OR6-5 | Variation in Likelihood of Undergoing Percutaneous Coronary Intervention for ST Segment Elevation Myocardial Infarction among United States Hospitals

There may be considerable variability in hospitals' or providers' willingness to perform percutaneous coronary intervention (PCI) in higher risk patients who present with ST segment elevation myocardial infarction (STEMI). We sought to describe current selection patterns and hospital-level variability in performing PCI in the setting of STEMI. We identified all adult patients presenting with STEMI with a culprit lesion on coronary angiography between January 1, 2019 and March 31, 2023 using the NCDR CPMI Registry. We compared patient-level characteristics of patients who did and did not undergo PCI at each hospital, as well as their predicted risk of mortality. There were 178,984 patients from 582 US hospitals presenting with STEMI who were included in the analysis. Among patients with STEMI and a culprit lesion, 6,180 did not undergo PCI (3.5%). Patients with a presentation of STEMI and a culprit lesion who did not undergo PCI were older 67 (IQR 58,76) versus 62 (IQR 54,71), p<0.001), more often Black (12.1% versus 9.4%, P<0.001), and were more likely to present with heart failure (15.0% versus 7.4%, p<0.001), had shock (12.1% versus 6.8%, p<0.001) or cardiac arrest prior to arrival (9.7% versus 5.1%, p<0.001) than patients with STEMI and a culprit lesion who underwent PCI. Patients with STEMI who did not undergo PCI had a higher predicted mortality compared with patients who underwent PCI (12.5 ± 17.9% versus 6.5 ± 11.5%, p<0.001). The observed mortality for patients with STEMI who did not undergo PCI was higher than the observed mortality for patients who underwent PCI (21.7% versus 6.4%, p<0.001). There is significant variability in the percentage of patients with culprit lesions on invasive coronary angiography undergoing PCI for STEMI nationally, with 3.5% of patients with STEMI not receiving PCI, and over 5% of patients not undergoing PCI in a quarter of US hospitals. Patients who did not undergo PCI for STEMI after invasive coronary angiography despite having culprit lesions were older, more likely to be Black, and sicker. Differences in the observed versus predicted mortalities for patients who did or did not undergo PCI may highlight the effects of risk avoidant behavior.