Perspective:

The following are 10 points to remember about this American Heart Association (AHA) Scientific Statement:

1. One of the main purposes of percutaneous coronary intervention (PCI) performance reporting is to identify systems that provide ‘good-quality’ or ‘poor-quality’ cardiac catheterization laboratory services and PCI.

2. Patients who experience out-of-hospital cardiac arrest (OHCA) have high mortality rates. Cardiac arrest (CA) may occur outside of a hospital, in a hospital, or in a catheterization laboratory during a revascularization procedure. The outcome of these CAs is affected by factors such as the location of the arrest, performance of immediate high-quality cardiopulmonary resuscitation (CPR), the presenting rhythm, rapid defibrillation, total ischemic time, and the extent of systemic reperfusion injury. It is nearly impossible to perform adequate risk adjustment for the single variable ‘CA,’ given the diversity of this population.

3. In cases of ST-segment elevation myocardial infarction (STEMI) without associated CA, there is a direct link between the PCI procedure, the underlying MI, and a subsequent cardiovascular death.

4. However, the majority of patients hospitalized after arrest who do not survive to hospital discharge die of neurological causes or multiorgan failure from massive reperfusion injury, and not cardiovascular complications of the PCI.

5. Patient deaths of brain damage or systemic injury after CA most often have little to do with the cardiovascular care they received, and their inclusion in a public performance-reporting program violates a key premise to all such registries that the mortality actually be related to the procedure.

6. If there is not a strong link between the PCI and the outcome, then the public is misinformed, and hospitals and providers are ranked inappropriately for the care they provide.

7. OHCA cases could be included in quality reporting if appropriate risk adjustment could be made. The problem is that current risk-adjustment models are not adequate, as noted, and given the diversity of the CA population, they are not likely to ever be adequate.

8. Categorizing OHCA STEMI-PCI cases separately from other STEMI-PCI cases represents the most appropriate solution, because the inclusion of OHCA patients in the public reporting of PCI outcomes does not accurately reflect quality.

9. OHCA cases should be tracked, but not publicly reported or used for overall PCI performance ranking, which would allow accountability for their management, but would not penalize high-volume cardiac resuscitation centers for following the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care.

10. Until an adequate risk adjustment model is created to account for the numerous out-of-hospital and in-hospital variables that impact survival more than the performance of PCI, categorizing OHCA STEMI-PCI cases separately from other STEMI-PCI cases and not including them in public reporting represents the most appropriate solution at this time.