted averages of the medians for each jurisdiction (state or territory). England reports the mean.
Source: 2025 OECD Cardiovascular Policy and Data Survey; Australian Government Productivity Commission (2025[72]), 11 Ambulance services – Report on Government Services 2025, https://www.pc.gov.au/ongoing/report-on-government-services/2025/health/ambulance-services; Nuffield Trust (2024[73]), Ambulance response times, https://www.nuffieldtrust.org.uk/resource/ambulance-response-times.
4.2.3. Specialised treatment and timely care are essential to improve CVD outcomes related to acute events
Patients experiencing hyper-acute CVD events often benefit significantly from specialised treatment when therapies are initiated early after symptom onset. The importance of well-organised care systems which can deliver highly specialised care to AMI and stroke patients has been internationally recognised and many countries have established, or are in the process of establishing organised care networks to respond to cardiac and stroke patients’ acute treatment needs (see Section 4.3). More detail on the specific care pathways needed for stroke, AMI, and cardiac arrest is discussed in more detail in Annex 4.D.
A door-to-balloon time in STEMI of over 90 minutes is associated with a significantly higher short- or medium-term risk of death (odds ratios of 1.52 and 1.53 respectively) as compared to more rapid procedures. Every 30 minutes’ delay adds 15% to those odds ratios (Foo et al., 2018[74]). The reduction in disability achieved through stroke revascularisation is also time dependant with thrombolytic therapy required within 4.5 hours to show a benefit and a more convincing benefit evident when patients are treated within three hours (The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995[75]; Hacke et al., 2008[76]). National evidence from Denmark shows that longer intervals between symptom onset and thrombolysis (longer than 90 minutes) also lead to worse long term outcomes, such as death or subsequent stroke withing three years (Yafasova et al., 2021[77]).
Bodies including the European Society of Cardiology (ESC Guidelines, 2023[78]), the European Stroke Organisation (Berge et al., 2021[79]), the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand (Brieger et al., 2025[80]), the American Heart Association (Gulati et al., 2021[81]) and the United Kingdom National Institute for Health and Care Excellence (National Institute for Health and Care Excellence, 2024[82]) develop and provide expert, evidence based, consensus guidelines on the management of the full spectrum of CVD with good agreement across key recommendations among the various bodies. From these, national healthcare quality agencies define quality standards and key performance indicators.
Based on these guidelines, time from first clinical contact to ECG interpretation for acute coronary syndrome patients should be less than 10 minutes. STEMI patients with symptom onset within 12 hours should have percutaneous coronary intervention (PCI) as soon as possible – with the alternative of thrombolysis if PCI will be delayed more than 120 minutes. For high-risk non-STEMI patients there is less urgency, however PCI treatment is recommended within 24 hours of symptom onset (ESC Guidelines, 2023[78]). Process indicators for acute CVD care include the proportion of eligible patients receiving the recommended treatments, the time delays to those treatments (or the proportion treated within target times) and supporting indicators like the proportion of patients delivered directly to a facility designated for that condition (Figure 4.13).
Subintervals of these may be defined to address specific process elements and disaggregation by age, sex and other determinants of access to care may assist with improving equity
In the case of STEMI management, there is significant diversity of reporting of process measures. Ireland reports revascularisation times starting from first medical contact (ambulance, GP or hospital) while NHS England reports time from EMS call to revascularisation. Starting the clock at first medical contact focusses the attention on the ability of the system to react to a diagnosis of STEMI, while starting it at the ambulance call includes the ability of the system to respond to the call in a timely fashion. In the case of cardiac arrest, response needs to be immediate, provided within minutes of symptom onset and the participation of first responders as well as availability of AED is crucial (see Section 4.2).
Monitoring complex timeliness indicators remains a challenge for many EU countries, and international benchmarking needs further work. In 2022, only 11 EU countries were able to report the median onset-to-needle times for IVT and median onset-to-groin times for MT in ischemic stroke patients for the ESO Stroke Service Tracker Data. Of the countries that could report (Austria, Czechia, Denmark, Estonia, Greece, Hungary, Latvia, the Netherlands, Romania, the Slovak Republic and Sweden), many had a longer history of formalised centralisation of highly specialised CVD care. Catalonia in Spain also reports the onset-to-needle and onset-to-groin time data to the ESO Stroke Service Tracker Data (European Stroke Organisation (ESO), 2025[83]).
Other time intervals may be measured to monitor other elements of the chain of care. In non-EU countries such as the United Kingdom (England), the mean average time from call until hospital arrival (an indicator of EMS performance) for stroke was one hour and 32 minutes in February 2022 (NHS England, 2023[84]), and the mean average time from call to catheter insertion (a measure of integrated EMS and hospital care) was 2 hours 57 minutes in December 2022 (NHS England, 2023[85]). In Korea, the average time from symptom onset to ED visit (an indicator of community awareness as well as EMS performance) for AMI was 153 minutes in 2019 for STEMI and 196 minutes for NSTEMI, 20.7% arriving in under one hour, 39.4% within two hours, and 40.6% taking over six hours (Kim, Kim and Hwang, 2022[56]) (See also Section 4.2 for discussion of gender differences in time to arrival).
During acute cardiac events, timely intervention was crucial. I have witnessed the life-saving impact of rapid emergency response and treatment in my own and family members’ experiences. However, delays due to system inefficiencies or lack of awareness can cause critical setbacks. It is vital that emergency pathways and public education continue to improve to ensure prompt care.
Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.
4.2.4. Time‑sensitive intravenous thrombolysis use for stroke treatment differs substantially between EU countries
IVT and MT in stroke are reserved for those patients in whom the potential benefit outweighs the risk of harm from the treatment. For this reason, eligibility for IVT is dependent on arrival of the patient at hospital and completion of diagnosis and assessment including neuroimaging and certain laboratory markers within the treatment window.4 ESO and AHA-ASA (American Stroke Association) guidelines define the treatment window for IVT in ischaemic stroke as 4.5 hours from symptom onset (after which the prospects of a benefit decline too much), and provide recommendations for patients with symptoms on awakening from sleep or with a longer time from onset but certain favourable imaging findings (Berge et al., 2021[79]; Powers and et al, 2019[86]). MT has a longer treatment window of six hours after symptom onset, and up to 12 hours in certain patients with favourable imaging findings but is limited in use to subset of ischaemic stroke patients with stroke due to occlusion in one of the larger arteries (Turc et al., 2019[87]).
Time to diagnosis and assessment is modifiable by improvements at every stage in the process from the call for help through to the decision to treat. The ESO-SAFE collaboration has set a target of 15% of ischaemic stroke patients in Europe to receive IVT by 2030, to drive improvements in the chain of care from onset to delivery of treatment. Achieving IVT rates above 15% is considered a feasible and attainable target because studies have shown that several countries are already meeting or exceeding this level, while others have demonstrated steady improvements in IVT uptake since 2017 (Mikulik et al., 2021[88]). Moreover, evidence suggests that the earlier treatment with IVT is administered, the greater the benefit for patient outcomes, further underscoring the importance of timely and widespread access to IVT (Norrving et al., 2018[89]).
IVT use in Europe has been increasing since its debut in the mid‑1990s and remains the only approved systemic reperfusion treatment in Europe for patients with acute ischaemic stroke (Berge et al., 2021[79]). The use of IVT varies across Europe and exemplifies the “inverse care law” – in regions where mid-life stroke‑related disability is highest, IVT use is among the lowest (Berge et al., 2021[79]). Rate of IVT varies by a magnitude of 20 between European Countries – from over 75 per 100 000 population in Latvia and Estonia to below 10 in Ireland and Greece (Figure 4.14). Furthermore, some countries with high mortality rates due to cerebrovascular disease have notably low rates of use of IVT, including Bulgaria and Romania. Latvia stands out as a country where there is high use of IVT and high cerebrovascular mortality, while Estonia, has lower than average cerebrovascular mortality and high rate of use of IVT.
Note: Dotted lines indicate the average (31 ITV treatments per 100 000 inhabitants and age‑standardised morality of 117 due to cerebrovascular disease).
Source: Aguiar de Sousa et al. (2023[90]), “Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020”, https://doi.org/10.1177/23969873231186042.
The proportion of eligible patients treated with IVT is likewise an indicator of the ability of that facility to assess the patient, obtain and interpret imaging studies and relevant laboratory studies, and administer treatment before the window for treatment closes. “Eligible patients” are defined as those with a confirmed ischaemic stroke arriving within the treatment window (4.5 hours from onset). The ESO Stroke Action Plan for Europe has (SAP-E) set a target of delivery of IVT to 15% of all ischaemic stroke cases (note that this denominator is not limited to those arriving within 4.5 hours and so improvements depend on whole of system action). According to ESO Data, 13 out of 22 EU countries with available data reported providing IVT to more than 15% of their admitted ischaemic stroke patients in 2023 (ESO-SAFE, 2025[91]), yet the data reveal significant variation among EU countries. While some EU countries reported administering an IVT to just above 8% of their stroke‑unit admitted patients (and Bulgaria just 3%), Czechia, Estonia, the Slovak Republic, Austria and the Netherlands reported rates above 20%. Czechia improved their rate of IVT treatment from 1.3% in 2005 to 23.5% in 2018 with implementation of an integrated stroke system (Mikulik et al., 2021[88]).
Door-to-needle time for IVT in stroke as reported to the ESO Stroke Service Tracker shows a wide variability across Europe (see Figure 4.15), ranging from 20 minutes in Czechia to 60 minutes in Poland. The highest performing countries have a door-to-needle time of around 30 minutes or less – and the EU average is 40 minutes. International comparisons must be made cautiously as many countries are reporting data from nationally non-representative registries that collect data from significantly less than 100% of hospitals and which rely on hospital staff for the completeness of reporting of their own cohorts of patients.
Note: Data refer to median door-to-need time for ischaemic stroke patients treated with intravenous thrombolysis, measured from entering a hospital door to the start of administering the treatment. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries. 4. Estimate based on nationally non-comprehensive RESQ database. 5. Estimate through ESO-SAFE contacts to facilities.
Source: ESO Stroke Service Tracker Data (https://actionplan.eso-stroke.org/kpi/kpi-7c).
Median door-to-groin time for MT delivery to patients with stroke similarly shows significant variability in national performance, ranging from 28 minutes in Denmark to 157 minutes in Greece, with an EU average of 82 minutes (see Figure 4.16). The same caveats apply. A potential risk of excessive focus on a single indicator like door-to-needle time is that other patients competing for the same or similar resources (for example haemorrhagic stroke patients) may not see similar improvements in care.
Note: Data refer to median door-to-groin time for ischaemic stroke patients with endovascular treatment, measured from entering a hospital door to the start of the mechanical thrombectomy procedure. 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries. 4. Estimate based on nationally non-comprehensive RESQ database. 5. Estimate through ESO-SAFE contacts to facilities.
Source: ESO Stroke Service Tracker Data (https://actionplan.eso-stroke.org/kpi/kpi-7d).
Some studies also point out socio-economic inequalities in access to specialised CVD care within countries. One study in Sweden found that the median time from a call to emergency medical services to start of brain CT scan in hospital was 3 hours and 47 minutes for stroke patients with the lowest socio‑economic status (SES), and 30 minutes shorter for stroke patients with the highest SES (Niklasson, Herlitz and Jood, 2019[92]). One Danish study found that thrombolysis and thrombectomy treatment rates vary by socio-economic background (Buus et al., 2022[93]) and one study in England found that the likelihood of receiving complex ED care and hospitalisation was lower among people with lower SES (Turner et al., 2022[94]). Relatedly, survival rates of people who had stroke and heart attack are lower among people with lower socio‑economic background (Hyldgård et al., 2022[147]; (Jonsson et al., 2021[95]). A systematic review also found research findings on poorer access and health outcomes among people with heart failure in lower SES groups compared to those with higher SES groups (Shakoor et al., 2024[96]). These research findings suggest that there are obstacles to ensure timely and high-quality emergency care to people with low SES exist within countries, although their impact and possible solutions appear to vary across countries.
International collaboration is helping European countries improve their delivery of timely high quality stroke care
Providing a rapid treatment to ischaemic stroke patients requires a well-functioning healthcare system, including emergency dispatch centres, ambulance services, EDs, radiologists, and stroke teams co‑ordinated by a vascular neurologist or a stroke physician (Berge et al., 2021[79]). Many EU countries including Denmark, the Netherlands, Norway and Czechia have organised their stroke care providers into comprehensive networks to drive timely transport of stroke patients to the facilities capable of treating them (see Section 4.3). A study in 2017 surveying access to stroke care units and their delivery rates found major inequalities in acute stroke treatment between and within 44 European countries, with regional differences reported in 28 countries, and 28 countries lacking full-country endovascular treatment coverage at that time (Aguiar de Sousa et al., 2018[97]).
