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Erschienen in: Wiener klinische Wochenschrift 3-4/2020

Open Access 29.01.2020 | original article

Cardiac catherization in Austria

Results from the Austrian National Cardiac Catheterization Laboratory Registry (ANCALAR) 2012–2018

verfasst von: Prof. Volker Mühlberger, Lalit Kaltenbach, Katie Bates, Hanno Ulmer, Austrian National Cardiac Catheterization Laboratory Registry (ANCALAR), Österreichische Kardiologische Gesellschaft (ÖKG)

Erschienen in: Wiener klinische Wochenschrift | Ausgabe 3-4/2020

Summary

Background

Cardiac catheterization is one of the most widely performed cardiac interventional procedures worldwide. The Austrian National Catheterization Laboratory Registry (ANCALAR), started in 1992, collects annual data on cardiac catheterization in Austria. The registry enables in-depth understanding of the dynamics of cardiac catheterization procedures and their use across 34 cardiac catheterization laboratories in Austria.

Methods

Data from ANCALAR on cardiac catheterization including the latest data for 2017, voluntarily provided by centers with cardiac catheterization laboratories, were analyzed. Where possible, international comparisons in therapeutic and interventional cardiac procedures are made with Switzerland and Germany.

Results

Internationally, Austria ranks alongside the top countries in Europe. Whilst the number of people undergoing routine percutaneous coronary interventions (PCI) remains stable, complex and acute interventions are increasing year by year in Austria.

Conclusion

Evidence from ANCALAR revealed that Austria is another example of the difficulties of weighing current guidelines with new emerging evidence and resulting real-life clinical practice in the dynamic world of interventional cardiology.
Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s00508-019-01599-4) contains supplementary material, which is available to authorized users.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction

Cardiovascular diseases, in particular coronary artery disease (CAD), remain the world’s leading cause of mortality and morbidity [1]. The gold standard for diagnosis and intervention in CAD remains cardiac catheterization, angiography and percutaneous coronary intervention (PCI) [2]. Cardiac catheterization is one of the most widely performed cardiac interventional procedures worldwide, it is a high-cost, high-risk procedure and its history has been characterized by rapid advances in both technique and technology [3]. For such a dynamic field of medicine, registries provide a means to monitor adherence to international guidelines, standards of care and enable benchmarking at the subnational and national level [4].
The Austrian National Catheterization Laboratory Registry (ANCALAR) is an observational registry that collects data on cardiac catheterization in Austria. Data have been collected annually since 1992, data are submitted on a voluntary basis by hospitals performing interventional procedures in Austria, the data are then centrally processed and analyzed. The ANCALAR is a valuable resource, revealing the everyday practice of interventional cardiology in Austria and enabling international comparisons.
With new data from 2017 now available, trends in cardiac catheterization in Austria from 2012–2017 are described, contextualised with reference to both international treatment guidelines and international comparisons with Germany and Switzerland.

Data and methods

Data on diagnostic and interventional cardiac procedures in 2017 in the Austrian National Catheterization Laboratory Registry (ANCALAR) were used. In line with previous research, data were compared to the national cardiac catheterization registries of Germany and Switzerland [510].
ANCALAR is a voluntary, financially independent registry, maintained co-operatively by participating performing hospitals in Austria, coordinated by its initiator, Professor Mühlberger. The data are securely stored centrally and processed by the Department for Medical Statistics, Informatics and Health Economics at the Medical University Innsbruck. Whilst participation in the registry is voluntary, all hospitals providing interventional cardiac procedures in Austria participate, thus the data represent all cardiac intervention in Austria [5, 6].
Since 1992, the registry has collected over 90 parameters concerning cardiac catheterization, without interruption. Data are collected in accordance with the cardiology audit and registration data standards (CARDS) [11, 12]. Data collection tools are reviewed annually by the Interventional Cardiology working group of the Austrian Cardiology Society at its autumn meeting and, where necessary, updated. To ensure comparability over time only minimal, necessary modifications are made, for example when changes in treatment guidelines or available medical devices occur [5, 6, 1117]. All changes are made collaboratively, in cooperation with the participating centers, with updates to methods published in subsequent annual reports. Data collection tools and indicator definitions are available on the ANCALAR study homepage: https://​iik.​i-med.​ac.​at/​ [11].
Each center collects and summarizes their data annually, at the end of the year. During each calendar year, centers are visited or contacted in order to both perform audits and maintain working relationships. Quality control mechanisms have meant thatin Austria 100% of CathLabs submit data to the registry each year. Once 75% of clinics have completed the data entry, the remaining clinics are contacted personally (in-person meeting, telephone call or individual email), so far up to four repeat personal contact attempts have been required. Mass email follow-up, as has also been documented in Switzerland, has limited utility [7].
Using new data from 2017, trends in key cardiac catheterization indicators in Austria, including acute and non-acute PCI use, treatment of ST-elevation myocardial infarction (STEMI), puncture techniques and complications, re-interventions for chronic stent restenosis (REDOs), use of innovative medical devices, electrophysiology and transarterial aortic valve procedures (TAVI) are assessed [11, 18].
Indicators are constructed in line with the published ANCALAR methods, definitions of procedures presented in this paper are available in Supplementary Table 1 [5, 6, 11]. In brief, indicators are constructed using data pooled across all performing clinics and do not exclude cases with missing data in the numerator where denominator data are complete, thus underestimates are likely. To give a more accurate picture of what is happening in Austrian CathLabs, indicators are also constructed using pooled data from subsets of clinics where data are complete.
International comparisons are made with Switzerland and Germany using pooled data from PCI clinics in each respective country, diagnostic coronary angiographies (CA), TAVI and glycoprotein (GP) blockers are compared using both absolute numbers, and crude rates per one million inhabitants, in line with conventional methodology [711, 1721].

