Title British Cardiovascular Intervention Society National Audit of Percutaneous Coronary Interventional Procedures 

Public Report
 
Annual Public Report January 2011 - December 2011
    1
NICOR is a partnership of clinicians, IT experts, statisticians, academics and managers which manages six cardiovascular clinical audits and three clinical registers. NICOR analyses and disseminates information about clinical practice in order to drive up the quality of care and outcomes for patients.

The **British Cardiovascular Intervention Society** promotes education, training and research in cardiovascular intervention and develops and upholds clinical and professional standards.

The **Healthcare Quality Improvement Partnership (HQIP)** is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions.

Founded in 1826, **UCL (University College London)** was the first English university established after Oxford and Cambridge, the first to admit students regardless of race, class, religion or gender, and the first to provide systematic teaching of law, architecture and medicine. It is among the world's top universities, as reflected by performance in a range of international rankings and tables. UCL currently has 24,000 students from almost 140 countries, and more than 9,500 employees. Its annual income is over £800 million.

Authors The analysis and writing of this report was performed by: 

Dr Peter F Ludman MA MD FRCP FESC Queen Elizabeth Hospital, Birmingham, Audit Lead for the British Cardiovascular Intervention Society (BCIS).

Acknowledgments The National Audit of Percutaneous Coronary Interventional Procedures is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of the National Centre for Cardiovascular Prevention and Outcomes, based at University College London. The audit is funded and commissioned by the Healthcare Quality Improvement Partnership (HQIP). This report was completed in close collaboration with Tracy Whittaker and Andrew Donald from the NICOR team. We would especially like to thank the contribution of all NHS Trusts, hospitals in Scotland and Northern Ireland, UK private hospitals and the individual nurses, clinicians and audit teams who collect data and participate in the audit. Without this input the audit could not continue to produce credible analysis, or to effectively monitor and assess the standard of PCI procedures in the United Kingdom. This report is available online at www.ucl.ac.uk/nicor/audits/adultcardiacintervention. A full version of the analyses is available for download from the BCIS web site (www.BCIS.org.uk)
Tel: 0207 388  3950 Email: t.whittaker@ucl.ac.uk National Audit of Percutaneous Coronary Interventional Procedures National Institute for Cardiovascular Outcomes Research (NICOR) Institute of Cardiovascular Science, University College London 3rd floor, 170 Tottenham Court Road, London W1T 7HA

# British Cardiovascular Intervention Society National Audit Of Percutaneous Coronary Interventional Procedures

## January 2011 - December 2011

This is a report of the British Cardiovascular Society's National Audit of Percutaneous Coronary Interventional (PCI) Procedures. It has been produced specifically for anyone who wants to know more about the use of PCI procedures to treat angina and acute coronary syndromes including the treatment of heart attacks. It is written for people with little or no previous knowledge of PCI procedures, clinical conditions or clinical audit.

It is an abbreviated version of the United Kingdom's National Audit of Percutaneous Coronary Intervention. The full analyses is available for download at www.BCIS.org.uk All words in **blue** are included in the glossary at the end of the report.

## Contents

2
| Contents	                                        | 4   |
|----------------------------------------|-----|
| Executive summary                      | 5   |
| 1. Introduction                        | 7   |
|                                        | 1.1 |
| Coronary heart disease and the role of |     |
|                                        |     |
| 7                                      |     |
|                                        |     |
|                                        | 1.2 |
| The PCI procedure                      |     |
|                                        |     |
| 7                                      |     |
|                                        | 1.3 |
| The role of the audit                  |     |
|                                        |     |
| 9                                      |     |
|                                        | 1.4 |
| Use of the data                        |     |
|                                        |     |
| 9                                      |     |
|                                        | 1.5 |
| Organisation of the national PCI audit |     |
|                                        |     |
| 10                                     |     |
|                                        | 1.6 |
| The database                           |     |
|                                        |     |
| 10                                     |     |

	
1.7	
Data collection and IT	
10

| 2. Findings	                                             |   11 |
|---------------------------------------------|------|
|                                             |  2.1 |
| Data completeness                           |      |
|                                             |      |
| 11                                          |      |
|                                             |  2.2 |
| Patient characteristics                     |      |
|                                             |      |
| 11                                          |      |
|                                             |  2.3 |
| Improving access to PCI procedures          |      |
|                                             |      |
| 12                                          |      |
|                                             |  2.4 |
| Care and treatment of patients              |      |
|                                             |      |
| 14                                          |      |
|                                             |  2.5 |
| Improved access to evidence based treatment |      |
|                                             |      |
| 17                                          |      |

	
	
and guidelines	
	
2.6	
Outcome and improving patient experience	
18
 

| 3. The future	                                      |   20 |
|--------------------------------------|------|
| 4. Research use of PCI audit data    |   21 |
| 5. Glossary                          |   22 |
| 6. References                        |   24 |
| Appendix 1. Data completeness tables |   25 |

for UK NHS and Private hospitals

| Appendix 2. BCIS Data Monitoring and	             |
|-------------|
| Audit Group |

## List Of Figures And Tables

Figure 1	
Different types of acute coronary syndrome	
7
Figure 2	
The PCI procedure	
8
Figure 3	
Potential PCI complications	
8
Figure 4	
A summary of how the national audit 	
9

	
	
data is used to support improvement 	
Figure 5	
Characteristics of patients treated by PCI	
11

	
	
in the UK	
Figure 6	
Mean age of patients treated by PCI in	
11

	
	
each PCI centre	
Figure 7	
Indications for PCI	
12
Figure 8	
Increase in PCI activity 1991 - 2011	
12
Figure 9	
PCI centres and their provision of	
13

	
	
primary PCI therapy across the UK	
Figure 10	 PCI activity per million population in the	
13

	
	
UK countries 	
Figure 11	 Rates of primary PCI for STEMI,  per	
13

	
	
million population in the countries of the UK 	
Figure 12	 Rates of primary PCI for STEMI, per	
14

	
	
million population by  Cardiac Networks 	
	
	
and countries of the UK 
Figure 13	 Two procedural measures associated	
14

	
	
with better outcomes for patients 	
	
Figure 14	 Percentage of STEMI patients treated by primary	 15

	
	
PCI within target time by admission route 	
 	 	
Figure 15	 Median Call-to-balloon (CTB) times by direct	
15

	
	
admission (Direct) or by inter-hospital transfer (IHT)	
Figure 16	 Improvement in time delays to treat patients	
15

	
	
by primary PCI against overall PCI activity of	
	
	
each centre	
Figure 17	 Improvement in time delays to treat patients	
16
	
	
by primary PCI against performance of each	
	
	
unit in 2010	
Figure 18	 Call-to-balloon time: percentage of patients	
16
	
	
treated within 150 minutes of calling for help	
Figure 19	 Door-to-balloon time: percentage of patients	
16

	
	
treated within 90 minutes of arriving	
	
	
at a PCI centre 	
	
Figure 20	 Use of drug eluting stents in PCI	
17
Figure 21	 Drug eluting stent use by countries of the UK	
17
Figure 22	 The increasing use of the radial artery	
17

	
	
as access site for PCI centre 	
	
Figure 23	 Variation in the use of radial arterial	
18

	
	
access by PCI centre	
	
Figure 24	 Access site complication rates for PCI using 	
18

	
	
femoral access versus radial access 	
	
Figure 25	 Risk of death following PCI by syndrome	
18
Figure 26	 Independently validated 30 day mortality 	
19

	
	
following primary PCI 	
	

## Executive Summary

Coronary heart disease accounts for about one in five deaths in men and one in six deaths in women. 