In response to the study, the Stroke Action Plan for Europe 2018-2030 (SAP-E) was launched in 2018 by ESO in co‑operation with the Stroke Alliance for Europe (SAFE) (Norrving et al., 2018[89]). The SAP-E plan aims to support the improvement of stroke care in Europe through a development of integrated stroke care across care settings, and provides targets for several domains, including for management of acute stroke care. For example, a target has been set for 2030 of median onset-to-needle time of less than 120 minutes for patients receiving IVT and median onset-to-groin time of less than 200 minutes for patients receiving MT. In 2022, only a handful of those EU countries with available data were reaching, or close to reaching, these SAP-E targets, with Denmark and the Netherlands consistently performing the best (ESO-SAFE, 2025[91]). See Box 4.5.
A joint activity of patients and scientific organisations
The Stroke Action Plan for Europe 2018-2030 (SAP-E) is a joint action of physician and scientific community of the European Stroke Organisation (ESO) and of stroke patients of the Stroke Alliance for Europe (SAFE), which unites some 40 patient support organisations. The SAP-E is a key project of the ESO, aiming to reach a broad consensus on what care should be available in European countries for stroke patients, and on monitoring its accessibility and quality. The project builds on the assumption that moving forward in implementing national stroke action plans and enhancing quality of stroke care requires broad involvement of relevant stakeholders, including healthcare professionals and patient support organisations, but also governments and third-party payers.
The four overarching targets to be reached by 2030 include:
Reduction in the absolute number of strokes in Europe by 10%
Treating 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care
Having national plans for stroke encompassing the entire chain of care from primary prevention to life after stroke
Fully implementing national strategies for multisector public health interventions to promote and facilitate a healthy lifestyle and reduce environmental, socio-economic and educational factors that increase the risk of stroke.
For most people with CVD, hospitals play a key part in their care – either as a place for care following acute events (emergency response after chest pain), for advanced diagnosis and screening (magnetic resonance imaging (MRI) following stroke), or for elective or emergency care (implantation of a pacemaker). Despite playing a central role in all health systems as a care setting for CVD, hospital access, capacities, and outcomes vary and are not always sufficiently matched to disease burden and demand.
4.3.1. Access to hospital care varies across countries
People with CVD-related conditions are twice as likely to be hospitalised than other people
Reflecting difficulties in managing CVD-related conditions, among people aged 45 and over attending primary care, those with cardiovascular conditions are twice as likely to be hospitalised than those without CVD-related conditions (Figure 4.17). This highlights that accessibility and high-quality emergency care and hospital care are critical for treating CVD, although some CVD-related hospital admissions could be avoided with effective primary care. The likelihood of hospitalisation among people with CVD conditions varies greatly across countries. Among people with CVD conditions who use primary care services, 20% in the Netherlands, 22% in Portugal and 23% in Iceland report being hospitalised in the last year, but the share is much higher at 42% in Romania, followed by 32% in Italy and 30% in Czechia.
Percentage of primary care user aged 45 and older that report having been in a hospital for more than one night in the past 12 months
Note: The EU11 average is unweighted 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. Response to the question: “In the last 12 months, have you been in a hospital for one night or longer?” (Yes). * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. Hence, they are expected to have higher risk levels than the patient sample of other countries who had contact with primary care ** the United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
A large share of hospital care is provided to people with CVD and some countries in Europe heavily rely on hospital care
In almost all countries in OECD, circulatory diseases are the most common cause for inpatient care, and in 2023, 14% of hospital discharges across Europe were associated with cardiovascular diagnosis requiring planned surgical procedures and acute care after acute CVD events. The share varies two‑fold, ranging between 9% in Ireland to 18% in Latvia and Lithuania. Hospital discharges for circulatory diseases vary over four‑fold in the EU. They are less than 1 000 discharges per 100 000 populations in Portugal and Iceland, but exceed 3 000 in Lithuania, Latvia and Germany, and stand at more than 4 000 in Bulgaria (Figure 4.18).
Timely care was critical in my case. After my initial heart attack, delays in seeking medical attention led to complications like ventricular tachycardia and an electrical storm. However, the swift decision to transfer me to Budapest for catheter ablation saved my life. This experience underscores the importance of rapid response systems and well-coordinated care pathways for acute cardiovascular events.
Caius, artist, researcher, patient advocate, and heart attack survivor
High reliance on hospital care is marked in Bulgaria, Germany, Lithuania, Latvia and Austria. In Bulgaria, this is related to an oversupply of acute hospital beds and a shortage of GPs (OECD/European Observatory on Health Systems and Policies, 2023[100]). To shift away from hospital care, in Lithuania, a major restructuring was initiated in 2022 that aims to create a new model of service provision in primary care and reorganise the hospital network, with a view to improving the quality and accessibility of services (OECD/European Observatory on Health Systems and Policies, 2023[101]). Latvia has reduced the number of hospital beds but plans to undertake reform to improve access to high quality primary care through the use of digital health tools and better workforce planning (OECD/European Observatory on Health Systems and Policies, 2023[102]). Hospital discharges for circulatory diseases have decreased over the past decade – with an average decline of 243 discharges per 100 000 population between 2013 and 2023 in EU countries – despite a peak in several countries already preceding the COVID‑19 pandemic. Latvia and Ireland, notably, have plateaued or increased over this time period. The general downward trend is likely to be associated at least partly with improved quality of primary care in managing CVD risks for needing specialised care across countries (see Section 4.1.1) and streamlined delivery of hospital care through care concentration (see Section 4.3.2).
Note: The EU average is unweighted.
Source: OECD Health Statistics 2025.
Use of minimally invasive procedures, such as transluminal coronary angioplasty, vary substantially by five‑fold in Europe
Patients with coronary artery disease may undergo transluminal coronary angioplasty including percutaneous transluminal coronary angioplasty (PTCA) and percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) to improve blood flow. PTCA and PCI are provided in emergency care or planned in advance and it is a minimally invasive non-surgical procedure. CABG, an invasive surgical procedure, replaces arteries to the heart by blood vessels from another part of the body and this surgery is given to people with severe blockages in multiple coronary arteries. However, with improved techniques and technologies, PTCA and PCI have been used increasingly to patients with multiple blockages and narrowing of coronary arteries, although CABG still remains an optimal option for certain patients.
The number of transluminal coronary angioplasty per population varies five‑fold across countries and for CABG, the variation is lower at four‑fold (Figure 4.19). The number of transluminal coronary angioplasty (with or without insertion of stent) is less than 140 per 100 000 population in Luxembourg, Spain and Portugal. In these countries the number of CABG per is also low. Similarly, countries with a high number of transluminal coronary angioplasty per population tend to have a relatively high rate for CABG. Germany, a country with high reliance of hospital care, has high rates for both PTCA and CABG.
But there are some exceptions. In the Slovak Republic, Czechia, Slovenia and the Netherlands, the rate of transluminal coronary angioplasty is lower than the EU average while the rate for CABG is high. In the Netherlands, this pattern may be related to the fact that CABG is found more clinically effective and cost-effective than drug-eluting stent PCI in a long term in its health system (Osnabrugge et al., 2015[103]). On the other hand, the rate for PTCA in Latvia is among the highest in Europe, but the rate for CABG is less than the EU average, suggesting transluminal coronary angioplasty is overused although medications are also available to manage risk factors and treat symptoms. France also has relatively a high rate of transluminal coronary angioplasty but the rate for CABG is lower than the EU average.
Note: The EU average is unweighted.
Source: OECD Health Statistics 2025.
Following progress in medical technologies and demonstrated safety in same day discharge, an increasing share of less invasive surgical procedures is performed in day case across countries. In view of providing cost-effective high quality CVD care, about half of countries provide elective transluminal coronary angioplasty in day care but the extent of day cases varies across countries. On average in the EU, 11% of transluminal coronary angioplasty procedures are provided in day care – increasing from 6% in 2023. The value of this is more than 65% in Iceland, followed by 39% in Finland and the Netherlands, and 25% in the United Kingdom. But in several countries in Europe including Hungary, Estonia and the Slovak Republic, it is provided only in inpatient care. The share of transluminal coronary angioplasty in day cases has increased substantially in Finland over the past decade and the increase was also large in Denmark, Sweden, Iceland, France, Norway and Croatia (Figure 4.20).
Note: Break in time series for Denmark and Ireland.
Source: OECD Health Statistics 2025.
4.3.2. Hospital resources for treating CVDs vary across countries
Availability of medical technologies is increasing but substantial variation exists across countries
CT scanners and MRI units are used for diagnosing and identifying treatment options for various diseases including CVD particularly for stroke. CT scanners are commonly used to patients with suspected stroke to identify if areas of abnormalities in the brain are caused by ruptured blood vessel (haemorrhagic stroke) or insufficient blood flow (ischaemic stroke). Across countries, the majority of these technologies are located in hospital settings. This may be related to the concentration of specialised care taking place in an increasing number of countries. In Finland, Sweden and Denmark, all CT scanners and MRI units are located in hospitals and in Belgium all MRI units are in hospitals (Birk et al., 2024[104]).
However, there is less care concentration and a lower share of MRI and CT technologies available in hospital settings in some countries including France, Germany and Greece. In 2023, more than 90% of CT scanners are available in the hospital setting in Belgium, Czechia, Denmark, Luxembourg and the Netherlands (opposed to the ambulatory setting). More than 80% of MRI units are located in the hospital setting in Czechia, Ireland and the Netherlands. The availability of CT scanners and MRI units in hospitals vary by a factor of almost 2.7 across EU countries (Figure 4.21).
Note: The EU average is unweighted.
Source: OECD Health Statistics 2025.
While the availability of medical technologies has increased in ambulatory settings, the availability of CT scanners and MRI units in hospital settings has also increased on average in EU countries, and Norway and Iceland, in recent years, demonstrating expanded access to diagnostic tools (Figure 4.22). Total availability of MRI units per million people has increased by over 30% in Lithuania and Luxembourg between 2015 and 2023, and total availability of CT scanners has increased by over 40% in Lithuania, Luxembourg and Greece over the same period. Austria and Finland have observed a decline in availability of CT scanners over this period, and Belgium saw a decline in MRI units.
Note: Data pertains to Austria, Belgium, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Iceland, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Poland, the Slovak Republic, Slovenia, Spain, Sweden.
Source: OECD Health Statistics 2025.
4.3.3. Countries are advancing in organising highly specialised acute care and ensuring their access
Besides a general shift towards concentration of hospital care, many countries have concentrated delivery of CVD care at highly specialised care centres or larger hospitals. While many countries are centralising care for CVD in coronary care units and centralised stroke units, fewer have centralised care for CHF, either in specialised heart failure units or transplant units (Figure 4.23). Coronary care units or intensive cardiac care units are typically have access to needed diagnostic and treatment facilities with a health workforce trained to diagnose and co‑ordinate all aspects of acute coronary syndromes (ACS) care, such as management of arrhythmias and heart failure, as well as haemodynamic, ventilation and temperature monitoring and control, among others (ESC Guidelines, 2023[78]). On average, in the EU, there are 4.7 coronary care units per million people (see Figure 4.24). In 2022, the Slovak Republic, Bulgaria and Ireland had the highest number of dedicated coronary care units, with over 9 units per 1 million people. In contrast Lithuania, the Netherlands, Romania and Spain had the lowest number, with less than 2 units per 1 million people.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Stroke units are organised inpatient care provided by a multi-disciplinary team to manage patient with stroke. Patients treated in stroke units are more likely to be alive and independent compared to those treated in a general ward, according to a Cochrane systematic review (Langhorne and Ramachandra, 2020[105]). On average in the EU, there are 3.6 hospitals with dedicated stroke units per million people (Figure 4.24).
Stroke care unit also plays an important role in reducing disability and disability from stroke in some countries. In Czechia, since the start of concentration of care in 2007, and the accreditation of stroke centres, access to high quality and safe care for stroke and ischaemic heart disease has improved. Through concentration of care, designated networks for cardiology and stroke care were developed throughout the country. In 2021, it also improved criteria for stroke centre (Bryndová et al., 2023[106]). In Sweden, national guidelines recommend patients to be admitted to a stroke unit directly upon hospital arrival. In recent years, the share of patients admitted and treated in a stroke unit has increased, reaching 84% in early 2020. However, regional variations range widely between 50% and 93% in 2020, and only two regions attained the level above the national target of 90% (Janlöv et al., 2023[107]).
Note: Total number of hospitals, public or private, with dedicated stroke or coronary care units, ranked by stroke unit. The OECD average for stroke units is calculated over 24 OECD countries and includes France and Belgium but excludes Germany. The average for CVD units includes France and Belgium but excludes Germany due to data availability. Where 2022 data was unavailable, the most recent year was used. Bulgaria, Croatia and Romania are countries in process of accession to the OECD.
Source: ESC Atlas in General Cardiology (https://eatlas.escardio.org/).
4.3.4. Prescribing practices at hospital discharge generally conform to standards but adherence drops off in the long term
When someone is discharged from the hospital following a stroke, they are often prescribed a combination of medications aimed at preventing another stroke and managing underlying conditions. Commonly prescribed medications include anticoagulants, to reduce the occurrence of blood clots and statins to lower cholesterol levels. Blood pressure medications are also frequently used, especially if high blood pressure contributed to the stroke. Almost all (97%) of stroke patients receive anticoagulating drugs at discharge in countries that report data, while fewer receive statins (92%) and antihypertensive drugs (82%) (see Figure 4.25). While appropriate prescribing at discharge is key, effective co‑ordination with primary care is needed to ensure that medicines are taken consistently – and in most cases there is a steep drop between discharge and prescribing practices more than a year after the event. Findings from the OECD’s work on integrated care show that antihypertensive prescriptions within 18 months following stroke range from 83%‑68% in EU countries that are able to report the data (Figure 4.26), and antithrombotic prescriptions from 94% to 31%, with Sweden showing particularly strong performance – attributed, in part, to comprehensive diagnosis recording and co‑ordinated follow-up (Dahlgren et al., 2017[108]).
