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PERCUTANEOUS CORONARY INTERVENTION (PCI)
Percutaneous coronary intervention (PCI) is a mini-invasive procedure used to dilate the arteries that supply
blood to the structures of the heart (coronary arteries) when these vessels are partially or completely
occluded by atherosclerotic plaques. The aim of the procedure is restoring adequate blood flow to a specific
region of the heart muscle, preventing thus the onset of a myocardial ischemia.
High volumes of this intervention are associated with better outcomes, especially when PCI is performed
during the early phase of an Acute Myocardial Infarction (AMI). PCI in emergency settings requires greater
skill and experience than when it is routinely performed on patients with stable conditions (elective PCI), and
literature data indicate that the amount of time from hospital access to the procedure itself (door-to-balloon
time) is inversely related to short-term mortality in AMI patients. A recent systematic review identified a
volume threshold of PCI procedures (200 to 400 cases/year) below which the effectiveness of care provided
might be reduced.
Several randomized controlled trials and meta-analyses show that better clinical outcomes (in particular,
reduction of recurrent ischemic events) in patients with ST segment elevation myocardial infarctions
(STEMIs) are achieved with early invasive interventions, including PCI. In patients with STEMIs, PCI is
considered the treatment of choice if it can be performed within 90 minutes of the first health-care system
access, by skilled specialists and in a cardiac catheterization laboratory.
The management of AMI patients should be based on an accurate risk stratification, however in clinical
practice it is often influenced by the characteristics of the hospital where the patient is admitted. For this
reason, PCI rates seem to be significantly higher among those patients taken directly to hospitals with a
cardiac catheterization laboratory.
Some studies indicate that the mortality risk for STEMI patients admitted to well-equipped hospitals does not
significantly differ from that observed in hospitals without such laboratories, although a recent meta-analysis
shows that transferring such patients for reperfusion procedures was associated with a significant reduction
of 30-day mortality rates.
Thus, in case of arrival in a hospital with no cardiac catheterization laboratory, an accurate assessment of the
patient’s clinical conditions should be made according to the potential benefits of a reperfusion procedure
and to the risks of a treatment delay and of the transfer to the nearest hospital where angioplasty can be
performed.
Regarding the type of angioplasty performed (simple balloon angioplasty and with stent placement), a recent
meta-analysis showed no evidence of association between stenting and lower mortality, although the use of
stent does appear to reduce the risk of re-infarction and the need for revascularization.
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In the early phase of an IMA three types of PCI can be performed: primary PCI (angioplasty performed
without previous or concomitant fibrinolysis), PCI combined with pharmacological reperfusion therapy, and
rescue PCI after failed thrombolysis.
The available data sources (HDFs) did not allow to tell the three interventions apart neither to accurately
identify PCI with stent placement, since in the HDFs this procedure is often underreported. Furthermore it is
not possible to precisely define the time lapse between the arrival of the patient at the hospital and the
procedure using HIS data; for this reason a time lapse of 0-1 day is assumed.
Since mortality rates are associated with the severity of the disease and indirectly with an early treatment, we
evaluated the following 2 measures, measuring the outcome from the patient’s hospital admission date.
1. 30 day-mortality after PCI for AMI performed within >48 hours
2. 30 day-mortality after PCI for AMI performed after >48 hours
The following measures were calculated to take into account the volume of AMI or STEMI treated with a
PCI:
1. Proportion of AMI episodes treated with PCI within 48 hours
2. Proportion of AMI episodes treated with PCI in the index admission or in another admission within 7 days
3. Proportion of STEMI episodes treated with PCI within 48 hours
4. Proportions of No STEMI episodes treated with PCI within 48 hours
These measures aim at providing information on all stages of the diagnostic-therapeutic pathway. Attributing
the outcome to the hospital where the patient is admitted does not imply an assessment of the quality of care
provided by that hospital, but of the appropriateness and effectiveness of care of the specific diagnostictherapeutic pathway.
Furthermore we have measured also the hospital rate for PCI across areas of residence, to take into account
the variability of performing this procedure in the Lazio Region. This heterogeneity may be explained not
only by differences in the quality of care provided but also by difference in the case mix or in the
distributions of the risk factors (age, gender, and comorbidities).
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