National Audit of Angioplasty Procedures - HQIP

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1Executive summaryCoronary heart disease accounts forabout one in five deaths in men and onein six deaths in women. The British HeartFoundation estimate that angina affectsapproximately two million people living inthe United Kingdom.Percutaneous coronary intervention (PCI)is a rapidly evolving technique used totreat patients with narrowed or blockedarteries that supply the heart musclewith blood. The procedure mechanicallyimproves blood flow to the heart. Initiallythe patient has a ‘coronary angiogram’,x-ray images of the heart arteries arecreated, to visualise the position andshape of any narrowing or blockages.If the clinical circumstances and theangiogram findings suggest blood flow tothe heart must be modified, the majority ofpatients will be treated by PCI (a minoritywill be treated by coronary artery bypasssurgery). During PCI, a small balloon isinserted in to the narrowed artery andinflated. This squashes the fatty tissuecausing the blockage and widens theartery. In most cases a ‘stent’, a metalmesh scaffold, is implanted. The stentremains permanently in place and keepsthe artery wall open. Treatment aimsto prevent the arteries blocking (whichmight cause a heart attack) and improveflow to the heart muscle to alleviate thesymptoms of angina.The audit described here allows cliniciansto assess key aspects of the patternsand quality of their care when performingcoronary angiogram and PCI. This is a UKwide audit led by the Audit Lead of theBritish Cardiovascular Intervention Society(BCIS). Data collection and analysis forcentres in England and Wales has projectmanagement and specialist IT supportprovided by NICOR which is part of theUCL Institute of Cardiovascular Science.4
Key findings include:• There are now 114 PCI centres in theUK.• The number of PCIs in the UK was1,407 per million population (pmp).• There has been an increase in PCIactivity in all the UK countries except forWales which also has the lowest rate at1,112 pmp compared with the highestin Northern Ireland at 1,769 pmp.• In the last year the rate of increase inPCI pmp has been the highest for fouryears at 7.6%• The rate of primary PCI (to treat STelevation Myocardial Infarction (STEMI)in place of thrombolysis) continues torise and reached 287 pmp in 2010. Thistreatment option was provided 24/7 by52 of the 97 NHS PCI centres• Centre size: there is evidence thatsuggests improved outcomes forpatients being treated in higher volumePCI centres, particularly those thatperform at least 400 procedures perannum (pa). This forms part of therecommendations of the Joint WorkingGroup on PCI of BCIS and the BritishCardiovascular Society. 1 In 2010 25%of PCI units were performing 400 orless cases pa, but the majority of thesewere new units undertaking a graduallyincreasing volume of work.• The National Institute for health andClinical Excellence (NICE) recommendthat “Stents should be used routinelywhere PCI is the clinically appropriateprocedure for patients with eitherstable or unstable angina or with acutemyocardial infarction”. 2 The greatmajority of procedures do now involvestent insertion (92%), suggesting thatthis aspect of good practice is beingmet.• Following concerns about the safetyof drug eluting stents (DES) inSeptember 2006, there was a fall intheir use to 55% across the UK. Datafrom 2010 suggest an increase in theiruse now that safety issues are betterunderstood, and are not dissimilar fromwhat might be predicted from the NICEupdated guidelines. 3,4 Neverthelessthere are large differences in therate of DES use in the different UKcountries.• The use of the radial artery for accesshas increased progressively from10% in 2004 to over 50% in 2010. Thisaudit analysis supports the literaturedemonstrating a lower complicationrate when PCI is performed viathe radial artey, with approximatelya halving of access site relatedcomplications.• The overall rate of death beforedischarge from hospital following PCIhas gradually risen over the past fewyears. This is due to a change in casemix. There has been no evidence of achange in the outcomes when patientsin similar clinical presentations arecompared. For stable elective patients,in hospital mortality is less than 0.15%.For patients with unstable angina orNSTEMI (non-ST elevation MyocardialInfarction), the in hospital mortality isless than 0.6%. For patients with STEMIthe mortality is higher at about 4%.• Analysis of risk adjusted outcome(major adverse cardiac andcerebrovascular events) from the 2008,2009 and 2010 data combined showsthat all units in the UK are performingas well as would be predicted from themodel used for risk adjustment, butdifficulties with risk adjusted analyseswere identified.• National and international guidelinesrecommend that in the emergencytreatment of patients with STEMI,angioplasty treatment should beperformed within 90 minutes of arrivalof the patient at the angioplasty site,door to balloon (DTB) time, and within150 minutes of a patient’s call forhelp, call to balloon (CTB) time. Thedata for units performing primary PCI(PPCI) for STEMI are presented asfunnel plots. There has been a yearon year improvement. A DTB < 90minutes was achieved in 89.7%, andCTB < 150 minutes in 77.3% of cases.This compares very favourably withinternational statistics.• Patients who need to be transferredbetween hospitals for primary PCI hadlonger delays than those admitteddirect to a PCI centre, the transferadding about 50 minutes.• There has been a further improvementin the number of centres sending datato CCAD for electronic collection andanalysis, and a marked improvement inthe quality of data submitted.The rest of this report contains moredetails and graphs of the audit findings.The complete set of data from the2010 audit was presented at the BritishCardiovascular Intervention Society’sannual meeting (BCIS) in autumn 2011and is available for download at thesociety’s web site www.bcis.org.uk.5
Page 1 and 2: NICOR: NATIONAL INSTITUTE FORCARDIO
Page 3 and 4: National Audit ofPercutaneousCorona
Page 5: ForewordThe United Kingdom is uniqu
Page 9 and 10: Hospital nameDate ofbirthSexMedical
Page 11 and 12: 3InfrastructureThe number of sites
Page 13 and 14: 1800England Scotland N. IrelandWale
Page 17 and 18: 7Arterial access routeWhen performi
Page 19 and 20: Overall, the percentage of PCI for
Page 21 and 22: 9Delays to treatmentIn the treatmen
Page 23 and 24: 100SPHBETTER% CTB
Page 26 and 27: 11GlossaryAbbreviations in alphabet

National Audit of Angioplasty Procedures - HQIP

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