Results

All 34 PCI clinics operating since 2012 in Austria submitted data to the registry for 2017, with a total of 54 CathLab tables between them, in 2017 (Table 1). In 2017, 56,515 CAs were reported (Fig. 1; Table 2).
Table 1
Cardiac catheterization Laboratory structure in Austria 2011–2017
Year
2011
2012
2013
2014
2015
2016
2017
Number of centers
36
34
34
34
34
34
34
Number of tables
49
50
50
52
53
53
54
Number of physicians for diagnostics only a
243
261
272
271
291
309
304
Number of physicians for diagnostics and PCIa
214
222
226
238
250
250
262
Extended questionnaire of the European Society of Cardiology (ESC) [19]
Striking differences are in italics
PCI Percutaneous Coronary Interventions
aThe number of active physicians may be overrepresented due to multiple appointments
Table 2
Cardiac catheter diagnostics in Austria 2012–2017 across all reporting centers with available data. (Source: Austrian Questionnaire “diagnostics and related procedures”) [11]
Year
2012
2013
2014
2015
2016
2017
Diagnostic coronary angiography (CA)
53,064
54,566
56,062
54,853
56,750
56,515
Mortality CA overall (%)
76
(0.14)
61
(0.11)
59
(0.11)
61
(0.11)
59
(0.10)
25
(0.04)
CA without shock due to infarction
7969
7769
9467
9210
9453
9263
Mortality CA without shock (%)
29
(0.36)
23
(0.30)
23
(0.24)
20
(0.22)
27
(0.29)
12
(0.13)
CA with shock due to infarction
520
434
505
474
429
358
Mortality CA with shock (%)
27
(5.19)
25
(5.76)
28
(5.54)
19
(4.01)
15
(3.50)
11
(3.07)
Myocardial infarction as complication
31
28
25
32
32
8
With new Q‑wave
9
9
3
0
0
1
Defined by troponin or CK
24
23
6
32
28
4
Nonfemoral (radial) approach
12,055
18,441
20,735
27,673
31,850
34,627
Switch to femoral during procedure
1500
1702
1901
Local radial artery complications
112
Reversible neurological complications
33
41
37
48
37
44
Irreversible neurological complications
3
13
9
6
10
6
Vascular peripheral complication
277
309
264
223
192
113
With surgery or transfusion
56
41
49
42
28
25
With local injection of thrombin
77
115
105
75
59
34
Adverse reactions to contrast media
70
70
86
204
201
N.A.
Left ventricular angiography
18,163
18,572
11,834
12,628
11,646
10,941
Right heart catheterization
3142
3288
3515
3401
3489
3368
Striking differences in italics
CK Creatine (Phospho)Kinase
“–” data not available