Percentage of Ischaemic Stroke Patients Receiving Medication at Discharge, 2024
Source: ESO (2024[109]), RES-Q, https://stroke.qualityregistry.org/.
Source: Data Collection on Integrated Care 2022-2023, and OECD Health Statistics Database 2025.
Cardiac implantable electronic devices (CIED) – such as cardiac resynchronisation therapy (CRT) devices, implantable cardioverter defibrillators (ICDs), and transcatheter aortic valve implantations (TAVI)–are important tools in the prevention of sudden cardiac death, treatment of advanced heart failure, and in offering improved survival and quality of life for patients.
Cardiac resynchronisation therapy (CRT) devices (also known as pacemakers) function by sending small amounts of electrical energy to the heart to help restore appropriate timing of heart beats in people with heart failure. The use of CRT devices varies 15‑fold across EU countries, ranging from 241 devices per million inhabitants in Germany to 16 devices per million inhabitants in Romania (see Figure 4.27). Between 2019 and 2022, the average number of CRT implantations rose slightly, from 109 to 113 per million inhabitants (EU21) – while decreasing in several countries such as Czechia, Austria, Poland, France, Hungary, Finland, the Slovak Republic and Malta. The limited growth of CRT procedures may be being impacted by stricter patient selection and evolving guidelines, where the patient population has been narrowed (Tymińska et al., 2022[110]). In addition, increased use of SGLT-Inhibitors in patients with heart failure (discussed in Section 4.9.3) may reduce the need for CRT by better managing condition progression (Crispino et al., 2025[111]).
Rate of CRT per 1 000 000 population
Note: The EU average is unweighted. Where data for 2019 or 2022 was unavailable, the most recent year was used.
Source: ESC Atlas of Cardiology (https://eatlas.escardio.org/).
The use of implantable cardioverter defibrillators (ICDs), which are used in people with serious arrhythmias, have likewise modestly increased on average across EU countries. On average, ICD implantations grew from 150 to 169 per million inhabitants (EU27) – and represent a 16‑fold difference between Germany and Romania (see Figure 4.28). Costs of implementation of ICDs can be substantial – in France the healthcare costs related to ICDs were assessed at EUR 15 893 per patient-year – only a third of which were estimated to be attributed to the device itself (Piot et al., 2022[112]). As with CRT, the indications for ICDs have narrowed over recent years, as survival benefits were not observed for patients with some forms of heart failure (Beggs et al., 2017[113]; Køber et al., 2016[114]). Likewise, improved medication management – for example through the use of beta-blockers and SGLT-Inhibitors, can improve management of heart failure and reduce need for ICDs by reducing the occurrence of arrythmias (Minguito-Carazo et al., 2024[115]).
Rate of ICD per 1 000 000 population
Note: The EU average is unweighted. Where data for 2019 or 2022 was unavailable, the most recent year was used.
Source: ESC Atlas of Cardiology (https://eatlas.escardio.org/).
TAVI is a minimally invasive procedure to replace a diseased aortic valve. It was initially developed as an alternative to open-heart surgery for patients deemed too high-risk for traditional surgical valve replacement – including older adults who are at high surgical risk. Compacted with traditional surgical options, TAVI often results in shorter hospital stays, quicker recovery and better outcomes (Lemor et al., 2019[116]). Currently, guidelines from the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) support the broader use in suitable patients (ESC/EACTS, 2021[117]). European countries have rapidly scaled up the use of TAVI procedures, which have more than doubled from 98 to 151 per million (EU27) between 2019 and 2022 (see Figure 4.29). Variation between the highest and lowest use of TAVI procedures varies almost six‑fold between countries, ranging from 49 TAVI procedures per million in the Slovak Republic to 285 procedures per million people in Germany. The costs of TAVI procedures are relatively high, assessed at EUR 26 684.1 in Spain and approximately USD 35 000 in Switzerland (Areces et al., 2021[118]; Manolis, 2017[119]).
Rate of TAVI per 1 000 000 population
Note: The EU average is unweighted. Where data for 2019 or 2022 was unavailable, the most recent year was used.
Source: ESC Atlas of Cardiology (https://eatlas.escardio.org/).
Germany consistently ranks as the highest in the number of implantations, with 241 CRT implantations, 453 ICDs, and 285 TAVIs per million inhabitants in 2022. Other countries with high use of implantable devices include Czechia, Belgium and Italy, all reporting strong growth across all three interventions. In contrast, Romania has the lowest number of selected interventional devices, with 16 CRT implantations, 28 ICDs, and 49 TAVI procedures per million inhabitants in 2022. Bulgaria, Latvia and Lithuania also show persistently lower rates across all three device types.
What are the main barriers in your country to the effective use of high-risk implantable cardiovascular device (ICDs, pacemakers, coronary stents, and artificial valves)
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Note: Where 2022 data was unavailable, the most recent year was used.
Source: ESC Atlas of Cardiology (https://eatlas.escardio.org/).
Research has found geographic variability of cardiac implantable electrical devices (CIED) implant rates to be correlated to the number of centres performing ICD implants, number of cardiologists, lack of infrastructure and low referral rate, thus highlighting the importance of integration of care between heart failure clinics, electrophysiology laboratories and general hospitals to facilitate CIED treatment (Valzania et al., 2016[120]). Findings from the 2025 OECD Cardiovascular Policy and Data Survey show that just under half of responding countries (8/17) did not report barriers to the use of cardiovascular implantable devices. Those that did, indicated that limited operating theatre availability is the greatest challenge for the effective use of high-risk cardiovascular implantable devices, followed by healthcare worker shortages, and regulatory barriers (see Figure 4.30). Countries with fewer hospitals implanting ICDs tend to have lower implantation rates (see Figure 4.31). In 2022, Romania had just 0.84 implanting hospitals per million population and recorded the lowest implantation rate at 28 per million. In contrast, Germany had the highest number of implanting hospitals at 7.99 per million and also reported the highest implantation rate at 453 per million population. This suggests that hospital capacity plays a critical role in enabling access to device‑based treatments – though supply induced demand should also be considered.
While having many benefits, such as improved survival and symptom relief, implantable devices also bring serious risks. For example, device‑related infections remain common. A study of CIED procedure patients found that within three months of the procedure, almost 3% had developed a major infection (Baldauf et al., 2024[121]). Other studies have shown that these adverse outcomes can exacerbate inequalities, as device related infections are found to be were more common in people of non-white race and from a low-income status (Modi et al., 2023[122]). Most surveyed countries note that there are clinical standards in place in their country for device implantation and follow-up or that there are national or regional registries in place for post-market surveillance and safety monitoring – such as for tracking device use, complications and reoperation rates, which could be useful for continuous improvements. Fewer countries have adopted systems for quality audits, such as professional peer review, compliance checks or have implemented systematic measurement of patient-reported outcomes or experiences related to CIED procedures (see Figure 4.32).
What are the mechanisms used to ensure quality and safety in using high-risk implantable cardiovascular devices (i.e. ICDs, pacemakers, coronary stents, and artificial valves)?
Note: N=18 EU+2 and OECD G20 countries (Austria, Canada, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
In OECD countries, waiting times are generally determined by needs to prioritise more urgent cases, or patients whose health is more at risk of deterioration without treatment (OECD, 2020[123]). For instance, median waiting times for coronary bypass, and transluminal coronary angioplasty are shorter than for hip and knee replacement (OECD, 2025[124]).
Waiting times in healthcare can lead to inequalities in access, particularly along socio‑economic lines. Research from several OECD countries shows that people with higher socio‑economic status often experience shorter waits for elective procedures like cataract surgery, hip and knee replacements, and coronary bypasses. This has been observed in countries such as Australia, England, Norway and Sweden (García-Corchero and Jiménez-Rubio, 2022[125]). Beyond fairness, long waits can also negatively affect patients’ health – especially for conditions that worsen quickly or when clinicians struggle to prioritise effectively. For example, long waits for coronary bypass surgery have been linked to worse symptoms, higher chances of emergency admissions, and even pre‑surgical mortality (Moscelli, Siciliani and Tonei, 2016[126]).
Interpreting waiting times for revascularisation of chronic coronary artery disease is more difficult than for STEMI and NSTEMI. Revascularisation for STEMI is strongly agreed to be required as soon as possible; there is a treatment window measured in hours within which it is known to be useful, and there are commonly agreed targets for median waiting time measured in minutes. For NSTEMI the target is for revascularisation within 24 hours. By contrast, elective cases (for chronic coronary syndrome) should be medically managed (with lifestyle changes and medications) in most cases, with a stepwise diagnostic strategy applied that prioritises non-invasive and functional testing (stress tests) in the first instance before moving to invasive testing (angiography) (ESC Guidelines, 2024[127]). Canadian Guidelines recommend PCI within six weeks for patients without high-risk anatomy and offer a target for bypass surgery in those with high-risk anatomy of 14 days and for all others, six weeks (Graham et al., 2006[128]). However, the European guidelines do not offer any guidance on timeframe, focussing instead on careful patient selection, maximising of medical management, and choice of revascularisation procedure (CABG vs. PCI) (ESC Guidelines, 2023[78]).
Cross country comparison of waiting times for elective coronary revascularisation procedures are therefore complicated by variability in use of these procedures for this indication across countries. Figure 4.33 shows wide variation in waiting times for coronary angioplasty surgeries, ranging from 1.5 days in Spain to over 40 days in Finland, Norway and the United Kingdom in 2024. At the same time, the share of patients waiting more than three months for this procedure was just 0% in Iceland and 1.5% in Hungary in 2024, compared to over 50% in Slovenia and Portugal.
Notes: 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. 3. EU candidate countries. For the left panel (mean days), data for the United Kingdom refer to 2021 instead of 2019. Data for the United Kingdom, Australia and Norway refer to 2023 instead of 2024. Data for Italy refer to 2022 instead of 2024. Data for Spain refer to 2020 instead of 2024. For Italy, Norway, Australia and the United Kingdom there was a change in definition. For the Netherlands and Australia there was a time series break in 2019.
For the right panel (% of patients waiting more than 3 months), data for Portugal and the United Kingdom refer to 2021 instead of 2019. Data for Spain refer to 2020 instead of 2024. For Slovenia and the United Kingdom there was a change in definition. For Norway, waiting times are over-estimated because they start from the date when a doctor refers a patient for specialist assessment up to the treatment (whereas in other countries they start only when a specialist has assessed the patient and decided to add the person on the waiting list for treatment).
Source: OECD Health Statistics 2025.
Figure 4.34 also shows large cross-country variation in waiting times for coronary artery bypass graft surgeries. In 2024, average waiting times were below 25 days in Sweden and Italy, while patients in Portugal, Norway and the United Kingdom waited more than three times as long (77, 100 and 106 days respectively). Overall reporting on timeliness indicators remains limited, and changes in definition for several countries (including Italy, Norway, Slovenia, the United Kingdom, the Netherlands and Australia) further limit the comparability of the available data. An analysis in Annex 4.E shows the relationship between waiting times and number of surgical procedures per 100 000 population in 2023. The data suggest only a weak association for angioplasty and no relationship for bypass graft, highlight that higher procedure rates are not clearly linked with shorter waiting times.
Besides variation in the time spent on non-invasive management of these cases, there will also be differences in the first instance before moving to invasive testing (angiography) (ESC Guidelines, 2024[127]). Approaches will vary with regard to the point in the process at which a specialist referral (the starting point of the measured time interval) occurs. Moreover, a system that appears more efficient in the delivery of reperfusion to chronic coronary syndrome cases may actually be less guideline compliant. Note also that relatively few countries are able to report on these indicators.
Notes: 1. non-EU European Economic Area countries. 2. non-EU OECD G20 countries. For the left panel (mean days), data for the United Kingdom refer to 2021 instead of 2019. Data for Norway and the United Kingdom refer to 2023 instead of 2023. Data for Italy refer to 2022 instead of 2024. For the Netherlands, Norway and the United Kingdom there has been a change in definition. For the Netherlands there has been a time series break in 2019.
For the right panel (% of patients waiting more than 3 months), data for the United Kingdom refer to 2021 instead of 2019. For the United Kingdom there has been a change in definition. For Norway, waiting times are over-estimated because they start from the date when a doctor refers a patient for specialist assessment up to the treatment (whereas in other countries they start only when a specialist has assessed the patient and decided to add the person on the waiting list for treatment).
Source: OECD Health Statistics 2025.
