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Periprocedural MI Not a Reliable Measure of Hospital PCI Quality
Key Points:- Only 12.7% of hospitals measure cardiac markers routinely after PCI
- Periprocedural MI, a measure of PCI quality, is determined by cardiac marker testing
- Only 24.7% of the PCI population had CK-MB measured
By Jason Kahn
The benchmark for the overall quality of percutaneous coronary interventions (PCI) performed at individual hospitals, periprocedural myocardial infarction (MI) is established by measuring cardiac markers such as CK-MB following the procedure. But because there is such inconsistency in performing tests for these markers, periprocedural MI rates are inappropriate and unreliable measures of PCI quality, according to findings reported in the May 27, 2008, issue of the Journal of the American College of Cardiology.
Researchers led by Tracy Y. Wang, MD, of the Duke Clinical Research Institute (Durham, NC), analyzed data from the National Cardiovascular Data Registry on 213,395 patients who underwent elective PCI at 463 hospitals between January 1, 2004, and March 30, 2007.
They found that 52,746 patients (24.7% of the total PCI population) had CK-MB assessment after PCI. Meanwhile, only 59 of 463 hospitals (12.7%) performed post-procedure cardiac marker testing on a routine basis (≥70% of the time) in this population.
Those hospitals that did routinely measure cardiac markers were associated with higher diagnostic catheterization rates and PCI volumes per year.
Implications for Periprocedural MI
After adjustment for independent predictors of mortality, patients undergoing elective PCI at hospitals that routinely measured post-procedure markers showed a trend toward lower in-hospital mortality (OR 0.74, 95% CI, 0.53-1.02). In addition, patients treated at hospitals that perform routine cardiac marker testing were more likely to be discharged on guideline-recommended secondary prevention therapies.
However, periprocedural MI detection (peak CK-MB levels >3 times the upper limit of normal) was positively correlated with the frequency of CK-MB measurement (P < 0.0001), and hospitals that more routinely measured cardiac markers had significantly higher rates of periprocedural MI detection (4.8% vs. 1.6%, P < 0.0001).
The authors note that the trend toward reduced mortality and greater adherence to recommended medications for PCI patients at hospitals that routinely test for cardiac markers suggest better overall care, and that the higher incidence of periprocedural MI at such centers may be a case of “the more you look, the more you find.”
In an e-mail communication with TCTMD, Dr. Wang said, “The message here is that while periprocedural MIs are considered a benchmark of PCI quality across hospitals, in real-world practice, very few hospitals actually measure the markers that establish or rule out this complication. Therefore, true rates of this adverse outcome cannot be accurately assessed. Thus, at present, PCI quality of each hospital cannot be compared using this marker.”
Source:
Wang TY, Peterson ED, Dai D, et al. Patterns of cardiac marker surveillance after elective percutaneous coronary intervention and implications for the use of periprocedural myocardial infarction as a quality metric: A report from the National Cardiovascular Data Registry (NCDR). J Am Coll Cardiol 2008;21:2068-2074.
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С Уважением,
Мальцев А.А.