International context

In Austria and Switzerland, the absolute numbers of CA are comparable and varied between 2016 and 2017 whilst Germany has consistently higher rates of CA. The PCI/CA ratio increased, with 40.2 of all CAs resulting in PCI in 2016 whilst 42.1% resulted in PCI in 2017 in Austria, comparable with Germany and lower than Switzerland (Table 2; Figs. 23 and 4).
For CA and PCI rates, Austria places just under the top nations in Europe; Austria is in the middle range for TAVI (115 per million population in 2017), with the rate of TAVI per 1 million population increasing year by year (Fig. 5; [17, 21]) Austria began reducing the use of GP blockers years before guidelines reacted to new evidence and at the same time Switzerland stopped counting these cases in their registry (Fig. 6). In contrast, reduction in the use of balloon pumps and catheter thrombectomies in Austria has been protracted (Table 3 and 4; [1318]).
Table 3
Percutaneous coronary interventions (PCI) and related procedures in Austria 2012–2017
Year
2012
2013
2014
2015
2016
2017
Intracoronary diagnostic device without PCI (cases) e.g. FFR, IVUS, OCT
1808
2532
2148
PCI (cases) therapeutic interventions
20,543
21,698
23,044
22,538
22,837
23,808
PCI for acute situation OR ongoing infarction
7026
7148
7791
8084
8612
9553 ↑
PCI for ongoing STEMI
3476
3546
3959
3943
4070
4581 ↑
Bifurcation PCI with large side branch
989
1081
1175
1454
1922
1920
Multivessel PCI (in one session)
3231
3094
4309
4300
4519
4478
PCI during diagnostic study (ad hoc)
17,559
16,085
18,596
16,652
16,313
16,195 ↓
Radial/brachial approach (non-femoral) during PCI
4727
6664
9104
9713
12,551
13,468 ↑
Switch (crossover) to femoral during or before PCI
474
479
794
1017 ↑
Local radial artery complication
77
Infarction as complication (by any definition)
82
78
80
114
174
122
Iatrogenic left main artery dissection
18
16
24
20
14
27
Emergency surgery after PCI and/or CA
19
17
22
19
27
35 ↑
In-hospital death after PCI
170
185
243
205
239
180
In-hospital death despite emergency surgery post PCI
1
1
1
1
5
4
Number of STENT cases:
18,577
19,995
21,008
20,646
21,257
22,417 ↑
Drug eluting stents (cases) (DES)
15,778
17,010
19,451
19,735
20,509
21,565 ↑
Drug eluting balloon (DEB) (cases)
723
847
782
937
1169
1090
Biodegradable vascular scaffolds (BVS) (aka Biostent)
113
1019
1693
1058
593
112 ↓
Left main stents
402
452
473
522
636
636
Multiple stents (cases)
5360
5668
8021
6680
7496
6933
PCI for in stent restenosis
687
801
617
814
794
782
PCI due to chronic hyperplasia
329
505
470
559
639
613
PCI due to very late chronic stent thrombosis
82
102
94
103
71
65
Original questionnaire of the European Society of Cardiology (ESC) [19]
cases; n pooled analysis
Striking differences in italics. Striking changes from 2016 to 2017 are indicated with directional arrows ↑ (increase) ↓ (decrease)
“–” data not available
FFR Fractional Flow Reserve, IVUS Intravascular Ultrasound, OCT Optical Coherence Tomography, STEMI ST-Elevation Myocardial Infarction, CA Cardioangiography
Table 4
Percutaneous CathLab interventions and related procedures in Austria (2012–2017)
Year
2012
2013
2014
2015
2016
2017
Rotablator
312
369
418
373
312
300
Catheter thrombectomy (clot catcher/remover)
1848
1799
1606
1317
1077
891 ↓
Intracoronary pressure registration (“fractional flow reserve” (FFR))
2182
2547
2524
3153
3631
3668
FFR decision with adenosine and/or
3220
3164 ↓
FFR decision without adenosine (= iFR)
19
64
411
604 ↑
PCI for chronic total occlusion (CTO)
637
589
559
790
782
808
Intracoronary ultrasound (IVUS)
816
783
711
670
808
755
Intra-aortic balloon pump during PCI
121
87
82
69
37
53 ↑
Other devices (e.g. mechanical circulation support,, protection device) in PCI
53
22
118
102
18
30 ↑
Platelet glycoprotein IIb/IIIa antagonist
2025
1775
1815
1597
1467
1201 ↓
Direct thrombin inhibitor in PCI
1110
1277
1406
858
439
198 ↓
Optical coherence tomography (OCT)
350
570
503
580
707
638
Alcohol ablation for septal hypertrophy (PTSMA)
8
14
11
6
13
9
Special techniques, Original questionnaire of the European Society of Cardiology (ESC) [19]
cases; n pooled analysis
Striking differences in italics. Striking changes from 2016 to 2017 are indicated with directional arrows ↑ (increase) ↓ (decrease)
“–” data not available
PCI percutaneous coronary intervention
The number of elective non-acute PCI has plateaued, with the number of cases in 2017 (n = 14,255) remaining almost identical to 10 years ago (n = 14,254 cases in 2006) (Table 5; [18, 19]); however, the number of patients undergoing non-routine and/or acute PCI (which interrupt daily planned PCI) is increasing year by year (Table 6). In 2017, mortality rates for all acute PCI was 1.64%, although this value is based on the pooled analyzes of all centers, including those with missing data in the numerator, and thus is likely an underestimate of the true PCI mortality rates across Austria.
