More Heart Attack Procedures Across Europe, No Clear Drop in Deaths

The Expected Relationship That Did Not Materialize

Primary percutaneous coronary intervention -- commonly called primary PCI -- is one of medicine's most evidence-backed emergency procedures. Threading a catheter to a blocked coronary artery, deflating a balloon to open the vessel, and placing a metal stent to keep it open saves lives after heart attacks. National programs across Europe have spent decades expanding access to this procedure, building networks of 24/7 PCI centers and reducing door-to-balloon times.

The reasonable expectation is that countries performing more of these procedures would show lower heart attack death rates. A new cross-sectional analysis presented at the EAPCI Summit 2026 in Munich found something more complicated.

The Dataset and Its Scope

Investigators from King's College London and Mount Sinai Health System analyzed data compiled through the ESC Atlas of Cardiology and the ESC Atlas of Interventional Cardiology, integrating those figures with datasets from the World Health Organization, the Institute for Health Metrics and Evaluation, and Eurostat. The combined dataset covered 21 European countries.

The two main confounders accounted for were national wealth (GDP per capita) and cardiovascular disease burden. Both proved highly significant. Higher GDP per capita was associated with lower age-standardized heart attack mortality -- a moderate inverse correlation (coefficient -0.54; p=0.004). Greater CVD prevalence was associated with higher mortality (coefficient +0.45; p=0.02).

The Counterintuitive Finding

After adjusting for GDP and CVD prevalence, the association between primary PCI rates and mortality flipped. Higher rates of PCI per million population were associated with higher, not lower, age-standardized heart attack mortality -- a moderate positive correlation (coefficient +0.68; p less than 0.001).

"One would anticipate that increased provision of primary PCI would yield lower mortality rates; therefore, we will conduct additional analyses to elucidate why this trend is not evident in our preliminary findings," said Sukruth Pradeep Kundur, co-investigator from King's College London.

The interpretation most consistent with the data is that PCI rates alone are a poor marker of cardiovascular care quality at the population level. Countries with high PCI rates may also have older populations, higher rates of cardiometabolic risk factors, or more patients presenting with complex multi-vessel disease -- characteristics that drive both higher procedure rates and higher mortality, independent of procedural quality. Cross-sectional country-level data cannot fully resolve this confounding.

The Operator Volume Signal

One finding did trend in the expected direction: a weak inverse association was observed between the number of primary PCI procedures performed per interventional cardiologist and heart attack mortality (coefficient -0.27; p=0.23). This did not reach statistical significance, but the direction is consistent with the operator-volume literature -- the well-established finding that physicians who perform more of a given procedure tend to achieve better outcomes.

Senior author Dr. Sanjay Sivalokanathan from Mount Sinai noted that the global rise in cardiometabolic risk factors is likely increasing clinical complexity in patients presenting after heart attacks. This analysis is explicitly preliminary and cross-sectional; additional analyses are ongoing.