Building a national real-time cardiovascular quality infrastructure: five years of ESC EuroHeart implementation in Estonia
A Irs, M Serg, R JalakasAbstract
Background
Standardisation of cardiovascular data across Europe remains limited despite a high disease burden. The ESC EuroHeart initiative addresses this gap by implementing harmonised clinical data standards and real-time quality metrics to enable benchmarking and continuous improvement. Estonia (population 1.3 million) has a digitally mature publicly financed healthcare system and a national myocardial infarction registry ensuring complete case capture since 2012. Estonia was designated as the EuroHeart pilot country in 2020.
Purpose
To implement the ESC EuroHeart registry nationally, evaluate feasibility and coverage, assess adherence to selected acute coronary syndrome (ACS) quality indicators, and establish infrastructure for registry-based research and collaborative scientific activities.
Methods
Implementation was conducted through collaboration between the ESC, Uppsala Clinical Research Centre, the Estonian Society of Cardiology, both national tertiary cardiac centres and a local IT partner, with a university hospital serving as the central IT hub. Legal, data protection and ethical assessments were completed. The QReg5 platform was localised and launched for web-based data collection in ACS, PCI, TAVI and heart failure. ACS data collection began stepwise in two tertiary centres (first patient May 2021; second centre January 2023). Institutional coverage and selected ESC ACS quality indicators were analysed and contextualised using the national myocardial infarction registry.
Results
A national standardised dataset and IT platform were implemented within two years despite the COVID-19 pandemic. By 2024, national coverage reached 61% for STEMI and 38% for NSTEMI, with institutional inclusion rates of 90% and 63%, respectively. Most inpatient ACS quality indicators demonstrated consistent adherence across centres; however, marked variation was observed in early invasive management of NSTE-ACS (angiography within 24 h: 17% vs 57%), identifying actionable performance gaps. Aggregated national data contributed to three ESC EuroHeart annual reports enabling international benchmarking.
Conclusion
National implementation of ESC EuroHeart in a digitally mature health system is feasible and delivers high institutional coverage with measurable benchmarking outputs. Embedding EuroHeart within tertiary care while retaining the established national myocardial infarction registry as a comprehensive backbone enabled real-time, contextualised quality feedback without compromising complete population coverage. EuroHeart national architecture represents a scalable model for European cardiovascular quality infrastructure and provides a platform for real-world evidence generation and registry-based trials.