The British Heart Foundation estimate there are over 1 million men living in the UK who have or have had angina (heart-related chest pain), and over 840,000 women. 1
Percutaneous coronary intervention (PCI) is used to treat patients with narrowed or blocked arteries that supply the heart muscle with blood. The procedure mechanically improves blood flow to the heart. Initially a 'coronary angiogram' is performed, where X-ray images of the heart are obtained to visualise the position and shape of the arteries and any narrowing or blockages. If the clinical circumstances and the angiogram findings suggest that a patient will benefit from mechanical improvements to blood flow to their heart muscle, the majority (4 in 5) will be treated by PCI and about 
1 in 5 will be treated by **coronary artery bypass surgery**.  
During the PCI procedure, a small balloon is inserted in to the narrowed artery and inflated. This moves the fatty tissue and clot that is causing the obstruction out of the way and so widens the artery. In most cases a metal mesh (called a stent) is implanted to scaffold the wall of the artery open. Thus treatment by PCI aims to prevent coronary arteries blocking (which might cause a heart attack) and improve flow to the heart muscle to relieve the symptoms of angina. The audit described here allows clinicians to assess key aspects of the patterns and quality of their care when performing PCI between January and December 2011.

## Key Findings Include:

•	 There are now 117 PCI centres in the United Kingdom of 
which 99 are NHS centres.

•	 The number of PCIs performed in 2011 in the UK was 1,405 
per million population (pmp).  This represents a slight fall, in part due to changed population estimates following the 2012 census.  
•	 The rate of primary PCI to treat ST elevation Myocardial 
Infarction (STEMI) (in place of **thrombolysis**) continues to rise, 
and reached 341 pmp across the UK in 2011.  This treatment option was provided 24/7 by 57 of the 99 NHS PCI centres.
•	 There is evidence that suggests improved outcomes 
for patients treated in PCI centres that perform at least 400 procedures per year.  This forms part of the recommendations of the Joint Working Group on PCI of British Cardiovascular Intervention Society and the British Cardiovascular Society.2 In 2011 29% of PCI units were performing 400 or less cases per year, but the majority of these were new units undertaking a gradually increasing volume of work.
•	  The National Institute for Health and Clinical Excellence 
(NICE) recommend that "stents should be used routinely 
where PCI is the clinically appropriate procedure for patients with either stable or unstable angina or with acute myocardial infarction"3. The great majority of procedures now involve stent insertion (92%), suggesting that this aspect of good practice is being met. 
•	 Following concerns about the safety of drug eluting stents 
(DES) in September 2006, there was a fall in their use to 55% across the UK. Data from 2011 suggest an increase in their use now that safety issues are better understood, and are not dissimilar from what might be predicted from the National Institute for Health and Clinical Excellence (NICE) updated guidelines.4, 5 Nevertheless there are large differences in the rate of DES use in the different UK countries.
•	 The use of the **radial artery** for access has increased 
progressively from 10% in 2004 to over 58% in 2011. This audit report supports the literature demonstrating a lower complication rate when PCI is performed via the radial 
artery, with approximately a halving of access site related complications. There remains a large variation in the rates 
of radial access by different PCI centres.
•	 The overall rate of in hospital death following PCI has 
gradually risen over the past few years. This is due to a change in **case mix**. There has been no evidence of a change in the outcomes when patients with similar clinical presentations are compared. For **stable elective patients**, in hospital mortality is about 0.2%, for patients with unstable angina or NSTEMI (non-ST elevation Myocardial Infarction), the in hospital mortality is approximately 0.6 %. For patients with STEMI the mortality is higher at about 4 %.

•	 Analysis of risk adjusted outcome (major adverse cardiac 
and cerebrovascular events) from the 2009, 2010 and 2011 
data combined shows that all units in the United Kingdom are performing as well as would be predicted from the model used for risk adjustment.
•	 National and international guidelines for the emergency 
treatment of patients with STEMI, recommend that primary PCI treatment should be performed within 90 minutes of arrival of the patient at the PCI centre (door-to-balloon (DTB) time), and within 150 minutes of a patient's call for help (call-to-balloon (CTB) time). There has been a year on year improvement. A door-to-balloon time of less than 90 minutes was achieved in 92% of cases. A call-to-balloon time of less than 150 minutes was achieved in 80% of cases. This compares very favourably with international data.

•	 The improvement in delays to **reperfusion** treatment by 
each unit is presented and shows that those who had the 
poorest performance in 2010 have improved the most 

in 2011.
•	 Patients who need to be transferred between hospitals 
for primary PCI had longer delays to treatment than those admitted directly to a PCI centre, the transfer delaying treatment by about 50 minutes.
•	 There has been a further improvement in the number 
of hospitals sending data to NICOR and a marked 
improvement in the quality of data submitted.
The rest of this report contains more details and graphs of the audit findings. The complete analyses for the 2011 audit are available for download at the BCIS web site www.bcis.org.uk.

## 1 Introduction 1.1 Coronary Heart Disease And The Role Of Percutaneous Coronary Interventional Procedures

Coronary heart disease (CHD) is the largest cause of death and disability in the United Kingdom. CHD causes around 94,000 deaths in the UK each year and around one in five men and one in seven women will die from the **disease**. 

Coronary heart disease is usually caused by **atherosclerosis** 
which is a process where the walls of the arteries develop with fatty deposits called atheroma. Atherosclerosis manifests itself in a number of conditions: Stable angina occurs when the artery becomes progressively narrowed and blood supply to the heart muscle becomes restricted. People experience a tight constricting feeling, normally across the chest. It is brought on by physical exertion or stress. Stable angina is a chronic medical condition with a low but appreciable incidence of **acute coronary syndrome** 
and increased mortality. Patients with acute Coronary Syndromes (ACS) present with a set of symptoms that indicate a sudden or recent reduction in the blood supply to the heart and includes **unstable angina** and myocardial infarction (heart attacks). The symptoms for both unstable angina and a myocardial infarction can be similar (for example, chest pain or tightness, breathlessness and sweating) 
but can be distinguished with an **electrocardiogram** (ECG) and blood tests.  
A myocardial infarction (heart attack) occurs when the coronary artery is totally blocked by a clot (thrombus) which forms over the fatty deposits in the wall of the artery. If the blockage persists the region of the heart muscle supplied by that artery will progressively die (myocardial necrosis). This syndrome is referred to as ST elevation Myocardial Infarction (STEMI), because usually this pattern (elevation of the ST segments) is seen on the ECG. Sometimes the artery becomes partially blocked or only blocked temporarily. The ECG usually does not show ST segment elevation. Shortage of blood supply to the affected heart muscle is less severe or intermittent and may not lead to myocardial necrosis. If it does not then the syndrome is called unstable angina. If there is evidence of some myocardial necrosis without ST segment elevation it is referred to as non ST elevation Myocardial Infarction (nSTEMI).

In the PCI procedure, a very thin wire is guided under x-ray image control, across the narrowed part of the coronary artery (Figure 2). Once in place, a balloon is fed over this wire and so tracked across the narrowing. Inflating the balloon squashes Percutaneous Coronary Intervention is one of two coronary revascularisation techniques used to treat narrowed arteries, the other being **coronary artery bypass grafting** (CABG).

The PCI procedure works by mechanically improving blood flow to the heart. A small balloon is inserted which, when inflated widens the artery. In most cases a 'stent', a metal mesh scaffold is implanted to keep the artery wall open. The National Institute for Health and Clinical Excellence (NICE)6, 7 recommends that PCI is used to manage angina and acute coronary syndromes in three ways:

•	 Alleviate the symptoms of angina
•	 Prevent future myocardial infarction •	 Restore coronary blood flow during a heart attack 

(primary PCI)
The use of primary PCI has increased significantly in recent years because of worldwide research showing it to be more clinical and cost effective than drug treatment (**thrombolysis**).8 
 
National and international guidelines now recommend that in the emergency treatment of patients with ST elevation myocardial infarction, primary PCI should be performed within 
90 minutes of arrival of the patient at the centre (**DTB time**), and within 150 minutes of a patient's call for help (**CTB time**).

