Trends in percutaneous coronary intervention in China: analysis of China PCI Registry Data from 2010 to 2018 : Cardiology Plus

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Original Articles

Trends in percutaneous coronary intervention in China: analysis of China PCI Registry Data from 2010 to 2018

Liu, Zhaoping1; Li, Jianping1; Zhang, Yan1; Yu, Bo2; Ma, Yitong3; Ma, Genshan4; Wang, Jianan5; Liu, Bin6; Su, Xi7; Li, Bao8; Zhang, Zheng9; Chen, Yuguo10; Chen, Jiyan11; Chen, Lianglong12; Chen, Yundai13; Yuan, Zuyi14; Jia, Shaobin15; Gao, Chuanyu16; Tang, Yida17; Fu, Xianghua18; Han, Yaling19; Ge, Junbo20; Ma, Xudong21; Huo, Yong1,*

Author Information
doi: 10.1097/CP9.0000000000000021
  • Open

Abstract

INTRODUCTION

Since the first reported use of percutaneous coronary intervention (PCI) in 1984, interventional cardiology has experienced substantial changes in China[1–3]. In response to the rapid increase in the total number of PCI cases, the Ministry of Health of China implemented a standardization program in 2009 that included training, certification, and quality control (QC). Reporting of detailed data for all PCI cases to the QC system is mandatory for all medical centers in mainland China except for military hospitals for regulatory reasons. QC centers were established at multiple administrative levels to gather data via both online and offline means[4]. Data collected in 2009 has been reported previously[5]. In the current study, we analyzed the online-reported data during a period from 2010 to 2018. Results are reported below.

MATERIALS AND METHODS

Data resource and definition

The Ministry of Health of China stipulated that all medical institutions must report their PCI cases within 10 days after the procedure. The collected data include 71 items that cover demographic information, clinical features, coronary angiography findings, interventional therapy information, and clinical outcomes. Clinical outcomes are reported up to the reporting timepoint, rather than until discharge from hospital. The reporting system was upgraded in February 2012 to increase data accuracy. All variables are defined by the Expert Committee based on a variable dictionary set. For various reasons, a small number of hospitals do not have individual identification numbers for case reporting. PCI cases in these hospitals (only case number, with no descriptive summary) were collected offline by QC centers at the provincial level. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by Peking University First Hospital institutional review board (NO. 2019 Yan 103; date: May 8, 2019). Due to the retrospective nature of the study, informed consent was waived by Peking University First Hospital institutional review board.

Quality control

When a new center joins the program, the provincial QC centers train the personnel to ensure that the registration system is clearly understood and to guide the personnel through the reporting process. The QC program also verify data integrity and accuracy reported to the online reporting website. The provincial QC centers conduct regular audit to maintain reporting quality. A warning is issued to hospitals with sub-standard performance.

Statistical analysis

Statistical analysis was performed using R software (http://www.R-project.org). Continuous variables are presented as mean ± SD if normally distributed, or as median (interquartile range) otherwise. Categorical variables are presented as proportions. The differences in population characteristics were compared using Analysis of Variance (ANOVA), signed rank test, or Chi-squared test, as appropriate. The P value for trend was estimated by recoding the year as a continuous variable in linear regression or logistic regression. P < 0.05 (two-sided) was considered statistically significant.

RESULTS

Study population

The number of online-reported cases of PCI was 236,717 in 2010, and increased to 705,978 in 2018. The annual growth rate was 10% to 20%. Total number of cases (including both online and offline reported cases) was 284,936 in 2010, and increased to 915,256 in 2018. The case number per million population was 212 in 2010, and increased to 656 in 2018. The number of medical centers that reported PCI procedures was 941 in 2010, and increased to 1,788 in 2018. The percentage of tertiary hospitals in all centers that reported PCI cases was 90% in 2010, and decreased to 70% in 2018. The number of physicians performing PCI was 2,508 in 2010, and increased to 4,736 in 2018 (Table 1). In 2018, high-volume centers (at least 1,000 PCI cases per year) comprised 8.1% of the total centers, but conducted 41.3% of the total PCI cases. In contrast, low-volume centers (less than 100 PCI cases per year) comprised 29.3% of the total centers, but conducted only 3.6% of the total PCI cases (Figure 1).

