The Portuguese Society of Cardiology (SPC) established the National Registry of Interventional Cardiology (RNCI) in 2002 with the aim of providing a prospective and continuous record of percutaneous procedures and patient characteristics in Portugal.1 In parallel, the Directorate-General of Health (DGS) publishes official data based on surveys conducted in interventional cardiology centers.3

We have previously reported developments in interventional cardiology in Portugal from 1992 to 2003.4 We now present data from 2004 to 2013 and analyze trends in Portuguese interventional cardiology over the last 20 years (1992–2013).

In any analysis of this activity it is important to make comparisons with other countries, particularly within Europe. Meier et al. published European data for several years,5,6 but this has not been the case in recent years, and so we opted to compare Portugal with Spain and Switzerland. Spain has published annual data since 1990, and as a European country bordering Portugal, it is probably the closest to Portugal in economic and cultural terms.7,8 Switzerland has also regularly published data on its activity in this area, which enables comparison with a different context that is more representative of northern and central Europe.9,10

The RNCI is a voluntary, prospective, multicenter patient registry, compiled according to the Cardiology Audit and Registration Data Standards for clinical cardiology practice2 and centralized in the National Cardiology Data Collection Center (CNCDC), under the aegis of the Portuguese Association of Cardiovascular Intervention (APIC) of the SPC. Between 2004 and 2013, 113971 percutaneous coronary interventions (PCIs) were recorded. The RNCI has progressively included a greater percentage of all procedures performed over the years under analysis. The official data published by the DGS regarding the total number of coronary angiograms and PCIs, collected by annual surveys sent to interventional cardiology centers, are complementary to the RNCI, and the data presented, expressed as numbers and percentages, are based on the RNCI.

To compare our experience with that of Spain we used the annual reports of the Hemodynamics and Interventional Cardiology Section of the Spanish Society of Cardiology (1990–2013)8; for the comparison with Switzerland, we used the data published by Micha et al.9 for 2010 and the data presented for 2013 by the Swiss Working Group of Interventional Cardiology and Acute Coronary Syndromes, as reported by Gregor Fahrni and kindly made available by Meier et al.10

The percentage of patients included in the RNCI has progressively increased. For the first year of the period under analysis (2004), the sample represented only 46% of all procedures in that year, while in the last two years practically all patients treated in Portugal were included (Figure 1), with a slight decrease in 2013.

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Figure 1.

Percentage of patients included in the National Registry of Interventional Cardiology. RNCI: Portuguese National Registry of Interventional Cardiology.

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As mentioned above, there was marked growth in the number of PCI procedures between 1994 and 20084; the growth rate between 2004 and 2008 was 37% but this slowed to 20% in the following five years (2009–2013). After remaining relatively stable between 2010 and 2012, diagnostic procedures increased again in 2013, but this was not accompanied by growth in PCIs, leading to a lower ratio of PCIs to coronary angiograms of 0.38. The ratio between interventions and diagnostic procedures in Spain has been relatively stable since 2007, with a ratio of 0.55 in 2013. There is thus a difference between the two countries, with a larger proportion of diagnostic procedures in Portugal (3539 per million population in 2013 vs. 2592 in Spain) and a smaller proportion of PCIs (1333 per million population in 2013 vs. 1419 in Spain). However, the Spanish registry is not a patient registry, which may bias the comparison. In the Swiss registry,10 the ratio of PCIs to coronary angiograms was 0.48 in 2013, which is higher than in Portugal but lower than in Spain. It should be noted that publication of the COURAGE trial results in 200711 does not appear to have affected indications for interventional cardiology exams since neither the total number of coronary angiograms nor the ratio of interventions to coronary angiograms has decreased.

Assessing Portugal's performance in the European context is important not only for health professionals directly involved in the diagnosis and treatment of patients but also for decision-makers. Meier et al. collected and published data on interventional cardiology in Europe for several years,5,6 but with the exception of primary PCI12 the latest European figures are for 2005.6 The RNCI is unique in Europe since it now collects data from all interventional cardiology centers in the country and most systems enable patient data to be made available online, thus allowing almost instantaneous overall assessment and benchmarking. A robust, high-quality national registry ensures that the data are reliable and guards against the publication of results that may distort the true situation. For example, in the data published by the European Heart Network,13 the rate of PCIs per million population reported for Portugal in 2009 was 229, whereas the true figure was 1163 per million.3

With regard to multivessel PCI, this activity appears to have stagnated over the years. In 2013 the rate in Portugal was 18% of procedures, while Spain reported a rate of 30%.8 This may be because studies have shown that in diffuse multivessel disease, particularly in diabetic patients, PCI may not be the best option.15–17 It may also be related to the fact that increasingly older patients are being treated, with various comorbidities, especially renal failure, in whom a less aggressive approach is indicated, with staged procedures. In addition, from the standpoint of hospital contracts for interventional cardiology programs in Portugal, it is more advantageous to treat multivessel disease in multiple sessions. The good results achieved with second-generation DES18,19 mean that in the 2014 ESC/EACTS guidelines on myocardial revascularization, for the first time PCI for both multivessel and unprotected left main disease is on an equal footing with coronary artery bypass grafting for patients with low or intermediate SYNTAX scores.20

Treatment of unprotected left main disease accounted for 1.9% of all procedures in 2013, a lower percentage than in Spain (3.3%),8 and has remained relatively stable over the period under analysis. The good long-term results reported in the SYNTAX trial14–16 may well have an impact on treatment of unprotected left main disease in Portugal.

