“Managing a heart attack doesn’t begin in the hospital; it starts at home, when the patient recognizes the danger in time.”
– Professor Nicolas von Beckerath
Acute Coronary Syndrome (ACS) remains one of the leading causes of death among the adult population in Georgia. In this context, it is crucial to engage with those experts who have spent years studying, shaping, and implementing international standards in the field.
One such expert is Professor Dr. Nicolas von Beckerath, one of Germany’s leading interventional cardiologists. He is not only a highly experienced clinician but also an active researcher and strategist. For many years, Dr. von Beckerath has led nationwide initiatives in Germany aimed at improving the quality of care in acute myocardial infarction. His team is a participant in a nationwide project in Germany called “FITT-STEMI”, which tracks every critical moment from the onset of a heart attack to the final placement of the stent.
In his interview with Medscriptum, Professor von Beckerath explains why the first 90 minutes of a heart attack are critical, why proper management saves lives, and how implementing European standards of care could profoundly impact outcomes in Georgia.
From team-based decision-making to precise time management and the importance of continuous feedback loops, his insights highlight what every country, including Georgia, must prioritize to reduce cardiovascular mortality.
Our conversation went beyond treatment strategies. We explored the practical steps already proven to save thousands of lives in Germany, steps that, if adopted, could meaningfully transform patient outcomes in Georgia as well.
Dear Dr. Beckerath. Your speech today mainly focused on acute coronary syndrome, its acute and chronic subtypes. This is a hot topic in Georgia, where ACS is one of the leading causes of adult mortality. What general principles should guide the management of coronary artery disease to improve patient outcomes?
Dr. von Beckerath: First and foremost, the problem must be recognized. This begins with patient education. Individuals need to understand that chest pressure or discomfort is a warning sign, prompting them to seek immediate help rather than waiting for it to pass. Physicians also have an essential role: general practitioners must recognize these symptoms and be able to perform and correctly interpret ECGs.
Once ACS is identified, patients should be transferred without delay to a facility experienced in treating such cases. Early administration of antithrombotic medication is crucial. In acute situations, particularly ST-elevation myocardial infarction (STEMI), time is of the essence. Patients should not remain in the emergency department unnecessarily; they must be taken directly to the catheterization laboratory.
We have been involved for years in a nationwide project called FITT-STEMI, which tracks key time points in patient care: onset of symptoms, contact with emergency services, ambulance arrival, first ECG, transfer, hospital arrival, entry into the cath lab, arterial puncture, and balloon inflation. Collecting these data allows us to analyze delays at each step. Around 60 clinics in Germany participate, and each receives detailed feedback in the form of individualized reports and presentations. We regularly hold review sessions to discuss these results and identify opportunities for improvement.
Beyond logistics, the quality of the intervention itself is equally important. This depends mainly on the training and experience of interventional cardiologists, which develops over many years. Within institutions, we often review each other’s angiographic films, exchange feedback, and learn from congresses and meetings. Interventional cardiology is fundamentally team-based. Even though a physician may work alone while on call, procedures are discussed afterward with colleagues. This continuous exchange is key to maintaining and improving standards.
How do you approach the question of treating only the culprit lesion versus addressing other significant stenoses in ACS?
Dr. von Beckerath: In most cases, we treat only the infarct-related artery during the initial intervention. However, strong evidence also supports revascularization of additional significant stenoses. The true debate is about timing. I personally prefer to focus primarily on the culprit lesion during the index procedure, and then consider staged interventions later. The timing depends on vessel size and stenosis severity. For example, a large vessel with a 90% stenosis will often be treated during the same hospitalization, sometimes just 3–4 days later. A moderate lesion—say, a 70% stenosis in a mid-sized branch—can typically wait 4–6 weeks. While some data suggest earlier treatment may be advantageous, I do not believe performing too many interventions during the first procedure is in the patient’s best interest. I would like to mention that the new data indicate that a second vessel can be included in the index procedure. Although we sometimes do this, we usually prefer performing the second procedure later on.
What is the recommended time to postpone the other affected vessels to the latest point, let’s say?
Dr. von Beckerath: Based on the data from the complete study, the time frame is 45 days; however, physicians typically complete procedures on the most critical vessels earlier. There is also data, as I mentioned, that the earlier you do it, the better it is. Earlier intervention reduces the risk of reinfarction and repeat procedures, but doesn’t affect mortality. It’s more about the quality of life.
You mentioned the importance of timing in the chain of care, from the onset of the first symptom to balloon placement. We often refer to door-to-balloon time, but in your research, you emphasized starting the clock earlier, from the onset of symptoms.