Table 1 - Demographic and clinical characteristics of the patients who underwent PCI in China from 2010 to 2018
Characteristic Year
2010 2011 2012 2013 2014 2015 2016 2017 2018
Case number (online reported only) 236,717 289,537 332,925 383,835 434,153 479,635 541,458 616,078 705,970
Case number (including offline reports) 284,936 341,069 388,836 454,505 500,946 567,583 666,495 753,142 915,256
Case number per million population 212 253 287 334 366 413 482 542 656
Hospital number 942 986 1,093 1,138 1,212 1,251 1,407 1,586 1,788
Operator number 2,508 2,647 2,903 3,089 3,341 3,497 3,899 4,348 4,736
Male sex, n (%) 174,711 (73.8) 212,156 (73.3) 242,412 (72.8) 279,194 (72.7) 315,188 (72.6) 348,600 (72.7) 393,558 (72.7) 446,529 (72.5) 511,799 (72.5)
Age, year 62.2 62.2 62.2 62.2 62.3 62.4 62.7 63.0 62.6
Diagnosis, n (%)
 Silent myocardial ischemia 1,778 (0.8) 1,922 (0.7) 1,579 (0.5) 2,176 (0.6) 2,390 (0.6) 2,901 (0.6) 2,843 (0.5) 3,843 (0.6) 4,685 (0.7)
 Suspected angina 4,516 (1.9) 4,645 (1.6) 5,099 (1.5) 6,307 (1.6) 7,507 (1.7) 18,406 (3.8) 22,077 (4.1) 21,005 (3.4) 25,352 (3.6)
 Stable angina 17,296 (7.3) 18,413 (6.4) 22,116 (6.6) 23,682 (6.1) 28,388 (6.5) 29,117 (6.1) 34,666 (6.4) 40,778 (6.6) 48,951 (6.9)
 Unstable angina 132,690 (56.0) 170,191 (58.8) 196,824 (59.1) 225,959 (58.9) 250,606 (57.7) 265,639 (55.4) 296,804 (54.8) 333,066 (54.1) 373,485 (52.9)
 NSTEMI 15,637 (6.6) 19,353 (6.7) 23,824 (7.2) 29,876 (7.8) 36,056 (8.3) 42,418 (8.8) 49,735 (9.2) 59,908 (9.7) 72,232 (10.2)
 STEMI 64,798 (27.4) 75,001 (25.9) 83,469 (25.1) 95,829 (25.0) 109,203 (25.2) 121,154 (25.3) 135,333 (25.0) 157,478 (25.6) 181,265 (25.7)
Comorbidity, n (%)
 Hyperlipidemia 51,769 (21.9) 62,385 (21.5) 72,866 (21.9) 87,193 (22.7) 95,551 (22.0) 103,997 (21.7) 111,685 (20.6) 123,847 (20.1) 136,120 (19.3)
 Hypertension 97,923 (41.4) 122,561 (42.3) 142, 564 (42.8) 167,535 (43.6) 189,564 (43.7) 216, 569 (45.2) 235,643 (43.5) 272,338 (44.2) 306,634 (43.4)
 Diabetes 33,760 (14.3) 40,342 (13.9) 46,690 (14.0) 55,953 (14.6) 64,761 (14.9) 73,573 (15.3) 81,270 (15.0) 99,019 (16.1) 110,500 (15.7)
 Smoking 51,737 (21.9) 61,578 (21.3) 73,938 (22.2) 84,751 (22.1) 91,717 (21.1) 100,409 (20.9) 106,204 (19.6) 113,743 (18.5) 127,627 (18.1)
 Renal failure 1,431 (0.6) 1,708 (0.6) 1,901 (0.6) 2,324 (0.6) 2,790 (0.6) 3,214 (0.7) 3,800 (0.7) 4,741 (0.8) 5,447 (0.8)
 Heart failure 6,023 (2.5) 6,544 (2.3) 7,219 (2.2) 8,318 (2.2) 8,431 (1.9) 9,047 (1.9) 9,449 (1.7) 10,929 (1.8) 13,392 (1.9)
History, n (%)
 MI 24,198 (10.2) 27,610 (9.5) 32,474 (9.8) 36,082 (9.4) 38,772 (8.9) 42,793 (8.9) 45,505 (8.4) 48,734 (7.9) 53,717 (7.6)
 Stroke 6,734 (2.8) 8,194 (2.8) 9,342 (2.8) 11,455 (3.0) 13,626 (3.1) 18,111 (3.8) 20,757 (3.8) 24,051 (3.9) 28,263 (4.0)
 PCI 20,412 (8.6) 23,201 (8.0) 26,587 (8.0) 31,305 (8.2) 34,404 (7.9) 37,802 (7.9) 41,651 (7.7) 45,152 (7.3) 52,589 (7.4)
 CABG 1,159 (0.5) 1,172 (0.4) 2,837 (0.9) 3,494 (0.9) 2,828 (0.7) 1,430 (0.3) 1,565 (0.3) 1,324 (0.2) 1,671 (0.2)
Sex, age, comorbidity, and history are calculated based on online-reported data only.
CABG: Coronary artery bypass grafting; MI: Myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; PCI: Percutaneous coronary intervention; STEMI: ST elevation myocardial infarction.

