An increase in the number of percutaneous coronary interventions (PCI) – a life-saving procedure to restore blood flow during a heart attack – does not appear to have translated into lower mortality rates across Europe, according to research presented at the inaugural EAPCI Summit in Munich, Germany.
Primary PCI involves unblocking coronary arteries, often with a stent inserted via a catheter, typically from the groin or wrist. It’s a cornerstone of treatment for myocardial infarction (MI), commonly known as a heart attack. Despite widespread adoption and increased availability of this procedure, the study findings suggest a complex relationship between PCI volume and patient outcomes.
The analysis, conducted by researchers from King’s College London, examined data from 21 European countries, integrating information from the ESC Atlas of Cardiology, the ESC Atlas in Interventional Cardiology, the World Health Organization, the Institute for Health Metrics and Evaluation and Eurostat. Researchers sought to determine if a greater number of PCI procedures performed correlated with reduced mortality rates following an acute MI.
“It is well established that primary PCI plays a pivotal role in reducing mortality after MI; however, significant variability exists at local, national and regional levels in the provision of primary PCI and associated patient outcomes,” explained Ali Malik, the study presenter from King’s College London.
The data revealed a moderate inverse correlation between a country’s gross domestic product (GDP) per capita and age-standardized MI mortality rates – meaning wealthier countries tended to have lower death rates. Conversely, a higher prevalence of cardiovascular disease (CVD) within a country was associated with higher mortality rates. However, surprisingly, after accounting for these factors, the study found a moderate positive correlation between the number of primary PCI procedures performed and MI mortality rates.
Specifically, the analysis showed that for every increase in primary PCI procedures per million inhabitants, there was an associated increase in age-standardized MI mortality (population correlation coefficient=+0.68; p<0.001). This finding challenges the intuitive assumption that more interventions automatically lead to better outcomes.
Interestingly, the study also explored the impact of procedural workload. A weak inverse association was observed, suggesting that a greater number of primary PCI procedures performed per interventional cardiologist was associated with lower MI mortality rates (population correlation coefficient=−0.27; p=0.23). This hints at the importance of operator experience and expertise.
Sukruth Pradeep Kundur, a co-investigator from King’s College London, emphasized the need for further investigation. “One would anticipate that increased provision of primary PCI would yield lower mortality rates; we will conduct additional analyses to elucidate why this trend is not evident in our preliminary findings. The observed association with procedural workload highlights the significance of operator expertise. System-level factors include inter-centre variability and the interval between symptom onset and access to primary PCI.”
The findings underscore the complexity of cardiovascular care and suggest that simply increasing the volume of PCI procedures is not a guaranteed path to improved outcomes. Several factors likely contribute to this unexpected relationship. Variations in the timeliness of treatment – the time elapsed between symptom onset and PCI – could play a significant role. Differences in the overall quality of care, including pre-hospital management and post-discharge rehabilitation, may also contribute. The increasing prevalence of complex comorbidities, such as diabetes and chronic kidney disease, can make PCI more challenging and potentially less effective.
Senior author, Dr. Sanjay Sivalokanathan from the Mount Sinai Health System in New York, USA, highlighted the broader context of rising cardiometabolic risk factors. “The global rise in cardiometabolic risk factors appears to play a meaningful role in the clinical complexity of patients presenting with acute coronary syndromes. As such, PCI may be challenging in certain settings, highlighting the importance of operator experience and advanced interventional strategies. These developments emphasise the need for collaborative, multidisciplinary approaches, while prevention remains the cornerstone of reducing the overall burden of cardiovascular disease and associated mortality.”
These findings do not suggest that PCI is ineffective. Rather, they emphasize the need for a more nuanced understanding of how to optimize cardiovascular care. Future research will focus on analyzing the timing of procedures relative to symptom onset, assessing operator experience levels, and identifying variations in practice patterns across different centers and countries. A comprehensive approach that prioritizes prevention, early diagnosis, timely intervention by experienced operators, and comprehensive post-acute care is crucial for improving outcomes for patients experiencing heart attacks.
The EAPCI Summit, a new event organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), an association of the European Society of Cardiology (ESC), provided a platform for presenting these important findings and fostering discussion about the future of interventional cardiology.