4.6.1. Mortality rates for AMI and ischaemic stroke have been falling but at different rates
Reductions in smoking and improvements in access to specialised care and treatment for heart diseases have contributed to a decline in mortality rates due to coronary heart disease over recent decades (OECD, 2015[129]). Despite this progress, the need for further reductions in risk factors (see Chapter 3) and care quality improvements remain as AMI is still one of the leading causes of death and the main cause of cardiovascular death in many OECD countries (OECD/The King's Fund, 2020[130]). Figure 4.35 shows the 30‑day mortality rate calculated based on linked data, whereby deaths are recorded regardless of where they occurred after hospital admission (in the hospital where the patient was initially admitted, after transfer to another hospital or after being discharged). Case fatality rates for AMI decreased substantially between 2011 and 2019, falling by 13% on average in EU countries. However, more recent progress has stalled. Between 2019 and 2023, 30‑day morality plateaued on average in EU countries, increasing by 1% during this time. There were a few exceptions, 30‑day mortality rate for AMI substantial declined in Iceland between 2019 and 2013 (by 32%) but increases of more than 10% were observed in Slovenia and Poland.
While 30‑day mortality rates are widely used to evaluate hospital performance and integration of post-discharge care, 24‑hour mortality rates can capture information on AMI and the effectiveness of emergency interventions. A high 24‑hour mortality rate may indicate delays in treatment or lack of access to advanced care. Twenty-four‑hour mortality rates are highest in Lithuania, Romania and Latvia (above 3.5 per 100 patients in 2023), while 24‑hour mortality rates are lowest in Italy and Spain (1.5 per 100 patients) (Figure 4.38). In Lithuania, Czechia, Poland and Belgium, more than 40% of AMI morality can be attributed to the first 24 hours after hospital admissions. This suggests a significance of access to and quality of emergency care to reduce mortality rates among people who had AMI.
Note: The EU average is unweighted. 1. Latest data from 2020‑2022. 2. Data do not include deaths outside acute care hospitals.
Source: OECD Health Statistics 2025.
Note: The EU average is unweighted. 1. Latest data from 2020‑2021.
Source: OECD Health Statistics 2025.
Treatment for ischaemic stroke has advanced dramatically over recent decades, with systems and processes now in place in many OECD countries often in stroke units to identify suspected ischaemic stroke patients and to deliver acute reperfusion therapy quickly. Figure 4.37 shows the case fatality rate where deaths are recorded regardless of where they occurred, including in another hospital or outside the hospital where the stroke was first recorded. Across EU countries, over 13% of patients died within 30 days of hospital admission for ischaemic stroke in 2023.
Note: The EU average is unweighted. 1. Latest data from 2020‑2022. 2. Data do not include deaths outside acute care hospitals.
Source: OECD Health Statistics 2025.
As with heart attack, 30‑day mortality rates for ischaemic stroke increased during the pandemic and a number of studies conducted in OECD countries have found that despite lower levels of admissions overall, admitted patients showed higher severity of stroke during the COVID‑19 pandemic than in the pre‑pandemic period, owing to delayed hospital arrival time for stroke patients due to emergency medical services processing time – particularly during the initial phase of the pandemic. Close clinical links with COVID‑19 also complicate assessment and monitoring of the resilience of health systems in ensuring access to and quality of acute care.
4.6.2. Stronger monitoring facilitates improvement in quality of CVD care
Clinical guidelines support the delivery of quality care in many CVD manifestations and also support the application of clinical quality standards and monitoring programmes (Chew et al., 2016[131]; ESC Guidelines, 2023[78]; Gulati et al., 2021[81]) and some countries monitor compliance to guideline recommendations. The Danish system has a comprehensive, publicly facing datasets on healthcare quality, including CVD quality, with extensive data not only on EMS but also on hospital care of CVD emergencies benchmarked against indicator targets and recent trends. An example of metrics used in Israel is illustrated in Box 4.6.
Monitoring and analysis of good quality process data can improve system performance. For example, a Dutch study showed a 9.2% reduction in door-to-groin puncture for endovascular thrombectomy in acute stroke patients with implementation of a process to provide performance feedback to hospitals and close monitoring of guideline adherence drives quality of care in German chest pain units (Vafaie et al., 2020[132]). The EuroHeart project – a collaboration between national quality registries and the European Society of Cardiology – aims to improve CVD care through international benchmarking based on quality indicators identified in four domains (Table 4.2). The 2024 report (ESC EuroHeart, 2024[133]) brings together data from 63 961 patients admitted with STEMI and NSTEMI across 8 countries in 2023 and identifies areas for improvement in participating countries. For example, the median time between hospital arrival and reperfusion in STEMI patients ranged between 15‑20 minutes in Sweden and 70 minutes or more in Romania, Portugal and Estonia. Reperfusion within 90 minutes of initial diagnosis in STEMI patients also varied from more than three‑fourths of patients in Hungary and Sweden to fewer than one in two patients in Estonia, France and Portugal.
Note: Percentage of patients with STEMI who receive timely reperfusion. Timely is defined as follows:
(i) for patients presenting at primary PCI hospitals, <60 min from initial STEMI diagnosis to infarct-related artery wire crossing.
(ii) for patients diagnosed either in a non-PCI hospital or in the out-of-hospital setting and then transferred to a PCI capable centre, <90 min from initial STEMI diagnosis to infarct-related artery wire crossing.
(iii) for patients treated with fibrinolysis, initiation of fibrinolysis within 10 minutes after STEMI diagnosis.
Source: ESC (2025[134]), “European Society of Cardiology quality indicators for the management of acute coronary syndromes: developed in collaboration with the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the ESC”, https://doi.org/10.1093/ehjacc/zuaf014.
In 2013 Israel has launched its National Program for Quality Indicators (NPQI), which measures outcomes at the levels of diagnosis, procedure and facility performance. Indicators are published at the disaggregated level of individual hospitals. Nationally aggregated results are released only after stable national adherence rates to a given protocol have been achieved.
Since the introduction of the program, adherence to optimal protocols has improved across several areas. For example, the median time from hospital arrival to head CT/MRI for patients with acute ischemic stroke was 55 minutes when the QI was first measured in 2015. By 2022, his had decreased to 25 minutes (MoH, 2023[135]). NPQI adds new indicators each year. In 2025 it will introduce and report on the rate of administration of intravenous thrombolytic therapy (IV rtPA) in acute ischemic stroke within 60 minutes (MoH[136]).
Acute myocardial infarction is one of the core goals of the program. Indicators for AMI care were developed to reflect the full care pathway – from initial patient contact and symptom recognition, through EMT treatment and triage, to coronary intervention. The primary QI in this area of care is PCI within 90 minutes for patients presenting with STEMI. This has been tracked since 2013, showing significant improvement in adherence rate, from 68% that year to 92% in 2019. The measure also captures disparities in adherence based on population features: adherence rate for older patients (over 65) and for women is lower (MoH, 2023[135]).
Additional indicators measured for AMI care are pre‑hospital administration of aspirin for suspected STEMI cases, pre‑informing the hospital of EC results in suspected cases (examining the interface between the ambulance team and the hospital’s emergency department), intensive statin treatment recommendation in discharge letters of patients with ACS and dispatcher-assisted CPR in suspected cardiac arrest. For stroke care, measured indicators are pre‑hospital standard stroke assessment for patients presenting related symptoms, pre‑informing the hospital of incoming suspected stroke patients, intravenous thrombolytic treatment and/or mechanical embolectomy for acute ischemic stroke, carotid duplex within 72 hours of ED admission for transient ischemic attack patients, and stroke risk assessment for patients with atrial fibrillation.
4.7.1. Performance varies widely in post-acute care, with one‑year mortality rates after stroke varying by two-fold, and 1.5 times for heart failure
After-care for acute cardiovascular events includes commencement of secondary prevention and risk factor modification. Because heart attack (AMI) and stroke both leave lasting morbidity burden in many cases, rehabilitation is a critical final piece of CVD care. Stroke and AMI can be physically and psychologically debilitating. A goal of care is the return of the patient to as near as possible their previous level of function. This can depend on active rehabilitation, whether in hospital or in the community. Well-functioning post-acute care will shorten acute hospital length of stay, moving the patient as early as possible to a more cost-effective and targeted environment. Other important goals of this phase include optimisation of secondary prevention and complication management (medication management and lifestyle modification), integration with community and primary care, and ongoing monitoring and readmission prevention.
Medication management has been essential in controlling my heart disease. Challenges include side effects, medication complexity, and occasional difficulties in obtaining refills or adjustments. Support from pharmacists and clinicians who listen and explain treatment goals has made adherence easier. Polypharmacy remains a concern and requires careful oversight.
Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.
Long-term indicators – such as one‑year mortality, hospital readmission rates, and follow-up medication prescriptions – offer valuable insights into the effectiveness of post-acute care co‑ordination and the continuity of care across settings. These metrics help reveal gaps in care transitions and assess the capacity of health systems to support sustained recovery and prevent avoidable complications. For patients with congestive heart failure or ischaemic stroke, such adverse outcomes are often preventable with timely, well-co‑ordinated, and integrated post-acute care (Barrenho et al., 2022[137]).
Note: The EU average is unweighted.
Source: OECD Health Statistics 2025.
Data from 2023 show considerable variation in post-acute outcomes following hospitalisations for ischaemic stroke and CHF across EU countries (Figure 4.38). On average, 60% of stroke patients survived without readmission within a year, while 24% were readmitted (5% for stroke‑related causes), and 16% died. For CHF patients, 43% survived without readmission, 33% were readmitted (11% for CHF-related causes), and 24% died within the year. One‑year mortality in EU countries ranged widely, from 7% to over 24% for stroke patients, and from 8% to 30% for CHF patients, depending on the country. Stroke‑related readmission rates varied from less than 2% to over 10%, and CHF-related readmissions from 5% to 17%.
Description: The OptiMedis integrated care model emerged in 2005 with the launch of Gesundes Kinzigtal in Baden-Württemberg, following reforms in Germany to promote care co‑ordination. Since then, OptiMedis has expanded its model of care to the German states of Hesse, Hamburg and Thuringia, aiming to improve patient experiences and population health while reducing per capita costs. A key feature of the care model is its “shared savings contract”, which incentivises the delivery of high-quality, preventative care. As part of this contract, positive differences between the money sickness funds receive from the country’s central payment authority and the mean costs of all enrolees is shared between the sickness funds and OptiMedis. In November 2023, Optimedis transferred its shares in Gesundes Kinzigtal GmbH and now focusses its activities on other German regions.
Best practice assessment:
Enhancement options: To enhance the performance of the OptiMedis model and other population-based integrated care models, policymakers could consider ways to better target patients at high-risk of complex health needs. This will allow patients to access preventative programmes sooner leading to better health outcomes while lowering costs. Other policies include, but are not limited to, expanding programmes targeting disadvantaged groups and applying more rigorous methodologies to future evaluation studies.
Transferability: The OptiMedis model exists in the west (state of Hesse) and south-west (state of Baden-Württemberg) of Germany, and there are discussions to expand it to other regions in the country. Any future implementations will need to incorporate the core features of the model, such as obtaining long-term contracts. Although not yet transferred to regions outside Germany, underlying features that support the model exist in most OECD countries – e.g. preventative care, case management, and electronic patient data sharing. Further, there are active discussions to transfer this model of care to Belgium and France.
Conclusion: OptiMedis is a population-based integrated care model operating in parts of Germany. The model has the potential to increase life years and DALYs gained, while simultaneously reducing healthcare costs. Feedback from OptiMedis administrators indicates that the model can be successfully transferred in other regions with different populations and health service arrangements.
Source: OECD (2023[5]), Integrating Care to Prevent and Manage Chronic Diseases: Best Practices in Public Health, OECD Publishing, Paris, https://doi.org/10.1787/9acc1b1d-en.
4.7.2. Post-acute and rehabilitative care is a necessary, and increasingly emphasised, component of CVD care
Effective rehabilitative care for patients with CVD is multidisciplinary and comprehensive, addressing not only physical recovery but also psychological, social, and occupational needs. Effective cardiac rehabilitation typically includes physical training, psychological counselling, speech therapy (where applicable), and social support, with the involvement of a co‑ordinated team that may include cardiologists, physiotherapists, nurses, psychologists, social workers, and occupational therapists. Best practice also requires a structured discharge plan from hospital, with clearly assigned responsibilities for ongoing rehabilitation and secondary prevention in the community. According to ESC guidelines, continuity of care and seamless transition between inpatient and outpatient rehabilitation phases are essential to improve quality of life, reduce hospital readmissions, and support long-term adherence to treatment and lifestyle changes (ESC Guidelines, 2021[138]).
My post-acute care was a mix of challenges and triumphs. While the medical interventions I received were lifesaving, the lack of a structured rehabilitation plan made recovery more difficult. It was only through my own persistence, including taking up running and philosophical counselling, that I regained my physical and mental health. A more coordinated approach to post-acute care could significantly improve outcomes for patients like me.
Caius, artist, researcher, patient advocate, and heart attack survivor.