This primary PCI strategy requires emergency access to specialist **cardiac catheter laboratories** and staff 24 hours a day, 7 days a week. In 2011, primary PCI made up more than 
95% of reperfusion **treatment** for patients with STEMI.9

## 1.2 The Pci Procedure

A percutaneous coronary intervention starts with an angiogram. During an angiogram, x-ray images are made of the heart arteries, while a special dye is injected into them to make them visible. The procedure can be performed from the artery at the top of the leg (femoral artery) or in the wrist (radial artery) and is performed under local anaesthetic. Through this area a long thin tube (called a catheter) is fed into the artery. It is then guided under x-ray imaging control until the tip reaches the heart. When the tip of the catheter is in position a liquid is injected into the heart arteries so that they show up under x-ray. The position and shape of any narrowing in these arteries can therefore be identified. This part of the procedure is called an angiogram and is a prelude to a percutaneous coronary intervention (PCI), which would then occur immediately after the images are obtained. 

During PCI 
PCI procedures are very rarely associated with Major Adverse Cardiac and Cerebrovascular Event 
(MACCE). This includes complications such as stroke, heart attack, need for emergency coronary bypass surgery or death. Risk of adverse outcome is mainly determined by a patients presenting condition. For example, the treatment of a patient in a stable situation is associated with complication rates of less than 1 %. However, when primary PCI is used to treat a heart attack this may rise to 10% or more. Repeat revascularisation. After PCI, the symptoms of angina are usually much improved. There follows a period when the walls of the newly stretched arteries heal. If a simple metal stent has been deployed, then over the course of the first six months cells grow over this part of the artery wall, and form a new lining, embedding the stent within the artery wall. If the healing process is over exuberant this can lead to renarrowing of the artery (so called 'restenosis'), and a recurrence of angina. If this is going to occur it usually does so within the first six months. If a drug eluting stent has been implanted, there is much less proliferation of cells around the stented site. This means that the chance of recurrent symptoms in the first few months is much lower.  After both types of stent there is a small risk (less than 1 % per year) of the treated vessel blocking abruptly, usually due to clot formation. This risk is slightly higher for simple metal stents early after the PCI, and slightly higher for drug eluting stents later after the PCI.

the blockage (made of fatty tissue and sometimes clot) out of the way and widens the artery. This may need to be done several times to be successful in fully widening the artery. In most cases a stent is then implanted. A stent is a small metal mesh in the shape of a tube which can be used to scaffold the artery wall in order to keep it open. The stent is supplied crimped over a balloon, which is used to deploy it against the inner wall of the artery. As the balloon inflates, the stent is expanded, pressing out against the arterial wall, so helping to hold open the newly widened artery. The balloon is then deflated and withdrawn, leaving the stent in place. In the last few years we have seen the development of 'drug eluting' stents, which are coated in with drugs to prevent the development of **cell proliferation** which could otherwise block the stented artery. This drug passes into the wall of the artery to improve the longer term success rates of the procedure. Following a PCI, most patients return home the next day, though some patients can be treated and discharged the same day. If a patient has been admitted following a heart attack then they usually remain in hospital for a bit longer (on average 3 days). Generally, this is a very safe treatment. The potential complications can be broadly split into those that occur during or very shortly after angioplasty, and those that occur weeks or months later (see Figure 3). 

## 1.3 The Role Of The Audit

Clinical audit is the process of monitoring the care and treatment of patients against a given standard, with a view to driving up the quality of care and improving outcomes for patients. The British Cardiovascular Society (BCIS) has continuously audited PCI activity since 1988. Each hospital submits an annual return that summarises local PCI activity. An electronic system to collect data on each PCI procedure was developed after a pilot study in the late 1990s, and collected data from all PCI centres in the UK from about 2005. The audit provides information on the:   

•	 the structure of the provision of PCI services across the UK
•	 clinical care and treatment provided by each hospital, 
measured against national aggregated data and agreed national standards  

Local level
Hospital performance
Aggregated reports are produced for each hospital that summarises data 
completeness and a variety of anlyses of appropriateness, process and outcomes. 
Delays reports calculate a number of time intervals between various stages of 
the PCI pathway for 2 clinical presentations and 4 admission scenarios. It also generates graphs for door to balloon times. 
MACCE reports provide information on the number of actual events compared 
with predicted events.
Clinical performance
Clinical audit outcome data can be used to support the revalidation of cardiologists. Plans are in place to develop operator level reports for 

this purpose.
National level
Informing clinical 
guidelines
The Joint Working Group on Percutaneous Coronary Intervention of the British 
Cardiovascular Intervention Society and the British Cardiovascular Society used audit data to develop guidelines regarding the best practice of coronary intervention.2
Transparency of data
The British Cardiovascular Interventional Society provides comprehensive analysis of annual audit data from 1992 on the BCIS website (http://www.bcis.org.uk). The National PCI data will also be published on data.gov.uk website following the publication of this report in January 2013.
Quality accounts
Department of Health Quality Accounts 2011/12: In their Quality Account providers must report which of the national clinical audits they participated in. This information is published annually and made available to the public, in order to ensure the accountability of NHS institutions to the public, and to engage the leaders of hospitals in the quality improvement agenda of their organisation.

•	 the process of care e.g. delays in receiving treatments such 
as primary PCI 
•	 the outcome for patients such as complications, adverse 
cardiac events and death 

## 1.4 Use Of The Data

PCI audit findings are used in various ways to support quality improvements (Figure 4). Access to national comparative data allows clinicians and healthcare professionals to examine key aspects of the quality of care and impact on patients:

## 1.5  Organisation Of The National Audit Of Pci

The National audit of PCI is managed by the National Institute for Cardiovascular Outcomes Research (NICOR). The audit is one of six national cardiac clinical audits managed by NICOR, part of the National Centre for Cardiovascular Prevention and Outcomes at University College London. The purpose of NICOR is to provide information on quality and outcome of care provided to people with heart disease and to provide technical infrastructure, project management and statistical support for the national cardiac audits and clinical registries. The British Cardiovascular Interventional Society provides clinical leadership to the audit. The BCIS Data Monitoring and Audit Group is a working group of BCIS and responsible for:

•	 reviewing and assessing the UK wide audit data •	 reviewing applications to use the audit data for research 
(see Section 4)
•	 reviewing potential changes to the dataset
The national PCI audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP). HQIP holds commissioning and funding responsibility for this and other national clinical audits.

## 1.6 The Dataset

The audit is based on a dataset developed by BCIS and reflects national evidence based guidelines and recommendations. The current dataset v5.5.6 was published in January 2012 and contains 113 fields including patient demographics, clinical information and process information e.g. date and time of call for help. The dataset is available on the BCIS and NICOR websites.i, ii

## 1.7 Data Collection And It

Data are usually imported from existing hospital systems using commercial software. All data uploaded by hospitals are encrypted on transmission and stored encrypted on the NICOR servers. NICOR manages access control to the servers via user IDs and passwords. All patient identifiable data are pseudonymised by the NICOR technical team before release to the project management team via a secure drop box on the NICOR server. Patient identifiable data are only available for the purpose of record linkage. Data held within NICOR are managed within a secure environment for storage and processing provided by the UCL network and within the UCL Information Governance and Security policies. NICOR is registered under the Data Protection Act. Additionally, NICOR - of which this audit  is part - has support under section 251 of the National Health Service (NHS) Act 2006 (Ref: NIGB: ECC 1-06 (d)/2011). 

