NCDR Study: PCI Volume Increasing in U.S., Japan; Elective Cases Drive Increase in Japan

Journal of the American College of Cardiology

PCI volume has increased in the U.S. and Japan since 2013, but elective cases are about twice as common in Japan than in the U.S., according to a study published Sept. 7 in the Journal of the American College of Cardiology.

Taku Inohara, MD, PhD, et al., used data from ACC's CathPCI Registry and the Japanese PCI Registry to compare trends in PCI procedural volume, preprocedural testing, patient and procedural characteristics, and quality metrics in the U.S. and Japan. The researchers looked at a total of 2,965,457 PCIs performed in the U.S. between 2013 and 2017 and 1,071,292 PCIs performed in Japan in the same time period.

During the study period, PCI volume in the U.S. increased by 15.8%, from 550,872 in 2013 to 637,650 in 2017. In Japan, PCI volume increased by 36%, from 181,750 in 2013 to 247,274 in 2017. The increase was driven primarily by nonelective PCIs in the U.S., although the number of elective PCIs also rose, while the increase in Japan was primarily due to elective procedures. Overall, the proportion of elective PCIs was 33.8% in the U.S. vs. 72.7% in Japan. Preprocedural noninvasive stress tests were more common in the U.S. (55.3%) vs. Japan (15.2%). In Japan, preprocedural coronary computed tomography (CTA) was more common than in the U.S. (22.3% vs. 2%).

Overall, patients undergoing PCI in Japan were older and more likely to be male than those in the U.S. Patients in Japan also had a lower prevalence of hypertension, dyslipidemia, chronic lung disease and peripheral artery disease than U.S. patients. PCIs for acute coronary syndromes were less common in Japan (39.3%) than the U.S. (81%), particularly for STEMI and unstable angina. Other demographic characteristics were comparable between patients in the two countries.

In terms of quality metrics, adherence to registry quality metrics was generally lower in Japan than in the U.S. Median door-to-balloon time was 57 minutes in the U.S. vs. 71 minutes in Japan. Observed in-hospital mortality rates were about 2% in the U.S. and about 0.8% in Japan. In both countries, expected mortality rates increased over the study period (1.87% in 2013 to 1.9% in 2017 in the U.S. and 0.71% in 2014 to 0.76% in 2017 in Japan).

According to the researchers, PCIs increased in both countries over time, but the increase was largely driven by elective procedures in Japan vs. by nonelective procedures in the U.S. "Continued efforts towards international benchmarking can yield insights on global variation in care, and may be helpful in developing quality improvement efforts," they conclude.

In an accompanying editorial comment, Harold L. Dauerman, MD, FACC, and Michael J. Mack MD, MACC, write that it is unclear what is driving increased PCI volumes in the two countries, noting that the "relentless march of new percutaneous technology and advances in structural heart disease may continue to shape the culture of coronary artery disease treatment." As new evidence emerges it will be "critical" for international registries to "monitor the impact of these competing influences on clinical practice and patient outcomes," they conclude.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Hypertension, Chronic Angina

Keywords: Coronary Artery Disease, Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Benchmarking, Exercise Test, Hospital Mortality, Japan, Peripheral Arterial Disease, Percutaneous Coronary Intervention, Quality Improvement, Angina, Unstable, Registries, Hypertension, National Cardiovascular Data Registries, CathPCI Registry

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