Use of percutaneous coronary intervention to treat heart attack continues to rise in UK, audit showsBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f629 (Published 30 January 2013) Cite this as: BMJ 2013;346:f629
Primary percutaneous coronary intervention (PCI) is now used as the reperfusion strategy in the acute treatment of most patients who have had a heart attack, but large regional variations in its use remain, show the latest results from a UK audit.1
The 2011 annual report from the national audit of percutaneous coronary intervention shows that primary PCI accounted for more than 95% of reperfusion treatment for patients with an ST segment elevation myocardial infarction (STEMI), replacing thrombolysis as the preferred option.
The proportion of patients with STEMI treated with primary PCI, which improves blood flow to the heart by inflating a small balloon that widens narrowed arteries identified by coronary angiography, has more than doubled since 2006, from 11% to 25.1%.
The time to treatment has also improved, with 80% of patients being treated within the recommended target of 150 minutes from calling for professional help and 92% undergoing PCI within 90 minutes of arriving at a PCI centre.
But having to transfer patients between hospitals for primary PCI delayed treatment by about 50 minutes. In the 2011 audit nearly one in four patients (22.5%) were transferred for primary PCI because the hospital they first went to could not perform the procedure.
“While there have been year on year improvements in treating patients within target times, transferring patients between hospitals causes additional delays,” the report authors noted.
The audit showed large differences in rates of PCI between UK countries. The rate of primary PCI for STEMI was lowest in Northern Ireland (158 per million population) and highest in England (362 per million). Within England and Wales there were also differences in PCI rates between cardiac networks.
“It is clearly easier to get a patient to a PCI centre if they live in the same city as the PCI lab but a completely different matter if they are in a geographically remote area with poor transport links,” said Peter Ludman, consultant cardiologist at the Queen Elizabeth Hospital, Birmingham, and audit lead for the British Cardiovascular Intervention Society.
He added, “Primary PCI requires a complex interaction of different services, from the patient’s recognition that they need to seek help, to accurate diagnosis by the first medically trained responders, to transport to the nearest PCI lab, and finally to the PCI procedure itself. The PCI is therefore just the very last piece of a complex chain of interaction.”
Ludman thought that better identification of eligible patients would lift rates where they were low and that cardiologists had an important role in this.
The British Cardiovascular Society has audited PCI every year since 1988 as part of efforts to improve the quality of care. The latest audit collected data on 88 692 PCI procedures carried out between January and December 2011 by 97 NHS PCI centres (only two did not submit data) and seven of 18 private hospitals providing PCI.
The latest audit showed a continuing rise in the number of PCIs carried out each year over the past decade, achieved by expanding the number of PCI centres to a total of 117 and increasing the service to 24 hours a day, seven days a week, with 60% of centres now providing this.
“Increasing volume has an additional benefit,” the audit report noted. “Evidence from the UK and other countries shows that patients treated in higher volume centres have improved outcomes, particularly centres performing at least 400 procedures each year.” The 2011 audit showed that most PCI centres carried out “considerably more” than 400 a year; 29% of units performed fewer than this, generally because they were new.
The data showed that practice was in line with the latest developments in PCI, including an increase in the use of the radial artery instead of the femoral artery for access, which the audit team considered might explain the reduction seen in complication rates.
Cite this as: BMJ 2013;346:f629