## 2 Findings 2.1 Data Completeness

Of 99 NHS PCI centres in the UK, all but 2 submitted data for 2011 to NICOR. The centres that failed to submit were one Scottish Centre (Hairmyers Hospital), and one centre in Northern Ireland (Altnagelvin). Seven of 18 private hospitals in the UK also submitted data to NICOR.  
There has been a further improvement in the completeness of the fields for each of the procedures entered for the 2011 data. The percentage completeness for hospitals in England and Wales is provided in Appendix 1. 

| 2007           | 2008   | 2009   | 2010   | 2011   |
|----------------|--------|--------|--------|--------|
| Age (mean)     |        |        |        |        |
| 64.3           | 64.4   | 65.0   | 65.1   | 65.3   |
| Sex (male)     |        |        |        |        |
| 73.6%          | 73.8%  | 73.9%  | 74.0%  | 74.0%  |
| Diabetic       |        |        |        |        |
| 17.5%          | 18.0%  | 18.2%  | 18.7%  | 19.5%  |
| Previous CABG  |        |        |        |        |
| 8.5%           | 9.1%   | 8.6%   | 8.4%   | 7.9%   |
| Previous PCI   |        |        |        |        |
| 18.6%          | 21.1%  | 22.3%  | 22.6%  | 22.7%  |
| Previous MI    |        |        |        |        |
| 29.5%          | 30.2%  | 28.8%  | 28.4%  | 27.6%  |
| Current smoker |        |        |        |        |
| 26.0%          | 26.1%  |        |        |        |
| Ex smoker      |        |        |        |        |
| 39.0%          | 37.0%  |        |        |        |
| Never smoked   |        |        |        |        |
| 35.1%          | 37.0%  |        |        |        |

## 2.2 Patient Characteristics

The characteristics of patients treated by PCI are shown in Figure 5. Although the average age of patients treated by PCI is 65.1 years, there is a wide range in patient characteristics across different regions in the UK. The mean age of patients treated in each PCI centre therefore differs and is shown in Figure 6. A full list of hospital codes and names are provided in Appendix 1.

## Using Pci To Treat Different Groups Of Patients

Primary PCI is now the preferred treatment of choice for STEMI and now makes up more than 95% of reperfusion treatment for patients with STEMI.9 This is supported in this audit which has seen a year on year increase in the use of primary PCI in place of thrombolysis to treat patients presenting with STEMI. Overall, the percentage of patients receiving primary PCI for STEMI has more than doubled over the last few years; the percentage of patients with stable angina has decreased from approximately 50% to 35%, while those with non ST elevation acute coronary syndromes has remained level at approximately 37% (Figure 7).

## 2.3 Improving Access To Pci Procedures Increasing Overall Pci Rates In The United Kingdom

The most appropriate rate of PCI pmp is difficult to judge and is dependent on many factors, including the varying characteristics of populations in different countries. While the rate of PCI pmp in the UK has, historically, been considerably lower than most other European countries, there have been steady increases in activity. A total of 88,692 PCIs were performed from January to December 2011and represents a rate of 1,405 PCI pmp (Figure 8). This represents a small fall in rates pmp compared with 2010. The main reason for this apparent fall is that the 2011 
census demonstrated a larger population size for all the UK countries than had been expected based on the estimates from the 2002 census.

The increase in PCI activity has been possible by increasing the number of PCI centres, extending the service to 24/7 coverage within the centres and increasing the volume of procedures undertaken each year:
An increase in the number of centres The number of hospitals performing PCI has increased this year and there has been a fall in the number of sites performing angiography only.  In 2011, in the United Kingdom there were a total of 117 PCI centres, and 61 centres performing angiography only.  
An increase in availability of service Primary PCI is an emergency treatment that needs to be available at all times. In 2007, only 50% of hospitals offered primary PCI as a treatment for STEMI during working hours. In 2011, over 70% provided a working hours service. In 2007, 30% of PCI centres offered this service at all hours every day. In 2011 this has almost doubled and almost 60% of centres now offer a 24/7 service. A map showing the distribution of this activity across the UK is given in Figure 9.

An increase in number of patients treated Increasing the number of patients treated by each centre has also helped to improve access. Increasing volume has an additional benefit. There is increasing evidence from the UK (BCIS data) and other countries that patients treated in higher volume centres have improved outcomes, particularly centres that perform at least 400 procedures per year. The BCIS and BCS 'Recommendations for good practice and training'(5) recommend that centres undertake at least 400 PCI procedures each year. In 2011, the majority of units perform considerably more than 400 cases per year. Only 29% of units perform less than 400 cases and in the majority of cases this is because the unit is new, and undertaking a gradually increasing volume of work. Details of number of cases performed by centres are available in the full analyses (www.bcis.org.uk).

Variation in access across the UK 

Whilst overall access to PCI and primary PCI has improved, there remain large differences in PCI rates between the countries of the United Kingdom, with the lowest in Wales at 1,170 pmp, with the highest provision in Northern Ireland at 1751 pmp (Figure 10).

As with overall PCI rates, there are differences in the provision of primary PCI between the UK countries, with N. Ireland having the lowest rates per million population (Figure 11).

Within England and Wales there are also differences between cardiac networks and countries (Figure 12). 

## 2.4 Care And Treatment Of Patients

Primary PCI and delays to treatment National and international guidance recommend that in the emergency treatment of patients with STEMI, primary PCI should be performed within 90 minutes of arrival at the PCI centre (doorto-balloon time) and within 150 minutes of a patient's call for professional help (call-to-balloon time) (Figure 13).  

In the treatment of STEMI by primary PCI, any 
delay in the performance of primary PCI is 
associated with a worse outcome for the patient. 
There are 2 important procedural measures:

•	
The time the patient calls for professional help to the time of primary PCI treatment (call-to-balloon time) measures the entire process of care.
•	
The time a patient arrives at a PCI centre to the time of primary PCI treatment (door-toballoon time) which assesses how quickly the PCI unit can perform primary PCI.
In 2011, 80% of all patients were treated within 150 minutes of calling for professional help and 92% treated within 90 minutes of arriving at the PCI centre. However, how the patient gets to the PCI centre can cause delays. There are two routes into a PCI centre for heart attack patients:
Direct admission The patient is brought directly to the PCI centre usually by ambulance. In 2011, 77.5 % of patients who received primary PCI were direct admissions to the centre.

Interhospital transfer (IHT)

The patient is transferred from a hospital not capable of performing PCI to the PCI centre that performs the PCI. In 2011 22.5% of patients were transferred from another hospital to the primary PCI centre for treatment. Whilst there have been year on year improvements in treating patients within target times, transferring patients between hospitals causes additional delays (Figure 14).   
Call-to-balloon (CTB): 89% of patients admitted directly to a PCI centre were treated within 150 minutes. Only 51% of patients who were transferred from another hospital to the PCI centre were treated within 150 minutes of calling for help. 

Door-to-balloon time (DTB): is an indication of how quickly the PCI centre can perform PCI when the patient is in the PCI centre. A strategy to avoid interhospital transfers would result in quicker and therefore better treatment. In 2011, this would have saved approximately 50 minutes of delay (Figure 15). There have been important improvements in CTB time delays by the majority of PCI centres. In 2011, there is little difference in **door-to-balloon** times for either admission route. This shows that the process of care from arrival at the PCI centre to treatment now works well. Figure 16 shows the improvement in door to balloon times between 2010 and 2011 by each centre according to the overall volume of their activity. Clearly those centres already performing well may not need to improve as much. Figure 17 shows the degree of improvement according to how well a unit was performing in 2010.  It is very encouraging to see that those centres who had the most room for improvement (on the left of the graph) have indeed improved the most. More details regarding the analyses of delays are provided in the full analysis available in the BCIS web site. Enlarged versions of these graphics are also available for download.

The percentage of cases treated within target times by each PCI centre are presented in Figure 18 and Figure 19.