While 81% of European countries have cardiac rehabilitation programmes available (Turk-Adawi et al., 2019[139]), a smaller number of countries explicitly incorporates rehabilitation and continuity of care into their national cardiovascular or noncommunicable disease (NCD) strategies. France, Ireland, Norway and the United Kingdom have well-established frameworks where cardiac rehabilitation is explicitly defined as a pillar of long-term CVD care. National regulation in France secures that all 140 dedicated cardiac rehabilitation centres are certified in multifaceted rehabilitation and patient education, and national guidelines in cardiac rehabilitation exits since 2012 (Iliou, 2022[140]). Ireland’s National Cardiovascular Health Policy supports structured rehabilitation as part of integrated care pathways (Department of Health, 2010[141]); Norway’s NCD strategy emphasises follow-up and rehabilitation through co‑ordinated services (Ministry of Health and Care Services, 2013[142]); and England’s NHS Long-Term Plan (NHS, 2024[143]) positions rehabilitation as a key element to improve post-CVD outcomes. Similarly, Luxembourg, Slovenia and the Netherlands have integrated rehabilitation within broader chronic care strategies. Luxembourg supports Phase II and III programmes through both hospital-based and community-led services (Beissel, 2019[144]); Slovenia offers multidisciplinary rehabilitation in specialised centres; and the Netherlands, while not having a standalone national CVD action plan, promote rehabilitation through national care standards and professional guidelines (World Health Observatory, 2021[145]). In Switzerland, there are national strategies for promoting regional networking of existing services in the areas of cardiovascular prevention and rehabilitation (Gassner and Reinsperger, 2021[146]).
Czechia has national coverage of rehab services through health insurance (Winnige et al., 2021[147]), while Estonia and Latvia mention rehabilitation as part of chronic disease management, particularly for stroke (Viigimaa, 2014[148]; Bērziņa et al., 2016[149]). Finland reimburses cardiac rehabilitation via its Social Insurance Institution and supports physical activity through national guidelines and patient courses aimed at aiding reintegration into daily life. Meanwhile, Germany uses the statutory pension insurance to fund a multi-phase rehab system – including vocational reintegration models such as the Hamburg plan – which supports patients’ gradual return to work after cardiac events (OECD/European Commission, 2025[150]). In Iceland, early stroke rehabilitation typically takes place at the National Hospital’s rehabilitation unit in the capital, or in local hospitals outside the city. Post-acute rehabilitation is provided in rehabilitation centres and outpatient clinics, offering services such as physiotherapy and speech therapy (King’s College London for the Stroke Alliance for Europe, 2017[151]).
Coordinating care between my cardiac condition and other health needs has been complex. Positive experiences involved a primary care physician who helped navigate specialist referrals and medication adjustments. Negative experiences included fragmented communication between providers and lack of shared health records, which sometimes led to duplicated tests or conflicting advice.
Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.
Other countries have made significant progress in defining the importance of post-acute care, though with more variable implementation. Canada incorporates rehabilitation via provincial programmes and the Heart & Stroke Foundation’s national efforts, with guidelines supporting secondary prevention and outpatient rehabilitation. Japan recognises post-acute care in national strategies and supports its inclusion through policies on chronic disease management and health literacy, although uptake remains modest. Türkiye includes cardiac rehabilitation in national NCD programmes and hospital care packages.
4.7.3. Challenges in implementation and uptake of cardiac rehabilitation
Despite formal inclusion in national strategies, countries face widespread challenges in ensuring equitable access to and participation in cardiac rehabilitation, which is further hindered by geographical disparities, shortages of specialised staff, lack of automatic referral systems, and weak integration into primary care. In Canada, service access varies by province, with rural areas particularly underserved (Grace et al., 2016[152]). In Türkiye, cardiac rehabilitation remains underutilised due to low awareness among health professionals and patients, despite its inclusion in clinical guidelines (Kayıkçıoğlu and Aslanger, 2020[153]). Czechia and Estonia offer insurance‑funded rehabilitation, but participation is inconsistent, and services are not uniformly structured (Winnige et al., 2021[147]; Viigimaa, 2014[148]). In Latvia, while early rehabilitation for stroke is available, long waiting lists and unclear care pathways affect the timeliness of the services. Further, community-based and long-term rehabilitation are still developing, with limited co‑ordination between medical, family, and social care (Bērziņa et al., 2016[149]).
Even in countries with structured systems, uptake and continuity remain challenging. In France, Ireland and the United Kingdom, national programmes are well developed, but patient referral rates and adherence remain below targets, and there is limited long-term follow-up (HSE, 2024[154]; BHF, 2022[155]; Iliou, 2022[140]). Luxembourg offers ambulatory and community-based rehab, yet coverage reaches only a fraction of eligible patients (Lion et al., 2021[156]). In Slovenia, services are concentrated in urban hospitals, creating access barriers for rural populations. The Netherlands and Norway report gaps in participation and variable quality, despite strong professional guidelines and supportive care models (Budig and Harding, 2021.[157]; Grimsmo, 2016[158]). Germany’s system allows for extensive vocational reintegration and staged return to work, but data suggest that many eligible patients, particularly older adults, do not fully benefit due to logistical and informational barriers (Wengemuth et al., 2025[159]). Finland, while offering community-based rehab and peer support activities, lacks comprehensive nationwide monitoring of rehab outcomes, which limits quality assurance (Lehto et al., 2018[160]). Across most EU countries, data systems to track participation, adherence, and outcomes are often weak or fragmented, impeding evaluation and continuous improvement of rehabilitation services.
Interventions such as discharge planning, interdisciplinary care, and standardised treatment protocols have been shown to reduce hospital length of stay while maintaining care quality (Siddique et al., 2021[161]). Investments in acute care responsiveness and the expansion of outpatient and rehabilitation services can further optimise resource use and improve patient outcomes. Integrated care has been shown to reduce mortality and hospital readmissions among patients with chronic heart failure (Yang et al., 2022[162]). In parallel, person-centred cardiovascular care that extends beyond hospital settings is associated with improved clinical outcomes and quality of life (Ebrahimi et al., 2021[163]). These approaches enhance the continuity and co‑ordination of care, ensuring better management of chronic conditions outside hospital environments. Integrated models have demonstrated improved outcomes for patients with cardiometabolic multimorbidity (Otieno et al., 2023[164]). Similarly, collaborative care interventions in primary settings have been associated with reductions in cardiovascular risk factors in patients with diabetes (Tu et al., 2024[165]).
Delayed discharge is often a symptom of inaccessible rehabilitative and long-term care
Unnecessarily prolonged hospitalisations of patients that would be ready for discharge are costly to healthcare systems (Landeiro et al., 2017[166]; Pellico-López et al., 2022[167]). They block beds and human resources, contribute to increasing waiting times, put patients and providers under strain, can contribute to worse health outcomes, and disrupt care (Kuluski et al., 2022[168]). A lack of availability of rehabilitation services and existing unmet needs in long-term care amid growing demand, have created shortages in long-term care capacity. As a result, long-term care providers are in high demand and long-term care facilities face long waiting lists. Even if beds are technically available, workforce shortages may prevent them from being utilised (Brazier et al., 2023[169]). A lack of long-term care and rehabilitation structures are a common cause for delayed discharges and incorrectly blame hospitals for issues outside their control (Kuluski et al., 2022[168]; van den Ende et al., 2023[170]).
Due to the stroke, I developed other health problems, at the level of muscles and joints… I have many contractures because of the lack of mobility and activity.
Diana, 48, stroke survivor.
Effective discharge planning is crucial to facilitate smooth transition from hospitals to post-acute care, can prevent readmissions and reduce adverse events. Poorly standardised discharge processes are linked to negative patient outcomes (Omonaiye et al., 2024[171]). Early discharge protocols, particularly for low-risk ST-elevation myocardial infarction (STEMI) patients, have been shown to be both safe and feasible, offering a viable path to reduced hospital stay lengths (Rathod et al., 2021[172]).
Countries can increase the supply of post-acute care structures to ensure that hospitals can transfer patients to medically appropriate and less cost-intense setting. Intermediate care structures, such as transitional care and rehabilitation services, and community-based models such as Hospital-at-Home, which aim at shortening or replacing hospital stays, have also demonstrated effectiveness. A meta‑analysis showed these models are associated with a 26% lower risk of readmission compared to standard hospital care (Arsenault-Lapierre et al., 2021[173]). Integrated stroke care pathways to improve patient-centred care have also shown potential to reduce hospital stay durations and improve outcomes. A Cochrane systematic review found that early supported discharge services for stroke patients reduced hospital stays by an average of five to six days, and significantly lowered the risk of long-term institutional care (Early Supported Discharge Trialists, 2017[174]).
Despite strategic commitments, participation rates in cardiac rehabilitation after hospital discharge for ST-elevation myocardial infarction (STEMI) remain relatively low across countries. Rates of rehabilitation participation after stroke are generally higher than for cardiac rehabilitation – though overall data coverage related to access to rehabilitation is poor and comparability is limited (Figure 4.39). On average, 9% of patients in Ireland (2023), 56% of patients in Norway (2023) and 63% in the United Kingdom (2023), and 89% in Czechia received post-stroke rehabilitation services (King's College London, 2024[175]).5 In Estonia, 31% of patients receive these services at the inpatient and 10% outpatient. Rates of cardiac rehabilitation at discharge range from 16% in Sweden to 97% in Czechia. These differences are related to the availability of rehabilitative care, coverage of rehabilitation in publicly funded healthcare, and the amount of co-payment, and a range of rehabilitation services also varies across countries. For example, inpatient rehabilitation care includes spa treatment which can be fully or partially reimbursed from social health insurance in Czechia (Bryndová et al., 2023[106]), while in Sweden, patients can participate in a physical exercise programme, led by a physiotherapist, at least two sessions per week for at least three months.
Note: 1. inpatient: 31.3%; outpatient: 10.0%; 2. Estimated: Approximately 5% is admitted to a rehabilitation centre and 35% to a geriatric rehabilitation department; 3. Includes STEMI and Non-STEMI.
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Countries are implementing policies to improve the quality and accessibility of post-acute and rehabilitative CVD care. The United Kingdom (England) has introduced task shifting, including nurse‑led hypertension and cholesterol clinics, pharmacist involvement in CVD risk management, and expanded roles for allied health professionals in rehabilitation. These changes aim to optimise resource use and enhance continuity of care. In France, besides introduction of quality assurance measures for rehabilitation care in the CVD national plan, there are strategies to co‑ordinate primary healthcare providers and mental health professionals during cardiac rehabilitation after stroke. Israel, Estonia, Latvia, the Netherlands, Norway, Sweden and the United Kingdom are developing health literacy programmes that support patient self-care and shared decision making, while Ireland is already implementing such a program.
Source: NHS (2024[176]), National Audit of Cardiac Rehabilitation, https://www.cardiacrehabilitation.org.uk/site/docs/NACR%20Quality%20and%20Outcomes%20Report%202024%20Final.pdf; 2025 OCED Cardiovascular Policy and Data Survey.
Ensuring a robust health workforce is critical for preventing CVD and improving patient outcomes. Health systems across Europe are confronting a workforce crunch that threatens care quality – a problem dubbed a “ticking time bomb” by the WHO Regional Office for Europe that, if left unaddressed, is almost certain to lead to poorer health outcomes, longer treatment waiting times and preventable deaths (WHO Regional Office for Europe, 2022[177]).
4.8.1. Workforce shortages represent a looming challenge for CVD care
Many health systems simply do not have enough clinicians to meet current and future needs for cardiovascular care. Twenty EU countries recently reported doctor shortages and 15 reported nurse shortages. In 2022, EU countries experienced a shortfall of approximately 1.2 million doctors, nurses, and midwives, based on the recommended minimum health worker densities needed to achieve universal health coverage (OECD/European Commission, 2024[178]). This gap reflects rising demand as populations age and chronic cardiac conditions become more common as well as constrained supply. Over one‑third of European doctors and one‑quarter of nurses are over the age of 55 and are nearing retirement, yet too few young graduates are replacing them. Interest in nursing careers declined in over half of EU countries from 2018 to 2022 (OECD/European Commission, 2024[178]). The WHO projects a shortage of 4.1 million health workers in the European Region by 2030, including 600 000 physicians and 2.3 million nurses (Zapata et al., 2023[179]; Boniol et al., 2022[180]; WHO, 2016[181]).
Such workforce deficits directly affect cardiac care. Inadequate staffing leads to longer waits for cardiac procedures and clinics, while treatment delays increase the risk of heart failure, complications, and death. In England, for example, record staff shortages in the National Health Service contributed to a backlog of over 380 000 patients waiting for cardiac care in 2023, with tens of thousands waiting well beyond recommended times for “time‑critical” heart treatments (BHF, 2023[182]).
Beyond aggregate numbers, maldistribution of the workforce poses another challenge. Within and between countries, there are disparities in access to qualified health professionals. Rural and remote regions often struggle to attract GPs as well as specialists, creating “medical deserts”. Hospitals in many rural areas across Europe report chronic shortages of doctors, nurses, pharmacists and technicians, leaving insufficient staffing to meet medical needs (EPHA, 2024[183]). In primary care, maldistribution means some communities have few or no GPs, undermining preventive services for CVD risk factors. On average, only one in five physicians in the EU is a GP, suggesting a possible imbalance favouring specialists over family doctors (OECD/European Commission, 2024[178]). Geographic inequities in provider supply can translate into inequities in outcomes. When it comes to management and secondary prevention following AMI and heart failure, a study from the United States found that low cardiologist density is associated with modestly higher 30‑day and 1‑year risk of mortality (Kulkarni et al., 2013[184]).