Table 5
Cardiac catheter interventions in Austria 2012–2017
Year
2012
2013
2014
2015
2016
2017
Nonacute PCI
13,517
14,550
15,253
14,454
14,225
14,255
Mortality PCI non-acute overall (%)
14
(0.10)
15
(0.10)
25
(0.16)
13
(0.09)
26
(0.18)
23
(0.16)
Myocardial infarction as complication
83
78
80
107
174
101
With new Q‑wave
22
11
8
13
15
5
Defined by troponin or CK
58
66
55
79
132
93
Nonfemoral (radial) approach
3084
4260
5834
5817
5580
6868
Switch to femoral during procedure
256
366
551
Local radial artery complications
33
Reversible neurologic complications
19
14
17
7
11
24
Irreversible neurologic complications
4
4
2
1
1
6
Vascular peripheral complication
110
123
105
95
225
108
With surgery or transfusion
17
32
18
15
25
23
With local injection of thrombin
24
32
25
23
55
31
Adverse reactions to contrast media
27
29
30
24
30
Austrian Questionnaire “Non-acute percutaneous coronary interventions PCI” [11]
cases; n pooled analysis
Striking differences in italics
“–” data not available
PCI percutaneous coronary intervention, CK Creatine (Phospho)Kinase
Table 6
Cardiac catheter interventions in Austria 2012–2017
Year
2012
2013
2014
2015
2016
2017
Acute PCI (interrupts routine program)
(intention to treat with PCI)
7026
7148
7791
8084
8612
9553
Mortality acute overall (%)
156
(2.22)
170
(2.38)
218
(2.80)
192
(2.38)
213
(2.47)
157
(1.64)
PCI acute without shock
6537
6754
7316
7648
7648
7867
Mortality PCI without shock (%)
51
(0.78)
68
(1.01)
70
(0.96)
81
(1.06)
78
(1.02)
56
(0.71)
PCI acute with shock
489
394
475
436
467
318
Mortality PCI with shock (%)
96
(19.63)
102
(25.89)
148
(31.16)
111
(25.46)
135
(28.91)
101
(31.76)
Nonfemoral (radial) approach
1319
1912
2389
3004
3567
3937
Switch to femoral during procedure
144
186
145
Local radial artery complications
29
Reversible neurologic complications
10
7
6
4
5
5
Irreversible neurologic complications
2
1
1
3
3
2
Vascular peripheral complication
90
67
62
34
75
62
With surgery or transfusion
19
17
10
9
12
9
With local injection of thrombin
25
13
7
7
13
18
Austrian Questionnaire “Acute percutaneous coronary interventions”=PCI in suspected myocardial infarction
cases; n pooled analysis
Striking differences in italics
“–” Data Not Available
PCI percutaneous coronary intervention, Acute PCI PCI in patients that interrupt routine program
An increase of complex and acute interventions is evidenced by the increase in STEMI-PCI (Table 3 and 6) to 20.0% of all PCI (in reporting centers) in 2017 (Supplementary Table 2). The number of ad hoc multivessel PCI increased to 20.8% of all PCI in 2017 (Table 3). There is also an increase of PCI in bifurcation of large side branches from 6.7% (2012) to 12.4% (2017) and for left main stents from 2.0% (2011) to 3.3% (2017, Table 6).
Currently 21 centers fulfil the criterion of more than 36 STEMI PCI cases per year, down from a peak of 24 in previous years [20]. PCI for ongoing STEMIs have increased 32% since 2012, emergency surgery after PCI also increased, with some fluctuations, although n’s are small so this result should be interpreted with caution (Table 3). Mortality due to emergency surgery post PCI has more than doubled since 2012 to 11.4% in 2017 (Table 3), although again n’s are small (4 deaths in 35 emergency surgeries) and the definition of emergency surgery has become broader.
The incidence of major bleeding relative to all bleeding complications is declining, especially in acute PCI (from 34.0% in 2010 to 15.8% in 2017) (Supplementary Table 2). Use of glycoprotein IIb/IIIa (5.0%) or thrombin inhibitors (TI, 0.83%) is now extremely rare (Table 4, Fig. 6).
Reinterventions for chronic stent restenosis (REDOs) remain constant at 4.4% of PCI in reporting centers (in 2017 n = 782, in 2010: 4.6%, Supplementary Table 2); however, the proportion of very late stent thrombosis as the cause of the reintervention is decreasing, at 9.6% of all REDO’s in 2017 (2016: 11.0%, 2015: 15.4%) (Supplementary Table 2).
Non-femoral (mostly radial) puncture techniques (Table 235 and 6) in diagnostic CA increased in absolute terms from n = 18,441 (2013) to n = 34,627 (2017) (Table 2). During diagnostic CA, 6.4% required a switch from radial to femoral (Table 2), with 5.2% of those acute radial cases requiring a switch from radial to femoral during the procedure. Since 2016 there has been a plateau in the use of radial approach (Fig. 7). The number of ad hoc PCIs during diagnostic CA continues to decline (84.4% in 2015 to 75.0% in 2017).
Complications due to radial puncture techniques (Table 235 and 6) were first documented in 2017 [22]. Predictors of radial artery occlusions (RAO) are published by individual centers [22].

