Heart Safe Cities

Cross Border Heart Safe Cities

The Project

Project Background

Over the past years public investment in health and social welfare systems fell rapidly in Greece due to economic crisis. Increasing disparities and the risk of poverty are tightened. As a result the personnel in public health and social welfare has decreased and consequently the quality of health services provided has fallen, setting in some cases, people’s lives at risk. In Republic of North Macedonia the situation is worse, as 21% of the population live below absolute poverty line while many of them (54%) live in households with five or more members.

As such access to basic health care treatment is almost absent, resulting in fatal incidents that could be saved easily if they were identified and treated in time such as heart arrests and cardiovascular diseases. Also, high poverty rates and low educational level result, among others, to lower food quality consumed, which in turn is worsening the heart diseases and their symptoms, along with the ageing of population, thus creating more demands on the healthcare system which is gradually burdened.

Despite the ageing population, the average age of patients with cardiovascular diseases is decreasing. In other words sudden cardiac arrests occur now in younger people too, due to low access to doctors because of poverty, due to lack of systematic monitoring of heart as a matter of access and health culture, due to decrease in quality of food consumed, and increase of stress, anxiety and sadness.

Regarding heart, one of human’s most vital organs, the frequency of cardiac arrests is estimated between 0,4 and 1 for every 1.000 citizens annually (800 – 2,000 people daily), within a total population of ca. 730M people in Europe. In Greece and Republic of North Macedonia the situation is consistent with the EU statistics, with a slight ascending tendency over the last years, due to the causes mentioned above, resulting to serious losses of human life. A crucial factor in limiting those losses is the immediate provision of first aid and basic life support from trained individuals, within the very first minutes until advanced emergency care arrives to the spot. It is argued that the majority of the incidents would have been effectively addressed, if: (a) they had been early identified; (b) first aid and basic life support had been provided immediately; (c) early defibrillation had been available and (d) proper post-resuscitation care had been provided afterwards. This sequence, referred to as “The Chain of Survival”, has been accepted by the European Resuscitation Council and American Heart Association, while convincing scientific evidence has been produced that emphasise the importance of early identification and provision of basic life support, which, even without defibrillators, can “buy” valuable time for the victim, until advanced emergency assistance arrives.

Moreover, the monitoring of the current situation regarding cardio vascular diseases through population screening and timely diagnosis of potential threats are considered as the most important preventive factors of future health diseases. Given this situation it is clear that the problem is complicated and requires long-term and multi-faceted approach.

Chain of Survival

In 1991, the American Heart Association (AHA) published “Improving Survival from Sudden Cardiac Arrest: The Chain of Survival Concept.” This paper identified the idea that all communities should adopt the principle of early defibrillation and that all personnel who are expected, as part of their professional duties, to perform basic CPR, should be equipped with an AED and be trained to operate it. Since then, ILCOR (International Liaison Committee on Resuscitation) and the AHA have advocated that health professionals who have a duty to respond to a person in cardiac arrest should have a defibrillator available either immediately or within 1 to 2 minutes.

The Chain of Survival depicts the critical actions required to treat life-threatening emergencies, including heart attack, cardiac arrest, stroke, and foreign body airway obstruction. The links within this Chain of Survival include:

  1. Early Access to the emergency response system.
  2. Early CPR to support circulation to the heart and brain until normal heart activity is restored;
  3. Early Defibrillation to treat cardiac arrest caused by Ventricular Fibrillation; and
  4. Early Advanced Care by EMS and hospital personnel.

The first link, Early Access to the emergency response system, includes early recognition of the cardiac emergency and early notification of rescue personnel via a universal 1-1-2 telephone system as well as an internal alert system within specific facilities to trigger a response by designated trained and equipped personnel.

The second link, Early CPR, is a set of actions that the rescuer performs in sequence to assess and support airway, breathing and circulation.

The third link, Early Defibrillation, is the delivery of a shock to the heart to convert the heart’s rhythm from Ventricular Fibrillation back to a normal heart rhythm.

The fourth link, Early Advanced Care, relates to the response of highly trained and equipped pre-hospital EMS personnel (paramedics) who can respond to the patient and provide for the administration of drugs, advanced airway procedures, and other interventions and protocols, prior to the arrival of the patient at an advanced care facility.

