Global variations in coronary revascularisation and acute myocardial infarction mortality between 2006-2020: a longitudinal, population-level analysis of 16 high-income nations from the OECD database
Authors: Ojha U , Marshall D , Hammond-Haley M , Salciccioli J , Shalhoub J , Hartley A 
Published: October 2024

Abstract

Background
Revascularisation options for ischaemic heart disease (IHD) includes either, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Whilst PCI remains the preferred choice in ST-elevation myocardial infarction (STEMI)(1), several landmark trials have questioned its universal superiority (2,3), thus prompting re-evaluation of guidelines. A wide-scale contemporary overview of revascularisation trends is lacking.

Purpose
To examine the evolving pattern in PCI and CABG rates, alongside mortality from acute myocardial infarction (AMI) across a group of 16 high-income countries between 2006 and 2020.

Methods
Standardized PCI and CABG procedure rates alongside AMI age-standardised mortality rate (ASMR) were obtained from the Organisation for Economic Co-operation and Development (OECD) database. Data from 2006-2020 was extracted for; Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom (UK). Together, these countries are commonly known as the European Union (EU) 15+ and represent a cluster of high-income nations with comparable levels of health expenditure. Procedural trends including the estimated annual percentage change (EAPC) were evaluated using Joinpoint analysis whilst Locally Weighted Scatterplot Smoothing (LOESS) models was used to analysis trends in AMI mortality.

Results
Over 15 years, 14.0 million PCI and 2.8 million CABG procedures were recorded in total.
PCI rates varied amongst nations (Figure 1), however showed an overall increase in 11 countries, led by Finland (+36.0%). The steepest increase was observed in France between 2012-2018 (EAPC 5.4, 95% CI: 4.8 – 6.1). The greatest overall decrease in PCI was observed in Luxemburg (-33.5%). The fastest decrease was seen during 2018-2020 in the UK (EAPC -7.2, 95% CI: -9.7 – -4.6).
CABG rates declined overall in 15 countries (Figure 1), with Luxembourg (-71.3%), experiencing the largest fall and showing the steepest decline between 2014-2018 (EAPC -20.7, 95% CI: -28.3 – -12.3). Ireland was the only country to show an increase in CABG rate (+16.3%).
Throughout the study period, the PCI-to-CABG ratio increased (Figure 2A), whilst AMI mortality decreased consistently across all countries (Figure 2B).

Conclusion
Despite evidence supporting CABG over PCI in specific scenarios, CABG rates have declined, and PCI rates have increased. This trend may be influenced by several factors including patient preference for less invasive procedures and advancements in interventional techniques. The varied use of PCI among these nations, alongside a sustained decline in AMI mortality rates, may be expected given the importance of optimal medical therapy in the management of IHD. The results further highlight the significance of factors beyond revascularisation in driving improved outcomes.PCI and CABG rates between 2006 and 2020PCI to CABG ratio and AMI mortality rate