## 2.5 Improved Access To Evidence Based Treatment And Guidelines

Drug eluting stents The National Institute for Health and Clinical Excellence (NICE)3 recommend that "Stents should be used routinely where PCI is the clinically appropriate procedure for patients with either stable or unstable angina or with acute myocardial infarction". The great majority of procedures do now involve stent insertion (92%) suggesting that this aspect of good practice is being met. There has been a gradual increase in the percentage of patients treated with drug eluting stents now that initial concerns about long term safety are better understood, which reached 71.1% in 2011. The use of drug eluting stents appears to be approximately what might have been predicted if units were following recommendations from current NICE guidelines (Figure 20) though there are very large differences between the countries of the UK (Figure 21).

How the coronary arteries are accessed When performing coronary intervention, catheters are introduced to a patient's arterial system, so the coronary arteries can be reached and treated. During the development of PCI techniques the large femoral artery at the top of the leg was used. However, some of the commonest complications after PCI relate to the difficulty in stopping this artery from bleeding after removing the catheter at the end of the procedure. As PCI equipment has become smaller, it has been possible to perform almost all PCI from the smaller radial artery in the wrist. Robust data shows this is associated with a reduction in complication rate; it is easier to stop any bleeding, and there are fewer nearby structures that can be damaged. There has been a continued increase in the adoption of this method which is now used for more than half of all procedures (Figure 22). There is a large variation in the use of this approach between different PCI centres (Figure 23). This has had a positive impact and complication rates have reduced in the last five years (Figure 24).

## 2.6 Outcome And Improving The Patient Experience

The complications from PCI have progressively fallen as techniques have evolved. Nevertheless, this has also meant the procedure can be offered to patients who are considerably sicker, and in whom a higher risk of complications is expected. 

 
Emergency coronary artery bypass surgery This may be needed to treat a complication. In 2011, the need for emergency coronary artery bypass graft (CABG) remains very low at less than 1%.  

## Stroke: The Incidence Of Stroke Also Remains Low At Less Than 1% Of All Pci Procedures.

Mortality:  

The overall rate of death in hospital following PCI has gradually increased over the past few years. In 2007, inhospital mortality rates were 0.89% compared to 1.6% in 2011. 

This may reflect more accurate data entry. It may also be due to the increasing proportion of sicker patients undergoing PCI. If we look at the in hospital mortality for specific groups of patients, the mortality rates for patient undergoing elective, unstable angina (UA) and primary PCI have remained stable. 

In contrast, the mortality rates for **rescue PCI** have increased 
(Figure 25). The increase in overall mortality is due to an increasing proportion of sicker patients treated by PCI. This change in case mix is due to the increasing use of primary PCI to treat STEMI which has more than doubled in the last few years (see Section 2.3).

This figure clearly demonstrates the importance of risk adjustment in the assessment of outcome to help avoid misleading conclusions. This is further highlighted when the mortality rates of individual hospitals are compared. Results need to be interpreted with caution. Accuracy of the results depends on a number of factors including the statistical model 10 **used** and the accuracy of data entry. Not only must a patient's risk factors be correctly recorded, but also any complications after the procedure must be recorded correctly. More detailed findings are available at the BCIS website (www.BCIS.org.uk).

Using Office of National Statistics mortality data:

To attempt to avoid under reporting of adverse outcomes we plan to use a mortality only model, and link to ONS tracked mortality to validate outcomes. Mortality tracking has been used in this audit to assess the outcomes of relatively similar groups of patients. 

For example, the validated 30 day mortality of patients treated by a primary PCI is shown in Figure 26. In this figure each unit is represented by a point on the graph according to the total number of the primary PCI procedures performed against their 30 day mortality. Patients presenting in **cardiogenic shock** or needing ventilation are excluded from this analysis.  No unit has mortality above the 2 or 3 standard deviation (SD) line, suggesting that no unit's outcomes are statistically worse than the average.

NOTE: I can't read most of these 
hospital codes, the fle is far too low 
resolution, I will need to be told what 
they are or provided a high 
resolution version of this graph JPEG 
and the original data please

## 3 The Future

High quality information is vital to improve the care, treatment and outcomes for patients undergoing PCI. Our future plans continue to focus on improving the quality of data to ensure accurate and timely data are readily available.

Improve IT systems Earlier this year NICOR began a major project to upgrade its data collection and management systems. The current Lotus Notes software has become increasingly unwieldy as the NICOR databases have grown in size and complexity. A new platform will substantially improve NICOR's ability to derive high-quality results from the PCI database to inform hospitals. Cardiac Networks and patients regarding the provision of cardiac care. The first step in this project involved a transfer of all data from the Information Centre for Health and Social Care onto secure NICOR servers. The transition was not easy, and it led to some delays in accessing the PCI database. Despite these difficulties, participating hospitals submitted their data in time, making possible the timely publication of this report. We would like to thank everyone for their effort and patience during the migration. The new IT platform will be rolled out in stages throughout 2013, with the national audit of PCI scheduled for autumn 2013.

Improve reporting We plan to develop software to generate personalised funnel plots for individual cardiologists to use for **revalidation purposes**.

Improve data quality by encouraging the use of consistent definitions to improve the accuracy of data. We will also strengthen the link with the heart attack audit as both audits collect data on primary PCI. Work includes aligning the two datasets, definitions and analysis to enhance the completeness of the description and measurement of patient care. 

Improve analysis by developing the risk adjustment model to avoid misleading conclusions on mortality and MACCE. This will also require accurate and complete risk factor data. We will work with centres to improve the accuracy of hospital reported data but will also continue to track mortality through ONS. Plans are also in place to try to validate reported MACCE through Hospital Episode Statistic data (HES).

## 4 Research Use Of Pci Audit Data Clinical Research Is Used To Look At The Safety And Effectiveness Of Medications, Devices, Diagnostic Products And Treatments.

Audit and research are two distinct activities with different purposes. Research is used to establish good practice and is designed so that results can be generalised to similar groups. Research generates new knowledge. Data is used to monitor the care and treatment of patients against existing standards of care. There are overlaps between audit and research. Audit data can provide high quality data for non experimental research. Findings are based on 'real world' patients and not restricted to trial criteria. The national PCI audit collects data on all PCI procedures in the UK and now has nearly 600,000 records in the database. The data are a valuable research resource especially as they can be linked with external databases. Linkage to databases such as the Office of National Statistics life status provides key Patient outcomes A good number of the research studies look at differences in patient outcomes. The aim is to identify common factors that may have a negative or positive effect on outcomes such as reintervention, stroke and death. Studies focus on looking at patients grouped by illness, ethnicity, procedure or PCI Centre. Examples include:

•	 Comparing the PCI access site (e.g. femoral vs radial atery) and neurological complications •	 The outcomes for South Asian patients following PCI  procedures. •	 Looking at the clinical outcomes in patients with **cardiogenic shock**. •	 The use of drug eluting stents for groups of patients who need rotational atherectomy. This is a type of interventional 
procedure to help open coronary arteries blocked with heavily calcified material which is more common in the elderly, and 
restore blood flow to the heart. Often a drug eluting stent is inserted to improve the results.
•	 Comparing patient outcomes for ACS syndromes between different hospitals and explaining any differences. 
Review changing clinical practice including a study looking at whether clinical practice changed following publication of clinical trial findings that showed PCI may be deferred in patients with stable disease as long as medical therapy is optimised and maintained.

Linking audit data with other national datasets provides valuable information about the patient pathway and the cost effectiveness of certain treatments. One study will look at the health gains of cardiac rehabilitation by linking the national PCI audit data with other national heart disease audits, national cost data and cardiac rehabilitation audit data.

information about the relationship between care and treatment and patient outcomes. Outcomes include major adverse cardiac and cerebrovascular events (e.g. stroke and mortality), reintervention and process of care.

The BCIS Data Monitoring and Audit Group (Appendix 2 for membership) is responsible for reviewing and assessing the audit data and reviewing applications to use the dataset for research. A full list of approved studies is also available via the website. Figure 25 provides a summary of the type of research undertaken so far.