F1
Figure 1.:
Proportion of hospital and case of different volume hospitals in 2018.

Clinical characteristics

A total of 72.5% to 73.8% of the patients were men. The average patient age was 62.2 years in 2010 (60.9 for men, 65.8 for women), and increased to 62.6 years in 2018 (61.2 for men, 66.5 for women; P for trend <0.001). The most frequent indication for PCI was unstable angina (52.9%–59.1%), followed by ST elevation myocardial infarction (STEMI; 25.0%–27.4%). The percentage of non-STEMI cases was 6.6% in 2010, and increased to 10.2% in 2018 (P for trend <0.001). PCI was performed to treat other conditions (silent cardiac ischemia, suspected angina, and stable angina) in 10% of the reported cases (Table 1).

The risk factors and comorbidities did not differ significantly during the study period. Specific risk factors and comorbidities included smoking (18.1%–22.2%), hyperlipidemia (19.3%–22.7%), hypertension (41.4%–45.2%), diabetes mellitus (13.9%–16.1%), heart failure (1.7%–2.5%), history of myocardial infarction (7.6%–10.2%), previous PCI (7.3%–8.6%), history of cerebral vascular disease (2.8%–4.0%), and history of renal failure (0.6%–0.8%). The proportion of patients with coronary artery bypass grafting (CABG) was 0.2% to 0.9% (Table 1).

Procedure-related features

The radial artery was the most common access route; the radial artery was used in 65.4% of PCI cases in 2010 and 90.7% in 2018 (P for trend <0.001). The femoral artery route was used in 34.2% of PCI cases in 2010 and 8.8% in 2018 (P for trend <0.001). Other access routes (eg, brachial artery and ulnar artery) were used in 0.4% to 0.5% of the cases (Figure 2). Left main disease (including left main only, left main with single vessel disease, left main with two vessel disease, and left main with three vessel disease) was present in 5% of the cases. Single vessel disease was the most common situation (38.7%–44.4%). The rate of two- and three-vessel diseases was 22.3% to 27.5% and 27.0% to 28.7%, respectively (Table 2). The number of target vessels per case was 1.28 in 2010, and decreased to 1.14 in 2018 (P for trend <0.001). Majority of the patients (52.3%–59.7%) underwent left anterior descending artery PCI. The right coronary artery was the second-most common target vessel (35.0%–37.3%), followed by the left circumflex artery (22.6%–26.0%). The left main coronary artery was involved in 3.5% to 4.2% of the cases, and venous or arterial grafts were used in 0.1% of the patients. The intermediate artery was involved in 0.6% to 0.7% of the cases. The target lesion was narrowed by <75% in 2.0% to 5.5% of the cases, and most lesions (71.7%–74.6%) were narrowed by 75% to 99%. The lesion totally occluded the affected vessel in 22.8% to 25.0% of the cases. The number of stents implanted per case was 1.63 in 2010, and decreased to 1.46 in 2018 (P for trend <0.001; Figure 3). The rate of PCI procedures in which only one stent was implanted was 49.0% in 2010, and increased to 59.2% in 2018; in contrast, the rate of PCI procedures in which three or more stents were implanted decreased from 19.3% in 2010 to 11.2% in 2018 (Table 3). Patients with STEMI comprised 25% of the overall patient population; the rate of patients undergoing primary PCI (p-PCI) for STEMI increased from 28.0% in 2010 to 45.9% in 2018 (P for trend <0.001; Figure 4).