Similarly important to the number and location of the workforce is its composition and how well teams function across settings in a co‑ordinated manner through interaction and information sharing. Modern cardiovascular care relies on multidisciplinary teams: cardiologists, GPs, specialised nurses, mid-level providers, rehabilitation specialists, pharmacists, and others – and each play a critical role along the care continuum. An adequate mix of skills is indispensable for effective delivery of care, and evidence suggests that team-based approaches improve patient outcomes. For example, involving specialist nurses in cardiac care has been found to reduce hospital readmissions and improve patients’ adherence to treatments (Price, 2012[185]). Nurse‑led hypertension management has been shown to improve blood pressure control and medication adherence (Stephen et al., 2022[186]).
Involving pharmacists in medication reviews and adherence programmes can reduce cardiovascular risk, especially in older patients with multiple prescriptions (Zillich et al., 2014[187]). Collaborative care models that integrate pharmacists into the primary care team have demonstrated better control of key cardiovascular risk factors. Pharmacists, as accessible medication experts, help optimise therapy and improve adherence yet remain underused in many countries (Valliant et al., 2022[188]). Strengthening the multidisciplinary “heart team concept” can yield benefits even in specialised care. A non-randomised observational study found that complex cardiac patients managed by a multidisciplinary heart team has significantly higher survival probability than those whose care was decided by a general cardiology team (Sardari Nia et al., 2021[189]).
Expanding the skill mix through new roles is another policy lever. OECD countries are enabling advanced practice nurses or physician assistants to take on some tasks traditionally done by doctors. This can free up cardiologists for the most complex cases while ensuring routine hypertension or cholesterol management is still closely supervised by skilled providers. For example, advanced practice nurses can manage stable coronary artery disease patients or run prevention clinics, with physician oversight as needed. Such task-sharing can not only mitigate the impact of doctor shortages but can improve patient experience trough more continuous support. However, not all health systems currently recognise or train specialist CVD nurses or other mid-level practitioners. Investments in training programmes to develop these roles and revise regulations to permit full use of their competencies are key. Reskilling and upskilling the existing workforce is essential to create effective multidisciplinary teams.
Scotland’s Heart Disease Action Plan (2021) explicitly prioritised workforce development – one of its four pillars is ensuring appropriate staff resources and training to deliver timely, equitable heart care across the country (Scottish Government, 2021[190]). Spain’s cardiovascular health strategy emphasises multi-disciplinary units and improved training as keys to better outcomes (Bueno et al., 2025[191]).
4.8.2. A pivot to prevention for a “high-tech, high-touch” workforce
As healthcare evolves, so do the skills required by the workforce. Two areas stand out as particularly important for CVD care: digital health literacy and prevention expertise. The COVID‑19 pandemic accelerated the adoption of telemedicine and remote monitoring for chronic diseases like heart failure (Chapter 5). Going forward, clinicians will increasingly draw on digital tools to enhance cardiovascular prevention and disease management. To be effective, these need to be integrated into clinical workflow.
Surveys from the United Kingdom and Australia show that while uptake of tools like electronic health records is near-universal, comfort with data interpretation and telemonitoring remains variable, especially among older practitioners (Socha-Dietrich, 2021[192]), not to mention next generation advances like Artificial Intelligence (Almyranti et al., 2024[193]). Workforce policies that support digital training and access to technology are essential, as health professionals need competencies in using electronic health records, telehealth platforms, and data analytics. For example, telemonitoring of heart failure patients can flag early warning signs and has been shown to reduce hospital readmissions and mortality (Knoll et al., 2023[194]). To capitalise on such innovations, countries can strengthen capacity by incorporating digital health modules into medical and nursing curricula and offering continuing education so that even mid-career providers can confidently use new systems.
Harnessing digital tools can also extend the reach of scarce specialists – for instance, a cardiologist in a tertiary centre can remotely consult on patients in rural clinics, or a single heart failure nurse can manage a larger caseload via telephonic follow-ups and app-based check-ins. Embracing e‑health and mobile health solutions will be essential to improve CVD outcomes without solely relying on expanding the workforce (EC, 2024[195]). Leveraging technology is one strategy to augment health worker productivity and free up time for direct patient care (OECD/European Commission, 2024[178]), thereby partially offsetting workforce constraints.
Soft skills will become increasingly important not only because the heavy, cognitive work will increasingly be done by algorithms and large language models, but the strong evidence pointing the comparative effectiveness of team-based prevention and care in CVD and other diseases (OECD, 2019[196]; Socha-Dietrich, 2021[192]; Slawomirski et al., 2025[197]). As health systems aim to reduce inequities in cardiovascular outcomes, cultural competence and equity-oriented training are increasingly essential. CVD disproportionately affects low-income, Indigenous, and migrant populations in many OECD countries. A workforce that understands these dynamics – and is equipped to respond respectfully and effectively – is critical.
4.9.1. Several new medicines show modest improvements in cardiovascular outcomes or challenge health systems on coverage decisions
Innovation in cardiovascular medications is not just a clinical breakthrough – it is a systems-level challenge and opportunity. Recent advances in cardiovascular medication have introduced several new therapies that may offer both targeted cardiovascular benefits and broader clinical advantages, particularly for high-risk patient populations. However, many of these new medicines – such as direct oral anticoagulants (DOACs), PCSK9 inhibitors and SGLT2 inhibitors – demonstrate only modest added clinical value compared to the standard of care (Annex 4.F). As indications expand, so too does the potential budgetary impact, raising important questions about cost-effectiveness and long-term system sustainability.
As a result, health technology assessments conducted by several EU national competent authorities have evaluated the relative clinical benefit of these therapies and restricted their use as first-line treatments to select high-risk populations. As illustrated in Figure 4.40, more than half of responding countries report placing specific access restrictions to high-cost CVD medicines such as PCSK9 inhibitors and SGLT2 inhibitors. These restrictions are designed to manage uptake in line with clinical evidence, assessment of relative effectiveness compared to standard of care, and cost-effectiveness considerations. Decisions based on the assessments inform reimbursement decisions covered by government or compulsory insurance schemes, ensuring that access is prioritised for patients most likely to benefit, and hence, the implementation of these health authority requirements is crucial.
Note: N=19 EU and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
4.9.2. PCSK9 inhibitors offer only modest additional reductions in cardiovascular risk, compared to standard of care (statins and ezetimibe)
PCSK9 inhibitors are particularly beneficial for patients who fail to achieve target low-density lipoprotein cholesterol (LDL-C) levels despite receiving first-line treatments such as statins and/or ezetimibe (Mayor, 2016[198]). PCSK9‑targeting therapies including monoclonal antibodies (evolocumab, alirocumab) and the small interfering RNA (inclisiran) represent a notable advancement in lipid-lowering treatment and are increasingly used in European countries (Annex 4.G) (Tamargo et al., 2024[199]). Large scale clinical trials have demonstrated that PCSK9 inhibitors can lower LDL-C levels by up to 60%, offering an important option for individuals with refractory hypercholesterolemia at high risk of CVD (Sabatine et al., 2017[200]; Schwartz et al., 2018[201]).
After about 25 years of taking statins side effects became obvious – muscle pain and shrinkage – after taking different other statins and Bepidomin acid (Nustendi) the cardiologist finally prescribed PCSK9 inhibitor (Repatha) – no side effects yet and very effective.
Ulrich, 65, retired military officer, heart attack and transient ischaemic attack survivor, living with high cholesterol, arrhythmia and heart failure.
However, the clinical benefits beyond LDL-C reduction are more limited. A Cochrane review of 24 randomised controlled trials involving nearly 61 000 participants (18 on alirocumab, 6 on evolocumab) found that when compared to placebo, both alirocumab and evolocumab demonstrate modest absolute benefits in reducing CVD events (RD (risk difference): ‑2%; RD:‑2%), and myocardial infarction (RD:‑2%; RD: ‑1%) (Schmidt et al., 2020[202]). Compared to established standard of care (statins and ezetimibe), PCSK9 inhibitors offer only modest additional reductions in cardiovascular risk, with uncertain evidence of meaningful benefit in patients whose LDL-C is already well-controlled. Reflecting this, ESC clinical guidelines recommend PSCK9 inhibitors primarily for patients with primary hypercholesterolemia, mixed dyslipidemia, or established atherosclerotic CVD who are resistant to standard therapy (ESC Guidelines, 2019[31]). Research suggests that the prevalence statin intolerance, for example, is between 8 and 10% (Bytyçi et al., 2022[203]).
This selective use of PSCK9 inhibitors is reflected in HTA decisions. For instance, France’s Haute Autorité de Santé (HAS) concluded that evolocumab offers no significant clinical benefit over existing therapies for the general population (HAS, 2018[204]) and restricts reimbursement to high-risk subgroups. Similar recommendations have been issued in 2018 by the Gemeinsamer Bundesausschuss (G-BA), the Federal Joint Committee, in Germany (Federal Joint Committee, 2018[205]). England’s National Institute for Health and Care Excellence (NICE) also recommended restricted use of inclisiran in 2021 to those with pre‑existing cardiovascular events and intolerance to statins (NICE, 2021[206]). Several countries restrict use of PCSK9 inhibitors only after first-line treatment with statins fails to deliver health improvements as shown in Annex Table 4.F.1..
4.9.3. Wider clinical applications of SGLT2 inhibitors have accelerated uptake but questions about its economic value remain
Originally developed as glucose‑lowering agents for type 2 diabetes mellitus (T2DM), SGLT2 inhibitors such as empagliflozin and dapagliflozin have rapidly evolved into key therapies for heart failure and chronic kidney disease (CKD) (Talha, Anker and Butler, 2023[207]). Clinical trials have shown that these agents provide important cardiovascular and renal benefits, particularly for patients with HFrEF, CKD and, more recently, heart failure with preserved ejection fraction (HFpEF) (McMurray et al., 2019[208]; Heerspink et al., 2020[209]; Zannad et al., 2020[210]; Voors et al., 2022[211]). They are now widely recommended in clinical guidelines for use in management of chronic, stable HFrEF to reduce cardiovascular death and hospitalisations for heart failure, with and without diabetes (ESC Guidelines, 2023[212]; Heidenreich et al., 2022[44]).
Although some studies report modest reductions in cardiovascular and all-cause mortality, especially in patients with HFrEF (Svanström et al., 2024[213]), the mortality benefit remains limited in broader populations. Nevertheless, consistent reductions in hospitalisations for heart failure and renal decline across subgroups have positioned SGLT2 inhibitors as a cornerstone in the management of chronic heart failure and multimorbidity in cardiovascular care (Talha, Anker and Butler, 2023[207]; Usman et al., 2024[214]).
The expanding clinical profile of SGLT2 inhibitors has broadened the population eligible for treatment and driven increased utilisation across European countries (see Annex 4.G). Originally a second-line treatment for diabetes, SGLT2 inhibitors are now frontline option for multiple chronic diseases common in ageing populations. In the Netherlands, for example, they are now first-line therapy for T2DM patients at a very high risk for cardiovascular risk. Analysis of this guideline found that the 5‑year budget impact of the adoption the treatment guideline was over EUR 350 million, alongside nearly 4 400 quality adjusted life years (QALYs) gained (van Schoonhoven et al., 2023[215]). The marked increase since 2021, in particular, can be attributed to the publication of the previously mentioned EMPEROR-Preserve trial and expanded approved indications by the European Medicines Agency the following year (Anker et al., 2021[216]; European Commission, 2022[217]).
4.9.4. The rising use of GLP‑1s impacts both coverage decisions and financial burden for countries
Originally prescribed for diabetes treatment, Glucagon-Like Peptide‑1 Receptor Agonists (GLP‑1 RAs), and are now authorised to treat obesity in 13 of 17 surveyed OECD countries (Mathieu-Bolh, forthcoming[218]). Three different molecules are being used for obesity treatment: liraglutide, semaglutide, and tirzepatide. Besides their effectiveness to reduce body mass index (BMI), studies show that obesity treatment relying on GLP‑1 RAs results in a reduction of weight‑related co-morbidities that are risk factor of CVDs, as well as major cardio-vascular events, particularly in diabetics at high risk.
Cardiovascular effects are commonly assessed using hazard ratio (HR), which compare the risk of events over time between a treatment and standard care groups. A key outcome measure is Major Adverse Cardiovascular Events (MACE), typically comprising cardiovascular death, non-fatal myocardial infarction (heart attack), and non-fatal stroke. Badve et al. (2025[219]) report that in patients with type‑2 diabetes, GLP‑1 RAs reduce MACE by 13% (HR 0.87, 0.81‑0·93) compared to placebo (Haute Autorite de Sante (HAS), 2024[220]) and the SELECT trial findings a 20% reduction in MACE among non-diabetic obese patients with preexisting CVD (HR 0.80; 95% CI: 0.72‑0.90) (Lincoff et al., 2023[221]). The lowered risk of cardiovascular events associated to GLP‑1 RAs is confirmed when each event is studied separately. Xie, Choi and Al-Aly (2025[222]) find that against standard care, GLP‑1RA use was linked to a lower risk of each cardiovascular events studied. It was associated with a reduced likelihood of myocardial infarction (HR 0.91), cardiac arrest (HR 0.78), and incident heart failure (HR 0.89). Additionally, the risk of ischemic stroke (HR 0.93) and haemorrhagic stroke (HR 0.86) was also decreased.