## Publications

Ludman PF. The British Cardiovascular Intervention Society registry for Audit and Quality Assessment of Percutaneous Coronary Interventions in the United Kingdom. Heart 2011;97:1293-1297 The mechanism for applying to use these data for research are available on the NICOR web site (http://www.ucl.ac.uk/nicor). 

## 5 Glossary

Term
Abbreviation
Acute coronary 
syndrome
ACS
This term covers all cardiac episodes that result from sudden and spontaneous blockage or near 
blockage of a coronary artery, often resulting in some degree of cardiac damage. The underlying cause of the clot is rupture of the fine lining of a heart artery (plaque rupture), which allows blood to come in contact with the tissues of the wall of the artery, promoting the development of clot. The degree of damage and the type of syndrome (heart attack) that results from the blockage depends on the size and position of the artery and the amount of clot that develops within the artery. Not all acute coronary syndromes are suitable for treatment with primary PCI or thrombolytic drugs, and the decision is mainly guided by the appearances of the ECG.
Angina
Symptoms of chest pain that occur when narrowing of the coronary arteries prevent enough blood reaching the heart muscle when its demands are high, such as during exercise.
Angiogram
An X-ray investigation performed under a local anaesthetic that produces images of the flow of blood within an artery (in this case the coronary artery). Narrowings and complete blockages within the arteries can be identified during the angiogram and this allows decisions to be made regarding treatment. Often an angiogram is an immediate precursor to an PCI and stent implantation or to coronary artery bypass grafting.
Anti-platelet drugs
Drugs including aspirin, clopidogrel, prasugrel and ticagrelor that prevent blood clotting. Antiplatelet drugs act by reducing the 'stickiness' of the small blood cells that can clump together to form a clot.
Call-to-balloon time
CTB
The interval between the patient alerting the health services that they have symptoms of a heart attack and the performance of primary PCI. The cardiac catheter laboratory is where the angiogram and PCI are performed. 
Cardiac catheter laboratory Cardiogenic shock
Cardiogenic shock occurs when the heart fails to pump effectively.
Case mix
The type or mix of patients treated by a hospital including age and sex of patients.
CHD
The narrowing or blockage of the coronary arteries, usually caused by atherosclerosis.
Coronary Heart Disease Coronary artery 
bypass grafting 
CABG
Coronary artery bypass grafting (CABG) is a type of surgery used to improve blood flow to the heart. 
It is used to treat people with severe coronary heart disease.
Door-to-balloon time
DTB
The interval between the ambulance arriving at a hospital and the performance of primary PCI.
Drug eluting stents
These are coronary stents placed into coronary arteries that slowly release a drug to stop cell growth.
Electrocardiogram
Also known as 'ECG'. A test to record the rhythm and electrical activity of the heart. The ECG can often show if a person has had a heart attack, either recently or some time ago. It can also tell if reperfusion therapy is appropriate and if it has been effective.
Elective
An elective PCI is one scheduled in advance because it does not involve a medical emergency.
Funnel plots
Funnel plots were first introduced in 1984 as a means of estimating bias in clinical trials that contained varying numbers of subjects. In essence, each individual value is compared to the overall mean, and the control limits around that mean diminish as the number of subjects (or admissions) increases (as one would expect). A value which falls outside the 'funnel' is considered an outlier, and can represent abnormally high performance as well as abnormally low performance. The width of the control limits is determined by the statistical significance level from which they are calculated. To diminish the risk of a false positive 'outlier' we use +/- 3 standard deviations, which means that the chance of an outlier happening 'accidentally' (i.e. by random chance) is no more than 0.4%. The funnel plot was adapted for comparing clinical performance of surgeons, and can also be used to compare measures such as call-to-needle and call-to-balloon time.
Hospital Episode Statistics
HES
Hospital Episode Statistics (HES) is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. The HES 
database is a record level database of hospital admissions. http://www.hesonline.nhs.uk. 
Heart attack
The term applied to the symptoms, usually but not always involving chest pain, which develop when a clot (thrombus) develops within a heart artery as a result of spontaneous damage to the inner lining of the artery (plaque rupture). The heart muscle supplied by the blocked artery suffers permanent damage if the blood supply is not restored quickly. The damage to heart muscle carries a risk of sudden death, and heart failure in people who survive.
Heart Attack Centre
A hospital that provides a primary PCI service to patients with ST elevation Myocardial Infarction.
MACCE
MACCE is a selection of events that can happen after PCI and includes all causes of death, 
stroke, heart attack and emergency coronary artery bypass surgery.
Major Adverse Cardiac 
and Cerebrovascular Events Myocardial Infarction
A heart attack in which heart muscle damage is confirmed by blood testing and ECG charges.
Non-ST elevation Myocardial Infarction 
nSTEMI
A heart attack that occurs in the absence of ST segment elevation on the ECG. In these patients urgent admission to hospital is mandated but immediate reperfusion therapy may not be required.
Office of National Statistics
ONS
Office of National Statistics is the UK's largest independent producer of official statistics and the recognised national statistical institute of the UK. http://www.ons.gov.uk.
Percutaneous coronary intervention 
PCI
A technique to re-open the blocked coronary artery. A fine catheter (tube) is passed, under local anaesthetic, from an artery in the leg or arm into the blocked heart artery. A thin wire is then passed through the catheter and across the blockage, allowing the artery to be re-opened by temporary inflation of a balloon which tracks over this wire. Once the artery has been reopened and widened by a balloon, it is usually scaffolded by the implantation of a small expandable metal tube (stent) which is passed into the artery and deployed with an angioplasty balloon. The umbrella term that encompasses both balloon dilatation (angioplasty) and stent insertion (stenting) is 'percutaneous coronary intervention' (PCI).
primary PCI
When PCI is used in the treatment if a patient presenting with myocardial infarction associated with an ECG showing ST segment elevation.
Primary percutaneous coronary intervention
Radial artery
One of the arteries that passes through the wrist to provide blood supply to the hand.
Re-infarction
The development of evidence of re-occlusion (further blockage) of, or development of the coronary artery that was responsible for the original heart attack. This would normally occur after the original blockage had been successfully treated.
Reperfusion treatment
The term used to cover both techniques, thrombolytic treatment and primary PCI, for reopening a coronary artery as an emergency. These treatments are suitable only for certain types of heart attack characterised by typical electrocardiographic appearances described as ST segment elevation.
Rescue PCI
Patients with a heart attack are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed.
Revalidation
This is an appraisal process to provide reassurance to patients, the public, employers and other healthcare professionals that cardiologists are up-to-date and fit to practice.
Revascularisation
Interventions that improve the blood supply to the heart, including PCI or coronary artery bypass grafting.
Risk adjustment
Risk adjustment is a process used to account for the impact of individual risk factors such as age, severity of illness and other medical problems that can put some patients at greater risk of major complications than others.
| Risk factors                                                                                       | A risk factor is something associated with an increased risk to a patient. For example, the    |
|----------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|
| development of coronary heart disease is influenced by the following risk factors: increasing age, |                                                                                                |
| family history, smoking and obesity.                                                               |                                                                                                |
| Stable elective                                                                                    |                                                                                                |
| patients                                                                                           |                                                                                                |
| An elective procedure or surgery is scheduled in advance because it does not involve a medical     |                                                                                                |
| emergency. A stable condition is one in which the condition of the patient is not expected to      |                                                                                                |
| change in the near future.                                                                         |                                                                                                |
| Statistical model                                                                                  | A statistical model is a formal mathematical way of representing a real world situation that   |
| allows predictions to made.                                                                        |                                                                                                |
| ST elevation                                                                                       |                                                                                                |
| myocardial                                                                                         |                                                                                                |
| infarction                                                                                         |                                                                                                |
| STEMI                                                                                              | A heart attack characterised by a specific abnormal appearance of ST segment elevation on the  |
| ECG thought to be indicative of complete blockage of a coronary artery. Reperfusion therapy with   |                                                                                                |
| thrombolysis or PCI has been shown to be very beneficial in the treatment of this condition.       |                                                                                                |
| Statistical model                                                                                  | A statistical model is a formal mathematical way of representing a real world situation that   |
| allows predictions to made.                                                                        |                                                                                                |
| Thrombolysis                                                                                       | Thrombolysis is the breakdown of blood clots by drug treatment. Drugs are often referred to as |
| 'clot busters'.                                                                                    |                                                                                                |
| Unstable angina                                                                                    | The symptoms of unstable angina are the same as those of stable angina, but they do not follow |
| the usual pattern. For example, in unstable angina the symptoms can develop without any angina     |                                                                                                |
| triggers being present, can persist at rest, last longer than 5 minutes.                           |                                                                                                |

