Division of Cardiology Lisie Hospital Kochi Kerala India.
Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.
J Am Heart Assoc. 2020 Jun 16;9(12):e014968. doi: 10.1161/JAHA.119.014968. Epub 2020 Jun 1.
Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low- and middle-income countries. Methods and Results This prospective state-wide registry included ST-segment-elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100-199, and ≥200 PPCIs per year, respectively). Kaplan-Meier curves and Cox regression models were used to examine the association between PPCI volume and 1-year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low-volume, 8 (19%) medium-volume, and 10 (23.8%) high-volume hospitals. The median (25th-75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST-segment-elevation myocardial infarction risk score was 3 (2-5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low-, medium-, and high-volume hospitals, respectively (=0.02). Total ischemic time differed significantly among low-volume (median [25th-75th percentile], 3.5 [2.4-5.5] hours), medium-volume (median, 3.8 [25th-75th percentile, 2.58-6.05] hours), and high-volume hospitals (median, 4.16 [25th-75th percentile 2.8-6.3] hours) (=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low-, medium-, and high-volume hospitals, respectively (=0.01). The observed 1-year mortality rate was 6.5%, 3.4%, and 8.6% at low-, medium- and high-volume hospitals, respectively (<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12-2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78-3.58]) (<0.01). Conclusions Low- and middle-income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.
在低中收入国家，关于经皮冠状动脉介入治疗（PPCI）量的基准，用于指导政策制定的相关数据有限。
本前瞻性全州注册研究纳入了症状发作<12 小时或在 12 至 24 小时内仍有缺血症状的 ST 段抬高型心肌梗死患者，给予 PPCI 再灌注治疗。从 2013 年 6 月至 2016 年 3 月，我们连续招募了 5560 例患者。我们根据每年 PPCI 量将医院分为低、中、高容量组（每年<100、100-199 和≥200 例 PPCI）。Kaplan-Meier 曲线和 Cox 回归模型用于观察 PPCI 量与 1 年死亡率之间的关联。在 42 家参与招募的医院中，有 24 家（57.2%）为低容量医院、8 家（19%）为中容量医院和 10 家（23.8%）为高容量医院。中位（25-75%）TIMI（血栓溶解在心肌梗死）ST 段抬高型心肌梗死风险评分是 3（2-5）。低、中、高容量医院心脏骤停入院前的发生率分别为 4.2%、2.1%和 2.9%（=0.02）。总缺血时间在低容量（中位数[25-75%]，3.5[2.4-5.5]小时）、中容量（中位数，3.8[25-75%，2.58-6.05]小时）和高容量医院（中位数，4.16[25-75%，2.8-6.3]小时）之间差异显著（=0.01）。低、中、高容量医院中，血管入路分别为桡动脉 61.5%、71.3%和 63.2%（=0.01）。观察到的 1 年死亡率分别为低、中、高容量医院的 6.5%、3.4%和 8.6%（<0.01），多变量调整后差异仍然显著（低 vs 中：风险比[95%CI]，1.80[1.12-2.90]；高 vs 中：风险比[95%CI]，2.53[1.78-3.58]）（<0.01）。
像印度这样的低中收入国家，机构 PPCI 量与结局之间可能存在非线性关系，部分原因是治疗程序存在差异，以及获得治疗的机会不平等。