However, in order for the patient to have the best chance of surviving an out-of-hospital cardiac arrest, CPR and early defibrillation must be provided within the first 4 minutes of the cardiac arrest (the European Resuscitation Council/American Heart Association recommends 3 minutes), followed by Advanced Life Support within the first 8 minutes of the arrest.

Project Idea

The overall project objective is to increase the number of effectively managed out-of-hospital cardiac arrest incidents and save patients’ lifes.

The Heart Safe Cities project approaches the cardiovascular diseases, cardiac arrests and the provision of preventive health care in a special way, by trying to create multipliers addressing directly to the general public and confronting the occurrence of heart arrests immediately and effectively. In this way, a large part of the population acquires a rounded and general knowledge about heart matters, eg how it works and how it can be protected, what needs to be done in case of a heart attack etc, while at the same time people are engaged in social life, which enhances their lost sense of usefulness. At the same time, people at high risk of a heart arrest, most of who do not even know they belong to a high risk group because of their lack to health care access, gain higher possibilities of surviving such an incident, and they obtain access to cardiac examination, monitoring and information on how to prevent such incidents.

The project idea is consistent with the “Heart Safe Communities” Program, in a systematic effort to manage directly the relevant incidents, not only by health professionals but mainly by suitably trained citizens.

Project Scope


The main aim of Heart Safe Cities project is to increase the number of out-of-hospital cardiac arrest incidents that are effectively managed & the patient is saved from permanent effects or even death. The project contributes directly to the program’s SO 1.2 “Improvement of preventive health care & social services of children & elderly population”, as well as CP’s strategic choice 2 “Improve access to social & health care & promote social inclusion & Community Development” by providing to more people the chance to life in case of an emergency and setting up a permanent core of training and a pool of trainers.

Moreover, the project aims to:

  • Raise awareness on the seriousness of cardiac arrest incidents and inform for ways that they can be prevented and/ or effectively managed.
  • Improve early response readiness through mass training of citizens, as well as training of trainers (medical/ paramedical staff).
  • Improve capacities for effective management through the provision of AEDs (Automated External Defibrillators) in selected city spots.
  • Improve the life support services provided by local and regional health care units.
  • Increase the overall capacity for life support and first aid provision on city level & reduce the losses of human lives.
  • Enhance cooperation in life support issues & issues related to cardiovascular diseases.
  • Improve quality of life in the cross-border area.

Expected results

The Heart Safe Cities Project is expected to result to the creation of two pilot safe heart cities – Kalamaria & Ohrid – both in terms of equipment required in public spaces (Automated External Defibrillators) and closest health units as well as in terms of 5.500 trained citizens and public/ local servants in Basic Life Support (BLS), 550 certified BLS instructors and 750 doctors, nurses and other medical staff on Intermediate Life Support (ILS).

The project is also expected to result to:

  • Upgrading of the medical services provided in 9 health units in the cross-border area thanks to the supply of new medical equipment
  • Increased use of IT applications in the health care sector both by the potential beneficiaries as well as by medical staff (doctors & nurses).
  • Raising awareness on preventive health care with particular focus on cardiovascular diseases prevention and early diagnosis through a series of open information events and other promotional activities ending in an average number 8.000 informed citizens and relevant stakeholders.

Work Packages

The project is structurally organized into 5 working packages (WPs), relating respectively to the training of citizens and specialized medical staff, procurement of the necessary equipment for the AED spots and the hospitals’ emergency departments, and the design and pilot implementation of the Heart Safe Community in the cross-border area.

  • WP1 Project Management & Coordination
  • WP2 Communication & Dissemination
  • WP3 Life support and Training equipment Procurement
  • WP4 Training of citizens and trainers
  • WP5 Piloting Heart Safe Communities

Heart Safe Cities

Cross Border Heart Safe Cities

Project co-funded by the European Union and national funds of the participating countries

This webpage has been produced with the financial assistance of the European Union. The contents of the webpage are the sole responsibility of the 4th Health District of Macedonia & Thrace and can in no way be taken to reflect the views of the European Union, the participating countries and the Managing Authority.