## 6 References

1.	
Coronary Heart Disease Statistics 2010, British Heart Foundation.
2.	
Dawkins KD, Gershlick T, de Belder M et al. Percutaneous coronary intervention: recommendations for good practice and training. Heart 2005; 91 Suppl 6:vi1-27.
3.	
National Institute for Health and Clinical Excellence (2003) TA 71 Guidance on the use of  Coronary Artery 
Stents. http://publications.nice.org.uk/guidance-on-theuse-of-coronary-artery-stents-ta71 
4.	
National Institute for Health and Clinical Excellence (2008) TA 152. Drug-eluting stents for the treatment of 
coronary artery disease. http://publications.nice.org.uk/
drug-eluting-stents-for-the-treatment-of-coronaryartery-disease-ta152 
5.	
Doshi SN, Ludman PF, Townend JN, Buller N. Estimated annual requirement for drug eluting stents in a large tertiary referal centre, according to new NICE criteria. Heart 2004; 90(Suppl II):A41.
6.	
National Institute for Health and Clinical Excellence (2011) 
CG126 Management of Stable angina  http://publications.
nice.org.uk/management-of-stable-angina-cg126
7.	
National Institute for Health and Clinical Excellence (2010) CG94 Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segmentelevation myocardial infaction. http://publications.nice.
org.uk/unstable-angina-and-nstemi-cg94
8.	
ESC guidelines for the management of acute myocardial 
infarction in patients presenting with ST-segment elevation. European Heart Journal (2012). 33, 2569-2619.
9.	
Myocardial Ischaemia National Audit Project (2012). How the NHS cares for patients with heart attack. 
Annual Public Report. April 2011- March 2012. http://
www.ucl.ac.uk/nicor/audits/minap/publicreports/ pdfs/2012minappublicreportv2
10.	 Grayson AD, Moore RK, Jackson M et al. Multivariate 
prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England. Heart 2006; 92(5):658-663.

## Appendix 1 Data Completeness Tables For Uk Nhs And Private Hospitals

NHS 
number
PCI 
hospital 
outcome
Discharge 
status
date
Diabetes
Discharge 
Renal 
disease
treated
Vessels 
urgency
Procedure 
Preshock
procedure 
History
Sex
Medical 
Birth
Date of 
99.8 99.8 99.3
89.5
96 96
98.3 96.9
88.5
91.6
100
96.2
100 100
83.8
99.1
100 100
97.1 98.1
62.4
62.9
100
100.9
100
99.2 91.7
95.2 99.3 99.3 92.7 93.4
93.1
93
91.5 95.4
100 100
98.1
98.2
100 100
74.6 99.4
100
99.8
100
99.9
100 100
47.8
99.6
100 100
83.3 81.8
77.7
77.7
100
99.4
100 100
70.9
100
100 100
94.1 70.6
57.1
85.8
100
99.7
100 100 100 100
100 100 100 100
99.3
100
99.8
100
100 100 100 100
100 100
99.9 99.9
97
97.2
100
100.1
Data Completeness 
English NHS 
Hospitals
AEI. Royal Albert 
Edward Infirmary
AMG. Wycombe 
Hospital
BAL. Barts and 
the London
BAS. Basildon 
Hospital
BAT. Royal United 
Hospital Bath
BED. Bedford 
Hospital
BHH. Rochdale 
Infirmary
BHL. Liverpool 
100
99.8 99.8
99.8
100 100 100
99.5
100
100 100
99.4
100 100 100 100
98.7 99.3 99.3 99.4
98.7
99.6
100
99.8
100 100
92.1
100
100 100
94.7 97.2
98.5
99.9
100 100
100
99.6
100 100
100
99.1 99.6
100
100
100
99.6 99.2
100
99.8
95
97.9 99.9 99.6 98.3 98.8
99.7
99.7 99.8 99.2
100 100 100 100
100 100 100 100
100
100 100 100
Heart and Chest 
Hospital
BHR. Royal 
Berkshire Hospital
BLA. Royal 
Blackburn 
Hospital
BOU. Royal 
Bournemouth 
General Hospital
BRD. Bradford 
Royal Infirmary
BRI. Bristol Royal 
Infirmary
CGH. Conquest 
Hospital
NHS 
number
PCI 
hospital 
outcome
Discharge 
status
date
Diabetes
Discharge 
Renal 
disease
treated
Vessels 
urgency
Procedure 
Preshock
procedure 
History
Sex
Medical 
Birth
Date of 
100
99.9 90.7
100
100
97.7 99.9
100
99.7
99.7 97.7
100
100 100
98.7
100
100 100 100 100
100
100 100
99.9
100 100
85.1
100
99.9
100
84.9 94.1
100
100 100
99.8
100 100
88
100
92
100
76 88
100
96
100
88
100 100
93.6
99.6 98.5 99.9 98.7 99.1
97.4
98.1
99
99.7
100 100 100 100
100 100 100 100
100
100 100 100
100 100 100 100
100 100 100 100
100
100 100
99.4
100 100
98.1
99.3
100 100
91.7 99.6
99.2
99.6
100
100.4
Data Completeness 
English NHS 
Hospitals
CHG. Cheltenham 
General Hospital
CHH. Castle Hill 
Hospital
CHN. Nottingham 
City Hospital
CMI. Cumberland 
Infirmary
DER. Royal Derby 
Hospital
DGE. Eastbourne 
DGH
DUD. Birmingham 
City Hospital
DVH. Darent 
Valley Hospital
100
98.4
100
97.1
100
97.6
96
73.4
99.6
97.2
100 100
100 100
95.1
97.5
100
96.4
91
93.7
99.9
99.6 99.7 99.5
100 100 100
80.7 99.6
100
58.4 69.6
100
100 100 100
100 100
97.6
99.5
100
98.8 95.5 97.9
100
100
80.9 99.8
100 100 100 100
100 100 100 100
100
100 100
99.6
100 100 100 100
100 100 100 100
100
100 100 100
100 100
94.7
98.7
100
99.9 98.5 99.3
99.9
99.8 99.9 99.2
100 100
94.4
100
100 100
93.9
91
99.9
99.9 99.8 99.8
EAL. Ealing 
Hospital
EBH. Birmingham 
Heartlands 
Hospital
ESU. East Surrey 
Hospital
FRE. Freeman 
Hospital
FRM. Frimley 
Park Hospital
FRY. Frenchay 
Hospital
GEO. St George's 
Hospital
GRL. Glenfield 
Hospital
Hospital
Hospital
Wells Hospital
General Infirmary
County Hospital
Hospital
University Hospital
Park Hospital
MRI. Manchester 
Royal Infirmary
NCR. New Cross 
Hospital
NGS. Northern 
General Hospital
NHS 
number
hospital 
outcome
Discharge 
status
date
Diabetes
Discharge 
Renal 
disease
treated
Vessels 
urgency
Procedure 
shock
procedure 
History
Medical 
Data Completeness 
English NHS 
Hospitals
NHB. Royal 
Brompton 
Hospital
NHH. Basingstoke 
and North 
Hampshire Hospital
NOR. Norfolk 
& Norwich 
University 
Hospital
NPH. Northwick 
Park Hospital
NTH. 
Northampton 
General Hospital
PAP. Papworth 
Hospital
PIN. Pinderfields 
General Hospital
PLY. Derriford 
Hospital
PMS. The Great 
Western Hospital
QAP. Queen 
Alexandra 
Hospital
QEB. Queen 
Elizabeth Hospital 
Edgbaston
RAD. John 
Radcliffe Hospital
RCH. Royal 
Cornwall Hospital
RDE. Royal Devon 
& Exeter Hospital
RFH. Royal Free 
Hospital
RHI. Calderdale 
Royal Hospital
RSC. Royal 
Sussex County 
Hospital
SAL. Salisbury 
District Hospital
SAN. Sandwell 
General Hospital
SCM. James 
Cook University 
Hospital
SCU. Scunthorpe 
General Hospital
SGH. 
Southampton 
General Hospital
SPH. St Peter's 
99.8
99.7
99.7
94.9
98.8
99.4 99.2 99.5
Hospital
STH. St Thomas' 
Hospital
STO. University 
Hospital of North 
Staffordshire
SUN. Sunderland 
Royal Hospital
TOR. Torbay 
Hospital
UCL. University 
College Hospital
VIC. Blackpool 
Victoria Hospital
WAL. University 
Hospital Coventry
100 100 100 100
100 100 100 100
99
99.3
100 100
100
99.8 89.4
100
100
99.4 99.8 99.8
99.1
99.2 99.4
100
100 100 100 100
100 100 100 100
100
100 100
99.7
100 100
90.2
100
100 100
99.2 66.7
99.2
100 100 100
100 100
74
98.9 99.8 99.1 80.2 89.7
82.4
88.7 88.5 98.9
100 100
99.7
100
100
99.2
100 100
100
100
98.1
100
100
99.7 81.6
100
100 100
95.3 98.7
98.4
99
100 100
100 100 100 100
100 100 100 100
100
100 100 100
100 100
60.9
98.4 99.5 99.5 98.1 97.6
96.9
96.9 98.3 99.1
WAT. Watford 
General Hospital
WDH. Dorset 
County Hospital
WEX. Wexham 
Park Hospital
WHC. Whipps 
Cross University 
Hospital
WHH. William 
Harvey Hospital
WRC. 
Worcestershire 
Royal Hospital
WRG. Worthing 
Hospital
WYT. 
Wythenshawe 
Hospital
YDH. York District 
Hospital
NHS 
number
PCI 
hospital 
outcome
Discharge 
status
date
Diabetes
Discharge 
Renal 
disease
treated
Vessels 
urgency
Procedure 
Preshock
procedure 
History
Medical 
n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a
n/a n/a
n/a n/a
n/a
n/a
n/a n/a
Hospital
HBP. BUPA 
Hospital, Hull & 
East Riding
IND. London 
Independent 
Hospital
LBP. Leicester 
BUPA Hospital
LEB. BUPA 
Hospital Leeds
NHS 
number
PCI 
hospital 
outcome
Discharge 
status
date
Diabetes
Discharge 
Renal 
disease
treated
Vessels 
urgency
Procedure 
Preshock
procedure 
History
Sex
Medical 
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
100
100
99.7
100
100 100 100
100
99.1
100
99.7
n/a
100
100
99.7
100
100 100
99.6
99.6 96.3
100
97.8
n/a
100
100
97.3
99.8
100 100
96.9
96.9 92.3
100
97.2
n/a
Birth
Date of 
LNH. Leeds 
Nuffield Hospital
MHO. Manor 
Hospital
PHN. BMI Park 
Hospital
Data Completeness 
for Scottish NHS 
Hospitals
NIN. Ninewells 
Hospital
GJH. Golden 
Jubilee Hospital
RIA. Aberdeen 
Royal Infirmary
  