Since their introduction in 2002, Portugal has had one of the highest rates of use of DES. Despite a decrease in 2007 (from 71.4% in 2006 to 58.0% in 2008), possibly due to fears of risk of stent thrombosis,21 this soon changed, the rate of use reaching 67.3% in 2010. This fell again in 2011, which was attributed to financial constraints imposed by the economic crisis which favored the use of cheaper bare-metal stents. The rate again rose in 2012, reaching 73.1% in 2013, higher than in Spain (62%) but far lower than in Switzerland (92%).10 One possible explanation for these differences may be the price of stents, which is significantly lower in Portugal and Switzerland than in Spain, making their use more cost-effective.

Direct stenting decreased steadily from 2010. Since anatomical complexity in PCI patients has not increased, this may reflect differences in technique for lesion preparation or possibly use of devices with less efficient delivery systems for economic reasons.

Primary PCI has been the subject of particular attention within the European Association of Percutaneous Cardiovascular Interventions (EAPCI), notably through the Stent for Life initiative.22 The EAPCI considers that Europe should aim for a rate of 600 primary PCIs per million population per year.22–24 In 2013, the rate was 338 in Portugal and 395 in Spain.8 In 2014, Kristensen et al.12 published data for 2010/2011 for 37 European countries, in which only Austria (769), Bulgaria (694), the Czech Republic (596), Germany (638), Hungary (553), The Netherlands (884), San Marino (640) and Switzerland (506) performed over 500 primary PCIs per million per year. Portugal, with 303 per million per year, was in an intermediate group that includes Belgium (297), Finland (265), Greece (346), Greenland (396), Spain (225) and England and Wales (286). This is in contrast to a previous report by Widimsky et al.25 for 2007–2008, in which Portugal was among the countries with a low level of primary PCI. The percentage of primary PCI has progressively increased, accounting for 25% of total procedures in the last year under analysis. PCI in the context of infarction accounted for 26% of overall activity in Spanish centers in 2013.8

Aspiration thrombectomy began to be used more widely in 2008, coinciding with the publication of the TAPAS study.26 Its use in the last three years of the study period approached 50%, and the results of the TASTE trial are awaited to see what impact these will have on future use.27 In Spain thrombus aspiration was used in 67% of procedures in 2013,8 but a retrospective analysis of the RNCI in Portugal showed that the technique had no impact on in-hospital mortality in patients with STEMI.28

Pressure wire assessment of fractional flow reserve increased by 0.8% from 2008, coinciding with publication of the FAME study.29 In 2013, Portugal saw a slight decrease in use to 2.5%, while the rate in Spain was 6.2%,8 which indicates a need for greater experience in this technique in Portugal.

Use of intracoronary diagnostic methods has remained low. The highest rate of IVUS was in 2009 (3.1%) but this fell progressively to 1.5% in 2013, considerably below the Spanish rate of 6.7% for the same year.8 Optical coherence tomography (OCT) was not included in the RNCI, but it appears that use of intracoronary imaging techniques in general has remained stable.

Lastly, use of radial access increased, reaching 53% in 2012 and overtaking femoral access. This figure rose to 58% in 2013, close to the 64% reported in Spain.8

When assessing activity in interventional cardiology, as well as analyzing trends in the use of various techniques, it is also valuable to analyze clinical and pharmacological parameters, the devices used and outcomes, particularly complications. By the end of the period under study the RNCI included all patients treated in Portugal but the data on clinical follow-up are heterogeneous and should be the subject of a separate analysis; we therefore did not assess the rate of complications. This problem is common to registries that include all patients. Furthermore, there is additional information that should be collected in the future, in particular specifying the number of ad-hoc PCI procedures, drugs used, angiographic features, treatment of chronic total occlusions, type, size and generation of DES, and use of the latest diagnostic methods (OCT and instantaneous wave-free ratio).

Interventional cardiology is no longer focused exclusively on the treatment of coronary artery disease, the main developments now being in the treatment of structural heart disease. It is important to assess current trends in the percutaneous treatment of aortic stenosis, mitral valve stenosis and regurgitation, and hypertrophic cardiomyopathy and closure of shunts, and in the prevention and treatment of ischemic stroke, hypertension and peripheral vascular disease. APIC's working groups have established specific registries for transcatheter aortic valve implantation, renal denervation and atrial appendage closure, which will be published at a future date.

Interventional cardiology in Portugal expanded between 2004 and 2013 as assessed by the number of coronary angiograms and PCIs. In the last year under study, all centers involved in this activity contributed individual patient data to the RNCI.

Overall, a relative increase in primary PCI was observed, together with growth in the use of DES and considerably increased use of radial access. Use of intracoronary imaging techniques and invasive functional assessment showed only marginal progress. We have identified variables that should be included in the RNCI in the future.

The authors have no conflicts of interest to declare.