Use of new intracoronary interventional devices

The time of new devices and techniques (innovations) within CathLabs seems few and far between today [23, 24]. For example, use of the drug eluting balloon (DEB), is now declining (Table 4). Declining use of biodegradable vascular scaffolds (BVS) accelerated since 2014. A similar reduction can be seen with catheter thrombectomies (n = 891) and intra-aortic balloon pumps (n = 53) (Table 4). Left atrial appendage closures (LAA closures), showed a slight renaissance in Austria in 2017 (n = 76) (Table 7).
Table 7
Percutaneous CathLab interventions and related procedures in Austria (2012–2017)
Year
2012
2013
2014
2015
2016
2017
Renal, iliac or leg artery intervention in cathlab
559
475
551
593
816
706
Carotid artery intervention in cathlab
70
55
52
56
65
49↓
Mitral valvuloplasty
42
MitraClip implantation
51
62
89
91
123
139 ↑
Transcatheter aortic valve implantation (TAVI)
432
480
604
668
834
1016 ↑
Transapical valve (reporting incomplete)
29
35
26
55
46
133 ↑
Transarterial valve
403
445
578
613
788
881 ↑
PFO/ASD/PDA closure by catheter
193
191
218
217
218
198
Renal denervation (PRD=RND)
151
144
58
29
14
Other valve interventions
13
15
Left atrial appendix (LAA) closure
57
76 ↑
Austrian questionnaire “Non-coronary or non-cardiac interventions”
(cases; n =; pooled analysis).
Striking differences in italics. Striking changes from 2016 to 2017 are indicated with directional arrows ↑ (increase) ↓ (decrease)
PFO Persisting Foramen Ovale, ASD Atrial Septal Defect, PDA Persisting Ductus Arteriosus, PRD Percutaneous Renal Denervation
“–” or“ Data Not Available