 
n/a n/a n/a
n/a
n/a n/a n/a
n/a n/a
n/a n/a
n/a
100
100
97.5
100
100 100
97.7
97.5 93.8
100
88.1
n/a
100
100
67.1
100
100 100
88.5
95.2
100
100 100
98.4
RAI. Raigmore 
Hospital
ERI. Royal 
infirmary of 
Edinburgh
HAI. Hairmyres 
Hospital
NHS 
number
NHS 
number
PCI 
hospital 
outcome
PCI 
hospital 
outcome
Discharge 
status
Discharge 
status
date
date
Diabetes
Discharge 
Diabetes
Discharge 
Renal 
Renal 
disease
disease
treated
treated
Vessels 
Vessels 
urgency
urgency
Procedure 
Procedure 
Pre-
Preshock
shock
procedure 
procedure 
History
History
Medical 
Medical 
n/a n/a
| Birth                | Birth   |
|----------------------|---------|
| Date of              | Date of |
| Data Completeness    |         |
| for Scottish Private |         |
| Hospitals            |         |
| SSP. Spire           |         |
| Shawfair Park        |         |
| Hospital             |         |
| RHH. Ross Hall       |         |
| Hospital             |         |
| Data Completeness    |         |
| for Northern         |         |
| Ireland Hospitals    |         |
| CRG. Craigavon       |         |
| Area Hospital        |         |
| RVB. Royal           |         |
| Victoria Hospital    |         |
| BFT. Belfast City    |         |
| Hospital             |         |
| NHS                  |         |
| number               |         |
hospital 
outcome
Discharge 
status
disease
urgency
Procedure 
procedure 
Medical 
ALT. Altnagelvin 
Hospital
Data Completeness 
for Welsh Hospitals
CLW. Glan Clwyd 
Hospital
UHW. University 
Hospital of Wales
MOR. Morriston 
Hospital

## Appendix 2 Bcis Data Monitoring And Audit Group

| Name                              | Role                       | Organisation                                 |
|-----------------------------------|----------------------------|----------------------------------------------|
| Peter Ludman (Chair)              | Consultant Cardiologist    |                                              |
| (BCIS audit lead)                 |                            |                                              |
| Mark de Belder                    | Consultant Cardiologist    | South Tees Hospitals NHS Trust               |
| Rod Stables                       | Consultant Cardiologist    | Liverpool Heart and Chest Hospital NHS       |
| Foundation Trust                  |                            |                                              |
| Robert Henderson                  | Consultant Cardiologist    | Nottingham University Hospitals NHS Trust    |
| Andrew Wragg                      | Consultant Cardiologist    | Barts Health NHS Trust                       |
| Adrian Banning                    | Consultant Cardiologist    | Oxford Radcliffe Hospitals NHS Trust         |
| Timothy Gilbert                   | Consultant Cardiologist    | Norfolk and Norwich University Hospitals NHS |
| Foundation Trust                  |                            |                                              |
| Simon Redwood                     | Consultant Cardiologist    |                                              |
| (BCIS President)                  |                            |                                              |
| Nick Curzen                       | Consultant Cardiologist    |                                              |
| (BCIS Secretary)                  |                            |                                              |
| Jim Nolan                         | Consultant Cardiologist    |                                              |
| (BCIS Treasurer)                  |                            |                                              |
| Emmanouil Lazaridis               | Senior Information Analyst | NICOR                                        |
| NICOR project team in attendance: |                            |                                              |
| Tracy Whittaker                   | Project Manager            | NICOR                                        |
| Lynne Walker                      | Programme Manager          | NICOR                                        |
Queen Elizabeth Hospital Edgbaston Birmingham
Guys and St Thomas NHS Foundation Trust University Hospital Southampton NHS Foundation Trust University Hospital of North Staffs Stoke on Trent

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