Table 2 - Angiogram-related characteristics of the patients who underwent PCI in China from 2010 to 2018
Characteristic Year
2010 2011 2012 2013 2014 2015 2016 2017 2018
Diseased vessel, n (%)
 LM 788 (0.3) 858 (0.3) 1,063 (0.3) 1,302 (0.3) 1,391 (0.3) 1,429 (0.3) 1,705 (0.3) 2,080 (0.3) 2,454 (0.4)
 LM + single branch 1,941 (0.8) 2,174 (0.8) 2,487 (0.7) 2,857 (0.7) 3,108 (0.7) 3,587 (0.7) 4,173 (0.8) 4,926 (0.8) 5,626 (0.8)
 LM + double branches 3,030 (1.3) 3,457 (1.2) 3,687 (1.1) 4,071 (1.1) 4,591 (1.1) 5,340 (1.1) 5,985 (1.1) 6,801 (1.1) 7,998 (1.1)
 LM + tripple branches 6,146 (2.6) 7,495 (2.6) 7,689 (2.3) 8,988 (2.3) 9,973 (2.3) 11,737 (2.5) 13,941 (2.6) 16,187 (2.6) 18,695 (2.6)
 Single branch 92,514 (39.2) 111,787 (38.7) 138,347 (41.7) 163,970 (42.8) 185,470 (42.8) 207,442 (43.3) 235,411 (43.5) 270,404 (44.0) 313,770 (44.4)
 Double branches 64,589 (27.4) 79,246 (27.5) 87,498 (26.4) 97,613 (25.5) 108,674 (25.1) 116,519 (24.3) 127,164 (23.5) 140,555 (22.8) 157,639 (22.3)
 Triple branches 66,344 (28.1) 82,805 (28.7) 90,351 (27.2) 103,485 (27.0) 119,291 (27.5) 132,337 (27.6) 151,232 (28.0) 173,369 (28.2) 198,112 (28.0)
 Grafts 148 (0.1) 157 (0.1) 95 (0.0) 89 (0.0) 99 (0.0) 80 (0.0) 202 (0.0) 127 (0.0) 109 (0.0)
 Others 494 (0.2) 608 (0.2) 638 (0.2) 592 (0.2) 675 (0.2) 615 (0.1) 790 (0.1) 800 (0.1) 1,567 (0.2)
Stenosis, n (%)
 <75% 12,475 (5.5) 7,505 (2.7) 8,427 (2.6) 9,496 (2.5) 10,099 (2.4 10,004 (2.1) 10,710 (2.0) 12,576 (2.1) 13,640 (1.9)
 75%–99% 163,250 (71.7) 207,926 (74.5) 240,624 (74.7) 281,343 (74.9) 317,045 (74.6) 348,075 (74.3) 388,448 (73.6) 440,671 (72.9) 516,475 (73.2)
 100% 52,048 (22.8) 63,781 (22.8) 73,242 (22.7) 84,804 (22.6) 97,930 (23.0) 110,106 (23.5) 128,738 (24.4) 151,589 (25.1) 175,855 (24.9)
Proportion of disease vessel number and different stenosis are calculated based online data.
LM: Left main; PCI: Percutaneous coronary intervention.

