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Volume–outcome relation for contemporary percutaneous coronary interventions (PCI) in daily clinical practice: is it limited to high-risk patients? Results from the Registry of Percutaneous Coronary Interventions of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

¹ Klinikum Nürnberg Süd, Nürnberg
² Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg, Ludwigshafen
³ Herzzentrum, Kardiologie, Ludwigshafen
⁴ Burgfeld Krankenhaus, Kassel
⁵ Universitätskrankenhaus Eppendorf, Hamburg
⁶ Charité Universitätsmedizin, Berlin
⁷ Krankenhaus der Barmherzigen Brüder, Trier
⁸ Klinikum Siegburg GmbH, Siegburg
⁹ Klinikum, Bad Neustadt/Saale
¹⁰ Robert Bosch Krankenhaus, Stuttgart

Correspondence to:
Priv.-Doz. Dr. med. Ralf Zahn, Med. Klinik 8, Kardiologie/Angiologie/Internistische Intensivmedizin, Klinikum Nürnberg, Breslauer Straße 201, 90471 Nürnberg; erzahn{at}aol.com

ABSTRACT
Objective: The formerly observed volume–outcome relation for percutaneous coronary interventions (PCIs) has recently been questioned.

Design: We analysed data of the PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte.

Patients: In 2003 a total of 27 965 patients at 67 hospitals were included.

Results: The median PCI volume per hospital was 327. In-hospital mortality was 1.85% in hospitals belonging to the lowest PCI volume quartile and 1.21% in the highest quartile (p for trend <0.001). Two groups of patients were then compared according to their treatment at hospitals with either <325 PCIs (n = 5754) or >325 PCIs (n = 22 211) per year. Logistic regression analysis showed that a PCI performed at hospitals with a volume of >325 PCI/year was independently associated with a lower hospital mortality (OR = 0.67, 95% CI: 0.52 to 0.87; p = 0.002). If PCI was performed in patients with acute myocardial infarction there was a significant decline in mortality with increasing volume (p for trend = 0.004); however, there was no association in patients without a myocardial infarction.

Conclusions: This analysis of contemporary PCI in clinical practice shows a small but significant volume–outcome relation for in-hospital mortality. However, this relation was only apparent in high-risk subgroups, such as patients presenting with acute myocardial infarction.

Keywords: coronary angioplasty; risk; volume–outcome relation