Extracoronary interventions

The number of procedures on peripheral vessels, e.g. kidneys and legs remained constant, while the number of carotid procedures within the cardiac catheterization laboratories has decreased (Table 7).
Electrophysiology continued to increase in 2017 in all 21 performing centers (Fig. 4). Electrophysiological ablations (n = 3640, total) are well established and increasing, of which n = 1514 were for atrial fibrillation (AF) and n = 396 for ventricular arrhythmia (VT). Of the n = 2143 pacemaker implantations within the CathLabs n = 157 were “leadless pacemakers”, a real innovation pioneered in 2014 at an Austrian center, now spreading worldwide (Table 8).
Table 8
Percutaneous CathLab interventions and related procedures in Austria (2012–2017)
Year
2012
2013
2014
2015
2016
2017
Myocardial biopsies
180
226
292
303
340
356 ↑
Diagnostic electrophysiology
3087
3185
3417
3584
3742
3906 ↑
Electrophysiological ablations
3098
3019
3254
3313
3482
3640 ↑
Ablation in atrial fibrillation (reported since 2013)
142a
1162
1238
1285
1514 ↑
Ablation in ventricular rhythm disorders (reported since 2013)
4a
230
249
369
396 ↑
DEVICE implantations (pacemakers)
2109
2198
1932
2061
2102
2143
Leadless pacemaker
4b
32
64
84
157 ↑
Austrian questionnaire “Diagnostics and Electrophysiology”
cases; n pooled analysis
Striking differences in italics, Striking changes from 2016 to 2017 are indicated with directional arrows ↑ (increase) ↓ (decrease)
aincomplete response
bworldwide pioneer
“–” Data Not Available
In all 10 performing centers, increases are found in percutaneous valve implantations or valve replacements, e.g. TAVI/TAVR in 2017 (n = 1016), as well as in the MitraClip (n = 139) (Fig. 5; Table 7).
A visible phenomenon in 2017 are n = 2148 cases with intracoronary (IC) devices (Table 3) but without following therapeutic intervention (11.9% of PCI during 2017, Supplementary Table 2). This results in a rate of 42.4% (2148/5061, Table 4) of cases with IC devices (any) without following therapeutic intervention, such as pressure wire with or without adenosine (FFR; n = 3668), IC ultrasound (IVUS; n = 755), or optical coherence tomography (OCT; n = 638) in reporting centers in 2017. In 2016 the percentage was higher, at 49.2% (2532/5146; Table 4).

Data quality

The methods of ANCALAR have meant that data for benchmark parameters have been reported by 100% of clinics in each year the data were requested, generating a rich database. For a few specific parameters, particularly indicators of negative outcomes such as severe bleeding during CA or PCI, not all clinics report these data which could lead to underreporting if these outcomes are occurring but are not being reported in the registry. A description of missing data is available in Supplementary Table 2, which notes the exact number of clinics (out of the 34 possible) from which only complete data were pooled to calculate the respective indicator. ANCALAR provides the most comprehensive data concerning cardiac catheterization in Austria today, across all PCI capable health facilities operating in the country.