Table 3 - Procedure-related characteristics of the patients who underwent PCI in China from 2010 to 2018
Characteristic Year
2010 2011 2012 2013 2014 2015 2016 2017 2018
Target vessel, n (%)
 No. of average target vessel 1.28 1.26 1.21 1.18 1.17 1.17 1.16 1.15 1.14
 LM 2,887 (1.2) 3,298 (1.1) 3,044 (0.9) 3,197 (0.8) 3,460 (0.8) 3,827 (0.8) 4,396 (0.8) 4,973 (0.8) 6,193 (0.9)
 LM-LAD 5,197 (2.2) 6,077 (2.1) 6,781 (2.0) 7,999 (2.1) 9,578 (2.2) 11,638 (2.4) 13,480 (2.5) 15,715 (2.6) 17,440 (2.5)
 LM-LCX 1,525 (0.6) 1,671 (0.6) 1,819 (0.5) 1,900 (0.5) 2,157 (0.5) 2,439 (0.5) 2,833 (0.5) 3,161 (0.5) 3,692 (0.5)
 LM-intermediate 179 (0.1) 138 (0.0) 142 (0.0) 146 (0.0) 124 (0.0) 145 (0.0) 154 (0.0) 238 (0.0) 244 (0.0)
 LAD 140,392 (59.7) 168,557 (58.4) 189,327 (56.9) 212,347 (55.3) 237,097 (54.6) 260,064 (54.2) 290,154 (53.6) 325,872 (52.9) 369,135 (52.3)
 LCX 61,163 (26.0) 74,099 (25.7) 80,612 (24.2) 89,833 (23.4) 100,437 (23.1) 110,190 (23.0) 124,450 (23.0) 138,761 (22.5) 159,526 (22.6)
 RCA 87,659 (37.3) 106,516 (36.9) 119,628 (35.9) 134,893 (35.1) 152,249 (35.1) 168,226 (35.1) 190,073 (35.1) 215,811 (35.0) 246,854 (35.0)
 Intermediate 1,687 (0.7) 1,886 (0.7) 2,220 (0.7) 2,599 (0.7) 2,888 (0.7) 3,035 (0.6) 3,228 (0.6) 3,695 (0.6) 4,289 (0.6)
 A grafts 43 (0.0) 50 (0.0) 39 (0.0) 46 (0.0) 63 (0.0) 64 (0.0) 72 (0.0) 81 (0.0) 97 (0.0)
 V grafts 175 (0.1) 180 (0.1) 221 (0.1) 245 (0.1) 266 (0.1) 296 (0.1) 338 (0.1) 317 (0.1) 234 (0.0)
 Abnormality 32 (0.0) 16 (0.0) 13 (0.0) 12 (0.0) 22 (0.0) 19 (0.0) 129 (0.0) 23 (0.0) 30 (0.0)
Stent implantation, n (%)
 1 stent 104,782 (49.0) 139,474 (50.4) 172,374 (54.1) 208,495 (56.9) 240,902 (58.1) 265,299 (57.8) 298,017 (57.8) 342,627 (58.9) 393,226 (59.2)
 2 stents 67,679 (31.7) 87,875 (31.8) 100,627 (31.6) 113,829 (31.0) 127,159 (30.6) 140,664 (30.7) 157,096 (30.5) 174,478 (29.9) 196,761 (29.6)
 ≥3 stents 41,324 (19.3) 49,347 (17.8) 45,579 (14.3) 44,400 (12.1) 6,875 (11.3) 52,790 (11.5) 60,771 (11.8) 65,645 (11.3) 74,407 (11.2)
Average target vessel number, proportion of different target vessel, and stent number are calculated based online data.
A grafts: Artery grafts; LAD: Left anterior descending; LCX: Left circumflex; LM: Left main; PCI: Percutaneous coronary intervention; RCA: Right coronary artery; V grafts: Vein grafts.

F2
Figure 2.:
Trends of procedure access route from 2010 to 2018.
F3
Figure 3.:
Trends of stent number per case from 2010 to 2018.
F4
Figure 4.:
Proportion of patients with ST elevation myocardial infarction who received primary percutaneous coronary intervention (PPCI) in China 2010–2018.

Clinical outcome

The mortality rate was 0.31% in 2010, and decreased to 0.26% in 2018 (P for trend <0.001; Figure 5).

F5
Figure 5.:
Procedure-related mortality in patients who underwent percutaneous coronary intervention (PCI) in China from 2010 to 2018.

