For patients with heart attacks caused by blocked blood vessels to the heart, the recommended treatment is percutaneous coronary intervention (PCI). This minimally invasive procedure opens obstructed arteries by inserting a balloon or stent. 

To support informed patient decision-making and promote quality improvement, death rates after PCI are reported to state and national registries. However, these public reports may lead physicians to avoid providing cardiovascular procedures, including PCI, to patients they perceive to be at higher risk of dying.

In the first study to comprehensively describe patients who do and do not receive this recommended procedure, LDI Senior Fellows Ashwin Nathan, Alexander Fanaroff, Sameed Khatana, Lauren Eberly, Jay Giri, and colleagues found evidence suggesting that quality metrics-related risk avoidance may drive disparities in receipt of PCI.

Nathan answered questions about the goals, findings, and implications of the study, which analyzed 2019-2023 data from 582 U.S. hospitals on nearly 179,000 patients.

What motivated this investigation of who gets a balloon or a stent after a heart attack?

Nathan: In general, quality metrics like PCI mortality reports have a role in benchmarking performance. They can provide hospitals with insights for improving the quality of care delivery. However, when procedures are heavily scrutinized, an unintended consequence can be risk-avoidant behavior. 

That behavior may show up as fewer procedures for patients who generally have higher risks because of age, chronic conditions, or other factors. Some of these highest-risk patients, however, may benefit the most from an invasive approach like PCI. It’s a potentially life-saving therapy with low procedural risk.

What were the most important findings for improving care after a heart attack?

Nathan: We found evidence of risk avoidance in real-world cardiac practice: In our national sample, 3.5% of patients who qualified for PCI did not receive it. At one-quarter of the hospitals, 5% of patients indicated for PCI did not receive it.

Patients who did not undergo this necessary therapeutic procedure for their life-threatening heart condition were more likely to be Black, older, female, and higher risk due to other health factors. These patients had a death rate more than 9% higher than predicted. We estimated that providing PCI would potentially have avoided more than 350 deaths.

These findings may support the “risk-treatment paradox” in cardiology: Patients at the highest risk of adverse outcomes are less likely to receive guideline-recommended therapies than lower-risk patients, even though they may derive the greatest benefit.

What limitations are important to consider in order to understand these findings fully? 

Nathan: Many factors — including patient wishes — affect a clinical decision. Although we used the National Cardiovascular Data Registry, a rich clinical data source, some unmeasurable factors may have affected decision-making by the patients and the hospitals’ treatment teams.

For our analyses, however, we selected patients who had received angiography to confirm suspected artery blockages. This is also an invasive procedure, suggesting they could have undergone PCI.

What are the practice and policy implications of these results?

Nathan: This is the first study to clearly show how many patients do not receive PCI — even though they had a serious type of heart attack and a blocked artery identified by angiography. We hope our results encourage physicians to provide PCI as recommended while following patient preferences. 

As our group evaluates the role of quality metrics in other cardiovascular disease conditions and procedures, we hope policymakers and payers will consider some implications of this study’s results: We pour a tremendous amount of money and personnel work hours into health care metrics, creating what we might call a national “metrics industrial complex.” 

The goal of quality metrics should instead be to guide quality improvement at the highly local —and even individual clinician— level. We should reconsider nationwide public reporting and comparisons such as PCI mortality reporting, which can introduce the potential for risk-avoidant behavior.

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The study, “Variation in Likelihood of Undergoing Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction Among US Hospitals,” was published March 4, 2025, in the Journal of the American Heart Association. Authors include Ashwin S. Nathan, Kevin F. Kennedy, Kriyana P. Reddy, Alexander C. Fanaroff, Daniel M. Kolansky, Taisei J. Kobayashi, Sameed Ahmed M. Khatana, Elias J. Dayoub, MD, Lauren Eberly, Sunil V. Rao, Roxana Mehran, Deepak Bhatt, Robert W. Yeh, John A. Spertus, and Jay Giri.

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