Discussion

Austria currently ranks alongside the top countries in Europe in respect to CA and PCI use. As with other countries, complex and acute interventions are increasing year by year in Austria. STEMI-PCI is increasing year by year and now accounts for one fifth of all PCIs, this current trajectory will present logistical challenges given the need for complex cases to be assigned to experienced centers [24, 25].
With respect to international guidelines, Austria provides some interesting insights—guidelines are often slower in their reaction to new evidence than the daily practice of cardiologists. The use of the radial approach in Austria reflects this: over 50% of PCIs were conducted using TRA prior to the ESC classifying the evidence in support of the procedure as class I, in 2016 (Fig. 7); however, since 2016 TRA use has plateaued in Austria as cardiologists react to new evidence that the relative clinical benefits of TRA are less than previously thought, in spite of the current guidelines [23].
Registry data, by its nature, has strengths and weaknesses. ANCALAR has been collecting data on real world cardiology practice in Austria for over 30 years, enabling benchmarking and international comparisons. Personal communication with leading physicians in cathlabs across Austria has meant that year on year every center practicing interventional cardiology in Austria has submitted data to the ANCALAR. ANCALARs methods are transparent and standardized, with onsite audits, cross-validation of data where needed, and centralized data processing, ensuring high quality data that is comparable over time. Throughout each calendar year, leading physicians in all cathlabs offer feedback on ANCALAR, with annual meetings enabling personal discussion between cardiologists about adaptations to indicators and introduction of new indicators. ANCALAR is a valuable resource to cardiologists within both Austria and internationally, its integrity strengthened by its continued financial independence of any person or institution.
As expected with registry data, qualitative issues in definition and reporting make statistical analysis of mortality (Table 234 and 5) increasingly complex. For example, the classification of PCI in cardiogenic shock (ICD10: R57.0) leaves a lot of room for manoeuvre. Additionally, the decline of ad hoc PCIs in Austria may well be actually due to the discharge of a patient after radial diagnostics who are considered a “new” admission when a femoral instead of radial puncture for PCI is performed on a separate date. With respect to re-punctures, there are questions about whether switch to femoral access during PCI is also classified as re-punctures or not, leading to potential underreporting due to these qualitative definition issues.
Indeed, underreporting remains a key issue in registry data, not solely due to definitional issues. Of particular note is the potential underreporting and thus subsequent underestimation of mortality rates. It follows that it is is reasonable to expect that the low mortality rate for all acute PCI of 1.64% in 2017 is likely an underestimate due to underreporting and missing data. Many centers may only report mortality for acute PCI if deaths occur “on the cathlab table”, which could also lead to the underestimation of mortality. Additionally, PCI complications are underreported; however, some centers in Austria as well as in Switzerland independently publish their complication rates [7, 18].
Registry data cannot provide answers to causal questions. For example, the link between decreasing peripheral vascular complications and decreasing application of GPI and TI.
Registries are necessarily limited in the amount and type of data they collect. The impact of periprocedural myocardial infarction (MI) is important (Table 23 and 5), yet this area remains underdocumented in the ANCALAR [26]. Additionally, the distinction between restenosis due to chronic hyperplasia or late/very late stent thrombosis is not easily discernible from registry data, particularly given the data may not necessarily be recorded by the interventional physician [25, 27]; however, registry data are the key to highlight current trends in daily practice and provide evidence of the effects of changing practice. For example, there appears to be a decline in PCI for restenosis due to late stent thrombosis in Austria. Maybe the application of dual antiplatelet therapy (DAPT), even in all-comers, is now proving effective [28]. No restenosis is few and far between today [29].
Where feasible, specialist sub-registries are required to supplement registry data. For example, in Austria data on silent closures of radial arteries, higher technical and x‑ray exposure and differential learning curves in radial puncture techniques are available in the special Austrian registry, (http://​ptca.​i-med.​ac.​at), which observes STEMI patients [30].
Policy and practice are influenced by cardiac registries. Guidelines can be slow to react to emerging evidence and changes in real world practice. Registries such as ANCALAR can both influence the construction of guidelines and enable cardiologists to understand the “sinn und unsinn” (sense and nonsense) of current guidelines. Moreover, registries such as ANCALAR hold a mirror up to all stakeholders in the world of cardiac intervention, from authorities to cardiologists making everyone more alert to changes in everyday practice. For example, during the autumn conference of the ÖKG working group, which took place on 1 December 2017, in response to new ANCALAR data it was decided that every physician in Austria performing acute PCI should master both the radial and femoral techniques. Indeed, sometimes in interventional cardiology, registries such as ANCALAR are the only and/or most up to date benchmark.

Conclusion

The most recent results from ANCALAR highlight that interventional cardiology in Austria is, in the main, in line with the top countries in Europe. However, some Austrian idiosyncrasies in response to new evidence and guidelines exist. Often, Austria reacts very early to new evidence and guidelines, as seen by trends in GPIIb/IIIa, radial access and direct thrombin inhibitors. Indeed Austria remains hesitant in adopting new devices, particularly those with niche applications such as aspiration thrombectomy, and avoids “hypes”, such as biostents. Austria is often both ahead of the curve, adapting daily practice before new guidelines are released, whilst simultaneously proceeding with caution, particularly with respect to new devices.
The dynamic nature of cardiac catheterization and increasing number of complex cases has implications for cardiac registries, including ANCALAR. Quantitative changes in complication and mortality rates may in fact reflect qualitative changes in data reporting resultant of such dynamism, cardiac registers and the interpretation of their data need to continue to adapt in the face of such changes.
In conclusion our registry data show that Austria is another example of the difficulties of real life and science meeting in the world of interventional cardiology; with registry data careful interpretation is needed to identify artefacts and understand real differences in the practice of interventional cardiology [31].

Conflict of interest

V. Mühlberger, L. Kaltenbach, K. Bates and H. Ulmer declare that they have no competing interests.
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Metadaten
Titel
Cardiac catherization in Austria
Results from the Austrian National Cardiac Catheterization Laboratory Registry (ANCALAR) 2012–2018
verfasst von
Prof. Volker Mühlberger
Lalit Kaltenbach
Katie Bates
Hanno Ulmer
Austrian National Cardiac Catheterization Laboratory Registry (ANCALAR), Österreichische Kardiologische Gesellschaft (ÖKG)
Publikationsdatum
29.01.2020
Verlag
Springer Vienna
Erschienen in
Wiener klinische Wochenschrift / Ausgabe 3-4/2020
Print ISSN: 0043-5325
Elektronische ISSN: 1613-7671
DOI
https://doi.org/10.1007/s00508-019-01599-4