DISCUSSION

Quality control

The implementation of national PCI registries started in 1990 throughout the world; currently, there are 30 national and state PCI registries (three province or state registries were reported in Canada and in Australia)[6]. The China PCI registry and QC system was established by the Ministry of Health of China in 2009, and includes 31 provincial QC centers in China except Tibet (in which QC system is not established yet for the very small procedural volume), Hong Kong, Macau, and Taiwan. Similar to registries in Belgium, Switzerland, Norway, and Ontario in Canada[7–9], reporting of all PCI cases is mandatory in China. QC is audited by centers at multiple administrative levels.

Trends in PCI case number

The China PCI registry and QC system increased in tandem with the rapid economic development and increased demand for high-quality medical services. The number of PCI cases during the 9-year study period increased by 2.2-fold (from 284,936 in 2010 to 915,256 in 2018). The number of Chinese hospitals reporting PCI data during the study period increased by 90.0%. This rapid growth can be attributed to a variety of factors. First, the national Gross Domestic Product of China was 6.09 trillion USD in 2010, and increased to 13.89 trillion USD in 2018. The rate of increase in PCI case number seemly outpaced economic development, but the number of PCI cases per million population (656) in 2018 was still lower than in developed countries (eg, 1,645 in Spain 2016 and 889 in Korea in 2014)[10,11]. The ongoing reforms of the healthcare policy and insurance policy may have contributed to increased accessibility of PCI treatment in a wider section of the population in China[12,13]. For example, the cardiovascular interventional technology management instrumentation issued in 2011 permitted PCI to be used in county level hospitals[14], whereas the insurance policy in some of the provinces has become more supportive of PCI, especially for patients with acute myocardial infarction. Decreasing price of medical devices is also an important factor, particularly with the increasing use of domestic rather than imported devices[15]. In addition, a variety of training plans have expanded the number of qualified physicians[16]: the number of physicians reporting PCI data during the study period increased by 88.8% (from 2,508 in 2010 to 4,736 in 2018). Significant disparities, however, remained. For example, >40% of the PCI cases in 2018 were conducted in high-volume hospitals that consisted of only 8.1% of all centers, possibly reflecting varying levels of economic development and accessibility to medical resources across different regions.

Clinical features and procedure-related situations

More than half of all PCI procedures during the study period were performed to treat unstable angina[17,18]. Such a rate is much higher than in Korea (35.9%). The proportion of non-STEMI PCI cases in the current study was <10% in contrast to 19.7% in Korea[11]. The proportion of PCI for different indications changed significantly during the study period. The proportion of PCI procedures performed to treat unstable angina decreased from approximately 60% in 2010 to 53% in 2018. In contrast, the proportion of PCI procedures performed to treat non-STEMI increased from 6.6% to 10.2%. The proportion of PCI to treat STEMI (25%) was similar to reported in Spain (27.2%), and substantially higher than in Korea (18.4%)[10,11]. The proportion of PCI for stable angina was 6%[19], and much lower than in Korea (22.6%)[11]. Among the patients undergoing PCI for STEMI, only 28.0% were p-PCI in 2010; this rate increased to 30.6% in 2013, and then to 45.9% in 2018, with annual growth rate of 3%, indicating significant improvement in implementation of p-PCI for STEMI, possibly due to increased public awareness, infrastructural development with more specialized chest pain centers, and increasing level of PCI technique in lower-tier hospitals[20,21]. Nonetheless, the p-PCI rate in China remains much lower than in developed countries (88% in the United States and 82% in Spain)[10,22].

The proportion of PCI procedures performed transradially increased from 65.4% in 2010 to 90.7% in 2018. Comparison with the data from other countries in the same year (2014), the proportion of PCI procedures performed transradially in China was considerably higher (88.5% vs. 56.1% in Korea and 70.4% in Spain), confirming transradial route as the major route for PCI in China[23–25]. Consistent with previous studies showing very low rate of CABG in China[26–28], only 0.2% to 0.9% of patients who underwent PCI in the current study had a history of CABG, whereas 7% to 8% had a history of PCI. The proportion of PCI of any grafts among total PCI cases in the current study (0.1%) was much lower than that reported in Korea[11].