GLP‑1 RAs have also shown significant effects on key CVD risk factors, such as high blood sugar among diabetic patients – with different medications demonstrating differing levels of effectiveness. A meta‑analysis by Wen et al. (2025[223]) finds that tirzepatide is among the most effective GLP‑1 Ras in lowering blood sugar levels compared to placebo. Similarly, Yao et al. (2024[224]) report that tirzepatide induced the largest decrease in HbA1c – an average decrease of 2.10% (−2.47% to −1.74%)–among 15 drugs, including experimental drugs, such as the combination of cagrilintide and semaglutide. Evidence from SURMOUNT‑2 and SURPASS trials, reviewed by NICE (NICE, 2024[225]) further indicates that tirzepatide yields greater reductions in both weight and blood sugar levels in patients with T2DM compared to those without. Beyond BMI reduction, GLP‑1 RA’s have also been associated with improvements in hypertension and dyslipidemia. According to INESSS (2022[226]), terzepatide showed the largest reduction in systolic blood pressure among GLP‑1 Ras, with a mean decrease of ‑6.2 mmHg (95% CI: ‑7.7 to ‑4.8) compared to the two other GLP‑1 RAs. Gudzune and Kushner (2024[227]) report an even greater reduction of ‑8.6mmHG. However, NICE (2024[225]) found no statistically significant difference in systolic blood pressure improvement between tirzepatide 15 mg and semaglutide 2.4 mg, though specific data remain confidential. Regarding lipid profiles, tirzepatide appears to significantly reduce LDL-C levels and may be outperform other GLP‑1 RAs. Yet, findings on its comparative effectiveness versus semaglutide are mixed, with studies from (NICE, 2024[225]; INESSS, 2022[226]; Yao et al., 2024[228]; Gudzune and Kushner, 2024[227]), yielding inconsistent results.
However, there is currently little evidence of long-term effects of GLP‑1 RAs for CVD risk prevention or treatment. While side effects of GLP‑1 RAs effect are frequent and essentially gastrointestinal effects, treatment discontinuation appears to be highly frequent with GLP‑1 RAs. Patients regain weight after treatment is stopped and there is no evidence of durable long-term effects of those treatments. The Institute for Clinical and Economic Review (2022[229]) explains that if patients do not have initial co-morbidities, trials show no evidence of effects of GLP‑1 RAs on morbidity or mortality.
Bariatric surgery may be more effective at preventing CVDs than GLP‑1 RAs. Bariatric surgery appears to yield larger short and long-term weight loss than GLP‑1 RAs and is also considered the most effective treatment against type‑2 diabetes mellitus (Hsu and Farrell, 2023[230]). Bariatric surgery is associated with lower mortality compared to GLP‑1RAs for patients with diabetes duration of 10 years or less (Dicker et al., 2024[231]). There is no difference between bariatric surgery and GLP‑1 RAs regarding non-fatal MACE for patients with diabetes duration of 10 years or less (Dicker et al., 2024[231]).
A recent OECD review on GLP‑1 receptor agonists (GLP‑1 RAs) shows these may not be cost-effective according to commonly used HTA thresholds (e.g. $50 000/QALY) (Mathieu-Bolh, forthcoming[218]). For example, in the United States, current prices for semaglutide would need to fall by nearly 90% to meet typical cost-effectiveness thresholds. Exceptions are limited, with some United Kingdom-based studies showing more favourable results. Cost effectiveness may be reached in some countries when those drugs are prescribed to limited population groups, such as patients with high BMIs and related co-morbidities. Most budget impact analyses for GLP‑1 RAs used in obesity management suggest that they may not be affordable for the entire eligible population. The financial burden is growing rapidly, as seen in Medicare Part D spending, which jumped from USD 57 million in 2018 to USD 5.7 billion to treat T2DM with GLP‑1 RAS in 2022. Other countries, like the United Kingdom and France, have also flagged concerns over the high budget impact, with national health systems expressing hesitation or applying access restrictions due to cost-related uncertainties.
Lowering the cost of GLP‑1 RAs could significantly improve their cost-effectiveness. This may be achieved through greater availability of generic or biosimilar versions, especially as patents begin to expire between 2023 and 2039. Competition from new therapies is also expected to reshape the market. These include next-generation weight‑loss drugs – such as dual- and tri‑agonists, GLP‑1 analogues combined with other agents like cagrilintide, and innovative oral formulations – which have shown promising early trial results with greater weight‑loss efficacy than current treatments (Wen et al., 2024[232]). These developments could enhance therapeutic value while increasing pricing pressure on existing GLP‑1 RAs, potentially improving their affordability and public health impact over time (Mathieu-Bolh, forthcoming[218]).
4.9.5. Cardiometabolic pipeline growth: Is innovation targeting unmet medical needs?
Despite CVD being the leading cause of mortality globally and accounting for a significant portion of the healthcare burdens in Europe, research and development investment has historically lagged fields like oncology, neurology, and infectious diseases (IQVIA Institute, 2024[233]). This underinvestment stands in stark contrast to the scale of cardiovascular need: millions of Europeans live with heart failure, hypertension, or atherosclerosis, conditions that drive up hospital admissions and long-term care costs. In 2023, only 5% of documented clinical trials related to cardiovascular conditions – and only 21 novel active substances were introduced between 2014 and 2023 – among fewest launches per therapeutic area (Figure 4.41) (IQVIA Institute, 2024[233]).
Source: IQVIA Institute (2024[233]), Global Trends in R&D 2024, https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/global-trends-in-r-and-d-2024-activity-productivity-and-enablers.
Even so, cardiometabolic disease appears to be re‑emerging in the research and development pipeline of the pharmaceutical industry with a shift to therapies targeting obesity, diabetes, kidney disease, and NASH (Non-Alcoholic Steatohepatitis) (IQVIA, 2023[234]). While several new therapies have been developed, they only provide incremental improvements over established treatments, raising concerns about alignment between R&D priorities and the most pressing unmet medical needs. PCSK9 inhibitors only modestly reduce CVD events, particularly when used alongside statins. SGLT2 inhibitors are effective in reducing hospitalisation for heart failure for a subpopulation of patients with heart failure with HFrEF but evidence on their cost-effectiveness remains uncertain.
The key question is whether current clinical trial activity aligns with the most pressing medical needs. The industry pipeline features a wave of next-generation agents, including dual- and tri‑agonists targeting GLP‑1, GIP, and glucagon receptors (IQVIA, 2023[234]). Oral formulations and novel combinations – such as GLP‑1 with amylin analogues – aim to improve both efficacy and patient convenience. In heart failure, innovation is progressing with therapies like cardiac myosin activators and anti‑inflammatory agents. Precision medicine is gaining traction, with treatment strategies increasingly targeting metabolic and inflammatory pathways. Lipid management is evolving beyond statins, focussing on new targets like lipoprotein(a), ApoC-III (apolipoprotein C-III), and ANGPTL3 (angiopoietin‐like protein 3). RNA-based therapies, including small interfering RNAs (siRNAs) and antisense oligonucleotides, offer promising solutions for patients with genetic dyslipidemia or residual cardiovascular risk (IQVIA, 2023[234]). Non-alcoholic steatohepatitis (NASH) remains a major unmet need with no approved treatments. The pipeline is diverse, addressing metabolic, inflammatory, and fibrotic pathways through agents such as FXR (farnesoid X receptor) and PPAR (peroxisome proliferator-activated receptor) agonists, GLP‑1 analogues, and thyroid hormone receptor agonists, with the goal of preventing progression to cirrhosis and liver failure. Cross-cutting therapies – such as IL‑1 (interleukin‑1) inhibitors, NLRP3 (nucleotide‑binding domain, leucine‑rich – containing family, pyrin domain – containing‑3) inflammasome blockers, and anti-fibrotic agents – are also being explored across multiple indications, including heart failure, NASH, and atherosclerosis (IQVIA, 2023[234]).
This chapter has explored the quality of cardiovascular care across the continuum – from primary, emergency and acute treatment to post-acute and rehabilitative care. While many countries have made progress in expanding access to life‑saving interventions and improving adherence to recommended care practices, significant gaps remain in timeliness and quality of care, equitable access, and long-term follow-up. Post-acute care remains a critical but underdeveloped opportunity to reduce long-term mortality and improve recovery. Across all stages of care, better data is essential to monitor quality, guide improvements, and ensure accountability – an issue that will be addressed in detail in the next chapter.
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Percentage of primary care users aged 45 and older that report receiving advice on physical activity by a healthcare professional
Note: Having received advice on physical activity refers to those that responded “yes” to the question: “In the past 12 months has any Healthcare professional talked with you about your physical activity”. All within country differences are statistically significant except for Greece, Italy, and the United States. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
Percentage of primary care users aged 45 and older that reported receiving advice on healthy eating by a healthcare professional
Note: Having received advice on healthy eating refers to those that responded “yes” to the question: “In the past 12 months has any Healthcare professional talked with you about healthy eating”. All within country differences are statistically significant except for Greece, Italy, Romania, Australia and the United States. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
Percentage of primary care users aged 45 and older reporting having a care plan
Note:.In this analysis CVD includes people reporting hypertension. Response to the question: “Do you have a care plan that takes into account all your health and well-being needs?” (Yes). Differences between people with CVD (including hypertension) and those with CVD and diabetes are statistically significant in Belgium, Italy, Norway, and Australia. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** the United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
The OECD estimated the cost that could have had been saved through reducing hospital admissions for CVD based on data available in Luengo-Fernandez et al. (2023), Australian Institute of Health and Welfare (2024), Ministry of Health, Labour and Welfare in Japan (2024), Haidar et al. (2025), Cheema et al. (2022), OECD Health Statistics and EUROSTAT (Annex Table 4.B.1). Luengo-Fernandez et al. (2023) provided the unit cost of inpatient care for CVD in 2021 collected from national experts in each EU country. Australian Institute of Health and Welfare (2024), Ministry of Health, Labour and Welfare in Japan (2024), Haidar et al. (2025) and Cheema et al. (2022) provided total cost for CVD inpatient care for Australia, Japan, the United Kingdom and the Uinted States for years between 2020 and 2022, and the unit cost was derived for these countries by dividing the total hospital cost for CVD care with the number of hospital admissions for CVD available in OECD Health Statistics or in the literature. Since 2023 data on hospital admissions are available for most countries, the unit cost for 2023 was extrapolated by using consumer price index which is widely available, although the price change in healthcare is different from that for the entire economy.
Using OECD’s hospital admission rates, supplemented by EUROSTAT data, Haidar et al. (2025) and Cheema et al. (2022), the difference between hospital admissions for CVD per population and the lowest CVD hospital admission rate in 2023 (or nearest year) was calculated for each country. If hospital admission data is available only for a year earlier than 2023 for any country, this data was used as a proxy. In 2023, hospital admission rates in Chile (712 per 100 000 population), Colombia (325 per 100 000 population), Costa Rica (367 per 100 000 population) and Mexico (201 per 100 000 population) were lower than that of Canada (944 per 100 000 population) but data for Canada was used as a benchmark. This is because low rates in Latin American countries are likely related to relatively low accessibility to hospital care, compared to other OECD countries, and data comparability issues due to non-inclusion of admissions to private hospitals.
To estimate the total cost saving, the difference in CVD hospital admissions per 100 000 population for 2023 was converted to the number of hospital admissions for CVD by multiplying population data available at the OECD, and the number of hospital admissions for CVD was multiplied by the estimated 2023 unit cost for each country. To assess economic impact on healthcare system, cost saving in hospital care for CVD was divided by total health spending for each country (Annex Table 4.B.2).
Note For Cyprus and Malta, hospital admission data come from EUROSTAT. Hospital admission rates for the United Kingdom and the United States are derived from Haidar et al.(2025) and Cheema et al.(2022).
Source: (Luengo-Fernandez et al., 2023[235]; Australian Institute of Health and Welfare, 2024[236]; Ministry of Health, Labour and Welfare, 2024[237]; Haidar et al., 2025[238]; Cheema et al., 2022[239]), OECD Health Statistics and EUROSTAT.
Source: CZE, EST, – (Kalda et al., 2023[240]); DEU, ESP, HUN, IRL, LVA, LTU, NLD, NOR – (Bos et al., 2015[241]); LVA – (Behmane et al., 2019[242]); NOR – (Zakariassen, Burman and Hunskaar, 2010[243]), GBR (England) – (UK Government, 2025[244]).
Emergency care, including bystander response, prehospital or ambulance care, hospital ED care and the unplanned delivery of urgent interventional care, is essential to management of acute CVD. AMI and stroke are both amenable to urgent treatments which reduce long-term morbidity and mortality, but these treatments have treatment windows measured in minutes to hours. Cardiac arrest requires near immediate treatment to begin in the community and continue through to hospital in order to get the best outcomes. Many acute CVD manifestations all have potential to deteriorate rapidly leading to death or significantly worsened health if not managed promptly.
