Cross-sectional analysis of primary PCI provision and AMI mortality across europe: accounting for economic and disease burden

Abstract Background Primary percutaneous coronary intervention (PPCI) is central to reducing mortality in acute myocardial infarction (AMI). However, substantial variation persists in both procedural volume and patient outcomes, raising uncertainty over whether higher intervention rates consistently translate into lower mortality. Purpose To examine the association between PPCI rate and AMI mortality across European countries after adjusting for GDP per capita and ischaemic heart disease (IHD) prevalence. Methods Latest available data from 21 European countries were compiled from open-access databases (ESC atlas, WHO, IHME, Eurostat). Extracted indicators included: PPCI procedures per million, age-standardised AMI death rate (SDR), interventionalist density, GDP per capita, and IHD prevalence. Cross-country comparisons were conducted using Spearman correlations and linear regression. Analyses were stratified by GDP tertiles to assess income-dependent effects. To explore system efficiency, we derived procedural workload metrics including PPCI per interventionalist. Multivariable models assessed the relative contribution of economic and epidemiological factors to AMI mortality, visualised using scatterplots, with outliers excluded. Results After adjusting for GDP per capita and IHD prevalence, a moderate positive correlation was observed between PPCI rate and AMI age-standardised mortality across 21 European countries (ρ = +0.68, p 0.001). GDP per capita showed a moderate negative correlation with AMI age-standardised mortality (ρ = –0.54, p = 0.004), while IHD prevalence demonstrated a positive correlation (ρ = +0.45, p = 0.02). Stratified analyses showed positive correlations across income tertiles: low (ρ = 0.98), middle (ρ = 0.67), and high (ρ = 0.60). PPCI procedures per interventionalist showed a weak inverse correlation with AMI mortality (ρ = –0.27, p = 0.23). Conclusion Disparities in AMI mortality across Europe are not explained by procedural volume alone. After adjusting for GDP and IHD prevalence, higher PPCI rates did not independently predict lower mortality, suggesting that system maturity, operator experience, and prevention efforts drive outcomes more than intervention density. The inverse relationship between PPCI workload per operator and mortality supports the importance of concentrated expertise over procedural expansion. Stratified analyses showed progressively weaker benefits of procedural growth across income tertiles, consistent with diminishing returns in high-income systems. Sustained mortality reduction will depend on coordinated networks, timely access, and upstream cardiovascular risk control. Future work should integrate patient-level and temporal data to disentangle case-mix effects and assess procedural appropriateness.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.