Dr. von Beckerath: Exactly. We refer to this as contact-to-balloon time, and there is strong evidence that it correlates very closely with outcomes and mortality. The overall process can be broken down into several intervals: symptom-to-balloon, symptom-to-contact, contact-to-balloon, and finally door-to-balloon. Among these, the best correlation with outcome is found with contact-to-balloon time.
By “contact,” do you mean when paramedics arrive at the patient’s home?
Dr. von Beckerath: No, “first medical contact” begins when the patient calls emergency services. After that, the physician arrives at the scene.
Compared to the standard 90-minute benchmark for door-to-balloon time, what is the recommended timeframe for contact-to-balloon?
Dr. von Beckerath: The target is also 90 minutes for contact-to-balloon. For door-to-balloon, the ideal is 60 minutes. The biggest challenge worldwide is avoiding delays in the emergency department. That requires well-trained hospital staff and emergency services who can perform ECGs rapidly and alert the cath lab without hesitation. In many hospitals, the on-call cardiologist may need to drive in from home after hours, which highlights the importance of a coordinated system where all parties are alerted and working together efficiently.
Earlier, you mentioned patient education, training people to recognize the symptoms of myocardial infarction. What approaches in Germany have proven effective, and could these be applicable in Georgia?
Dr. von Beckerath: In Germany, we have the Deutsche Herzstiftung (German Heart Foundation), which is a patient-oriented organization. They organize events such as the annual “Heart Weeks” every November. Each participating clinic is expected to host at least one seminar or public lecture during this period. We advertise these events in local newspapers, and typically, more than 100 people attend.
So the focus is on local outreach?
Dr. von Beckerath: Exactly.
How about using media campaigns for symptom recognition? Do you see that as a valuable component of the system?
Dr. von Beckerath: Absolutely. The media could play a larger role in this area. At the same time, the seminars remain quite effective. Since every clinic participates during the same month, it creates a nationwide effort. The topic becomes very visible in the community, supported by reports in local newspapers, and it fosters broad public awareness. For those few weeks in November, everyone is talking about it, which makes a real difference.
In our previous discussion, we touched on the higher rates of ACS in Georgia. Chronic kidney disease and diabetes are also frequent comorbidities that affect heart function and coronary health. How do these factors influence your choice between PCI and alternative approaches?
Dr. von Beckerath: It always depends on the individual patient. We have several large trials comparing PCI with CABG that provide valuable guidance. For patients with moderate coronary artery disease, PCI is highly effective. The challenge comes with diabetes. In patients with diabetes who have three-vessel disease or left primary disease, surgery tends to be more beneficial than PCI. This is because in such patients, the disease progresses rapidly, and surgeons place bypass grafts on distal vessels. In this way, they are not only treating the disease that is already present but also protecting against the disease that will inevitably develop. That said, with modern diabetes management and more effective medications, this landscape is slowly changing.
Based on your extensive experience in both cardiology and angiology, what do you see as the most significant current challenge in interventional vascular medicine and cardiology?
Dr. von Beckerath: That is a difficult question. One of the biggest challenges relates to training and experience. Decision-making is crucial; you do not have to treat everything you see. Knowing what to treat and what not to treat requires both expertise and judgment. Beyond that, the increasingly complex interventions we perform will always remain a challenge, but they are also what make this field so exciting.
In reviewing some of your recent research, one topic that stood out was the use of drug-eluting stents. Despite significant advancements, in-stent restenosis remains a concern. What strategies have proven most effective in mitigating this issue, and what innovations are being investigated?
Dr. von Beckerath: The most crucial factor is the quality of the intervention itself. This is why intravascular imaging—IVUS (intravascular ultrasound) or OCT (optical coherence tomography)—is now recommended in the ESC guidelines for complex procedures. Using these tools improves the precision of interventions and leads to better outcomes with drug-eluting stents. Still, once a stent is implanted, there remains an annual risk of about 2% that a complication will occur. The task is to optimize the procedure so that this risk is minimized, ideally below 2%.
Another promising direction is the “leave-nothing-behind” approach. This involves avoiding permanent stents and instead using biodegradable scaffolds or drug-coated balloons. We already use this strategy frequently in angiology, and it is gradually being explored in cardiology. That said, I am cautious about avoiding stent implantation in large coronary vessels, because the risk of dissection and vessel closure is high, and that can be very dangerous for the patient. In smaller vessels, however, this approach appears promising.
For our last question, something you have already touched on briefly, when deciding on the optimal procedure for a patient, do you see this primarily as the responsibility of the interventional cardiologist, or is it a group effort?
Dr. von Beckerath: In complex cases, it should always be a Heart Team approach. That is what we practice: we consult with our cardiac surgeons and discuss the case together. When the situation is straightforward, we may not need their input, but for complex cases, collaboration is essential. Ultimately, we work as a team to determine the best solution for the patient.