The QC project has been critical in improving the practice and standardizing PCI procedures. The QC centers at multiple administrative levels conducted regular as well as surprise audits and case discussions to monitor the use of PCI for appropriate indications and device utilization. Such efforts have led to substantial improvement, such as decreased average number of stents per PCI case from 1.62 in 2010 to 1.46 in 2018, a level comparable to that in the United States (1.4 in 2012) and in Spain (1.44 in 2015)[10,22].

Clinical outcomes

The mortality rate of the patients undergoing PCI during the study period was 0.2% to 0.3%. Such a rate is similar to the mortality of staged PCI in the United States and Spain[10,22]. The lower rate of p-PCI for STEMI (45.9% in 2018 vs. >80% in the United States and Spain) may have attributed to such a finding. An important confounding issue here is the fact that mortality was based on the duration prior to report of the case to PCI registry; deaths that occurred after case submission were not recorded.

Limitations

The present study had several limitations. First, case report by some centers was with offline means for various reasons. More importantly, the offline reports lack detailed information. Accordingly, total case number and mortality were accurate, but other results are subject to considerable biases. Having said that, online-reported cases comprised 80% to 90% of the total cases; the results are therefore largely reliable. Second, reported mortality associated only included deaths that had occurred by the time that each case was submitted and not until patient discharge from hospital.

CONCLUSIONS

The number of PCI cases in China has been increasing rapidly over the past decade. Transradial access is the dominant PCI route. The mortality rate was relatively low. The use of p-PCI for STEMI has increased substantially, but remains far below the level in developed countries. The QC system may help to improve the PCI practice in China.

AUTHOR CONTRIBUTIONS

YH and XM designed and supervised the registry system for PCI quality control. YH, JG, YH, XF, YC, LC, XS, GM, CG, SJ, ZY, JC, YC, ZZ, BL, BL, JW, YM, and BY. designed the study and collected data, and helped in data interpretation. ZL, JL, and YZ performed data analysis and ZL drafted the manuscript.

CONFLICT OF INTEREST STATEMENT

Junbo Ge is the Editor-in-Chief of Cardiology Plus. Jianan Wang, Yundai Chen, and Yong Huo are the Editorial Board members of Cardiology Plus. The article was subject to the journal’s standard procedures, with peer review handled independently of these Editorial Board members and their research groups.

ACKNOWLEDGMENT

Directors of provincial QC centers in the following list provided assistance in data collection: Yuejin Yang (Fuwai Hospital, Chinese Academy of Medical Sciences), Hongliang Cong (Tianjin Chest Hospital), Xiaoyong Qi (Hebei General Hospital), Zhiyong Wang (Inner Mongolia People’s Hospital), Zhanquan Li (the People’s Hospital of Liaoning Province), Ye Tian (the First Affiliated Hospital of Harbin Medical University), Weifeng Shen (Shanghai Jiaotong University School of Medicine Ruijin Hospital), Xiangqing Kong (Jiangsu Province Hospital), Ji Yan (Anhui Provincial Hospital), Xiaodong Pu (Fujian Provincial Hospital), Lang Hong (the Jiangxi Provincial People’s Hospital), Congxin Huang (Renmin Hospital of Wuhan University), Shenghua Zhou (the Second Xiangya Hospital of Central South University), Lang Li (the First Affiliated Hospital of Guangxi Medical University), Bin Li (Hainan General Hospital), Quan He (the First Affiliated Hospital of Chongqing Medical University), Mao Chen (West China Hospital Sichuan University), Chenyun Zhang (Guizhou Provincial People’s Hospital), Zhaohui Meng (First Affiliated Hospital of Kunming Medical University), Bo Chen (Qinghai Province Cardiovascular and Cerebralvascular Specialist Hospital), and Junming Liu (the Xinjiang Production and Construction Corps General Hospital). We thank Kelly Zammit, BVSc, from Liwen Bianji, Edanz Editing China (www.liwenbianji.cn/ac), for editing the English text.

DATA SHARING STATEMENT

Research data will not be available to other researchers due to regulatory reasons. If anyone wants to use these data, application should be raised to the administrative department.

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Keywords:

Percutaneous coronary intervention; ST elevation myocardial infarction; China; Registry

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