Population access to, and effective delivery of, these therapies depend on integrated systems of care (ESC Guidelines, 2023[78]). Timely diagnosis depends upon a populace who are educated to recognise high risk symptoms and who are confident to call EMS and provide first aid when these occur, and on trained EMS (ambulance) providers, working in a system that is resourced for timely responsiveness, and that is well integrated with hospital EDs, and with cardiac and neurology interventional units and imaging departments within hospitals. Some other manifestations of CVD such as CHF and atrial fibrillation (AF) can present to the emergency care system because of the suddenness of onset of symptoms, the degree of distress they cause, or the difficulty patients have in accessing care for them outside the ED.
Determining the classification of an AMI as a STEMI or non-STEMI, and subsequent treatment options, requires testing for anomalies in the heart function using ECG readings (see Annex Box 4.D.1). Well-functioning EMS services are able to perform and interpret (or transmit for interpretation) lead ECG in the field. This investigation, along with time of onset of symptoms, provides the critical information for diagnosis and initial treatment. Early administration of aspirin, and prompt revascularisation (opening of a blocked artery, whether by thrombolytic agent or by PCI) both carry significant mortality reduction benefits. Other important therapies include further antithrombotics, lipid lowering agents and blood pressure control agents. Admission to a coronary care unit allows for cardiac monitoring and rapid defibrillation in the event of a dangerous disturbance to cardiac rhythm in the acute phase of the illness. This is followed by a period of cardiac rehabilitation aimed at restoring premorbid level of function and addressing lifestyle factors that can modify cardiac risk factors.
Acute myocardial infarction (AMI) is part of the spectrum of disease known as acute coronary syndrome (ACS). ACS occurs when there is a sudden limitation to flow of blood through one of the coronary arteries that feed the heart muscle with blood. Partial blockages reduce flow, causing pain, breathlessness and other acute symptom without causing the death of cardiac muscle. AMI occurs when the blockage is so severe that cardiac muscle cells start to die. The first step in risk stratification of patients with symptoms consistent with ACS is the Electrocardiogram (ECG). An ECG abnormality called ST segment elevation indicates the presence of the more severe category of AMI called a STEMI, or ST elevation myocardial infarction. STEMIs result from complete blockage of a coronary artery (the blood vessels that feed the heart muscle) with fresh clot that has formed on the surface of an atherosclerotic plaque. Mortality and morbidity are significantly reduced by urgent reopening of that artery, referred to as urgent revascularisation. This is ideally performed by primary percutaneous coronary intervention (PPCI), a minimally invasive procedure in which a wire is introduced via a needle at the wrist, into the obstructed coronary artery, and a ballon inflated over that wire to force the artery open. A stent (a metal device to keep that artery open) is then placed. The best results are achieved when the artery is opened within an hour of symptom onset, but there are significant benefits with up to 6 hours of symptoms and some persistent benefits out to 12 hours (KAMIR-NIH, 2021[245]). When PPCI cannot be performed promptly (within 90‑120 minutes, for example when the AMI is diagnosed at a non-PPCI capable hospital), a thrombolytic drug may be administered to break down the clot causing the occlusion, and a PCI performed in a semi-planned fashion (after transfer, ideally within 24 hours.).
Patients suffering ACS symptoms without elevation of the ST segment on the ECG undergo further risk stratification process blood tests, serial ECG measurements and consideration of the constellation of symptoms and signs. They are admitted to specialised coronary care units, started on medical therapies directed both at the acute process and at secondary prevention, and then investigated further with a semi-planned PCI, the goal being to prevent further symptoms and possible STEMI.
Effective care pathways require systems to manage patients who self-present to a non-PCI centre, or who are taken there because transport time to a PPCI centre would be prohibitive. Clear protocols are needed to guide timely use of IVT therapy and transfer protocols should ensure that time is not lost in trying to identify a PCI centre willing to accept the transfer. Experts recommend that the time from “door-in”, i.e. entering first hospital door, to “door-out”, i.e. patient being in an ambulance on the way to a PCI centre, is less than 30 minutes to expedite reperfusion therapy in a PCI centre (ESC Guidelines, 2023[246]). Systems should aim to ensure that secondary PCI can be completed within 24 hours.
The ambulance system plays a critical role in the early management of patients with suspected STEMI, including prioritisation of ambulance dispatch to possible cases, immediately establishing the initial diagnosis, initiation of treatment with aspirin (and in some systems, where transport times are long, IVT) and delivery of the patient to a hospital that is ready to perform immediate PPCI. For that very reason, parallel circuits for referrals and transport of patients with suspected STEMI that bypass the emergency ambulance service should be avoided (ESC Guidelines, 2023[78]). Some systems do not allow ambulance staff (paramedic or nursing) to make diagnoses or prescribe treatments. These systems must then make medical consultation possible usually by telemedicine.
Public awareness campaigns increase the likelihood that patients will recognise the seriousness of the key symptoms, and call EMS rather than seeking care at a GP or other service. Gender differences in time‑to-call after onset of STEMI symptoms have been identified in registry data from France (Lapostolle et al., 2021[53]), Ireland (Margey et al., 2024[247]), and outside of Europe (Stehli et al., 2021[248]) with women consistently calling later.
Stroke is a condition in which brain tissue is injured due to a vascular event. Stroke can be broadly classified as ischaemic (damage due to blockage of an artery that supplies blood to part of the brain, usually due at least partially to the presence of clot in that artery) or haemorrhagic (damage due to bleeding within the brain). The differentiation between the two needs to be accomplished as soon as possible as ischaemic stroke can often be treated with thrombolytic agents (drugs to break down clot) or mechanical thrombectomy (removal of clot using an instrument inserted into the vasculature via a puncture of an artery in the groin).
With the advent of time sensitive therapies for ischaemic stroke (intravenous thrombolytics and mechanical thrombectomy) systems have had to be developed to deliver them within the time windows in which they are effective. Significant public engagement is required to encourage people to call EMS immediately. Ambulance staff then need to be able to recognise potential acute stroke. This is aided by the use of simple stroke screening tools such as “FAST” (facial asymmetry, arm weakness, speech difficulty, time of onset) (Zhelev et al., 2021[249]). As for AMI, the EMS must then decide on a destination hospital capable of providing the therapies and deliver and hand over the patient to that hospital in time for these therapies to be delivered.
Mechanical thrombectomy (MT) is reserved for a subset of people experiencing strokes caused by blockage in a larger artery (LVO – large vessel occlusion). Some systems will aim to get all patients to a mechanical thrombectomy capable centre (often called a comprehensive stroke centre – CSS) and utilise other hospitals (Primary Stroke Centres – PSC) only when transport times to a comprehensive centre are too long. Other systems will select patients in field for CSS using screening tools, and take others to PSC. (Kleinig et al., 1910[250]) When applying such an approach it is essential that the PSC is capable of obtaining urgent CT imaging, providing a neurological assessment in person or by telemedicine, and administering thrombolytic agents.
A system for prenotification of the receiving hospital by EMS is essential for guaranteeing prompt access to diagnostics, to free up specialist teams, and to ensure seamless handover of care without loss of time. Standardised handover facilitates high stakes communication and overcomes difficulties created by poor quality radio connections, and communication from moving vehicles. By limiting communication to a clear statement that the case is a potential stroke, estimated time of onset, estimated time of arrival, and current physiological state there is less likelihood of understanding. Countries with well established pre‑alert systems as part of national guidelines include Ireland, Czechia, United Kingdom and others. Yet the ESO-SAFE experts reported four EU countries did not have prenotification of stroke admission in place in 2022, including Belgium, Cyprus, Estonia and Italy (data were not available for Slovenia and Luxembourg) (ESO-SAFE, 2025[91]).
A special case of CVD is cardiac arrest, the cessation of effective heartbeat. A significant proportion of cardiac arrests are reversible if resuscitation begins within minutes, and if the underlying disease process is itself treatable. Cardiac arrest management depends upon the “chain of survival” meaning immediate cardio-pulmonary resuscitation (CPR), early access to advanced life support, particularly early defibrillation (treatment with a measured electric shock) and expert post-resuscitation care (Annex Figure 4.D.1.). Survival rates are significantly higher when the collapse is witnessed, when bystanders begin CPR, and when defibrillation (application of a controlled electric shock to the heart) is applied early in appropriate cases, and when post-resuscitation care is well organised and includes management of underlying ACS and management of organ injury resulting from the period of cessation of blood flow (Yan et al., 2020[251]).
A 2020 systematic review and meta‑analysis of the previous 40 years of research established that people suffering an out of hospital cardiac arrest in Europe had their heart restarted in 36.7% of cases, survived to hospital admission in 25.7%, to hospital discharge in 11.7% and were alive a year later in 9.2% (Yan et al., 2020[251]). The survival rates for all out of hospital cardiac arrests in Europe are significantly better than those in Asia or North America but significantly behind Oceania (1 year survival is 9.2% in Europe, 5.3% in Asia, 4.0% in North America and 11.5% in Oceania) suggesting there may be room to improve European outcomes (Yan et al., 2020[251]). Within Europe there are also significant differences between countries. The Danish and Norwegian national cardiac arrest registries respectively report 47.4% and 43.6% 30 day survival or survival to discharge from hospital for shockable, bystander witnessed out of hospital cardiac arrests while the Pavia Cardiac Arrest Registry (Italy), the Swiss Registry of Cardiac Arrest and the Sudden Death Expertise Center Registry (Paris) respectively report only 29.8%, 24.4% and 20.9% for the same metric in the same cohort, respectively (Kiguchi et al., 2020[252]).
Source: American Heart Association and International Liaison Committee on Resuscitation.
Note: Left Panel: For waiting time, data for Finland and Italy refer to 2022 instead of 2023. Data for Spain refer to 2020 instead of 2023. Data for the United Kingdom refer to 2019 instead of 2023. For Norway, waiting times are over-estimated because they start from the date when a doctor refers a patient for specialist assessment up to the treatment (whereas in other countries they start only when a specialist has assessed the patient and decided to add the person on the waiting list for treatment). For Italy there has been a change in definition for transluminal coronary angioplasty. For Spain, value is estimated. For surgical procedures, data for Finland, Hungary, Italy, the Netherlands, Poland and Spain refer to 2022 instead of 2023. For the Netherlands, data refers to 2021 instead of 2023. For Hungary and Portugal, provisional values are provided.
Right Panel: For waiting time, data for Australia, Finland and Italy refer to 2022 instead of 2023. For Norway, waiting times are over-estimated because they start from the date when a doctor refers a patient for specialist assessment up to the treatment (whereas in other countries they start only when a specialist has assessed the patient and decided to add the person on the waiting list for treatment). For surgical procedures, data for Finland, Hungary, Italy, Norway, Portugal, Spain, Sweden refer to 2022 instead of 2023. For the Netherlands, data refer to 2021 instead of 2023. Provisional values were used for Portugal and Hungary.
Source: OECD Health Statistics.
Source: Authors’ compilation based on ESC Guidelines (2023[253]), “2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes”, https://doi.org/10.1093/eurheartj/ehad192; Developed with the special contribution of: European Association for Cardiovascular Prevention & Rehabilitation et al. (2011[254]), “ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS)”, https://doi.org/10.1093/eurheartj/ehr158; ESC Guidelines (2024[32]), “2024 ESC Guidelines for the management of elevated blood pressure and hypertension”, https://doi.org/10.1093/eurheartj/ehae178.
Note: PCSK9 inhibitors capture the sum of C10AX13, C10AX14, C10AX16. Data represented from selected countries pending validation.
Source: 2025 OCED Cardiovascular Policy and Data Survey.
Note: SGLT2 inhibitors A10BK. Data represented from selected countries pending validation.
Source: 2025 OCED Cardiovascular Policy and Data Survey.
← 1. The P3CEQ care co‑ordination scale, used in the PaRIS survey, assesses if the care a patient receives: includes a single professional responsible to co‑ordinate care across services the patient uses; is organised in a way that works for the patients, uses care plans, and provides information and support to self-manage (Lloyd et al., 2018[255]). PaRIS data show that out of these five components, insufficient care planning is the main contributor to lowering patient’s overall experience with care co‑ordination (OECD, 2025[3]).
← 2. RAAS: Renin-angiotensin-aldosterone system, ACE‑I: Angiotensin-converting enzyme inhibitors, ARB: Angiotensin receptor blockers, ARNI: Angiotensin Receptor-Neprilysin Inhibitors, MRA: Mineralocorticoid Receptor Antagonists, SGLT2 inhibitors: Sodium/glucose cotransporter‑2 inhibitors.
← 3. ST-elevation myocardial infarction.
← 4. Not all patients who are eligible on time grounds will be suitable for IVT due to the presence in some of contraindications (e.g. recent major trauma or major surgery that would increase the major bleeding risk, or severe comorbidities that would limit the prospects of a functional recovery).
← 5. 2025 OCED Cardiovascular Policy and Data Survey.