Mass. Registry Study Supports PCI Without On-Site Surgery

ORLANDO — In patients with ST-elevation MI who were treated with primary percutaneous coronary intervention and enrolled in a large Massachusetts registry study, the 1-year rates of mortality, MI, and target vessel revascularization were similar in hospitals with or without on-site cardiac surgery.

These data “suggest that in no-surgery on-site hospitals adhering to strict procedural volume requirements and the standards of care outlined in the ACC/AHA guidelines, primary PCI for STEMI patients may be performed with no difference in mortality through 1 year,” Dr. Ather Anis said.

Primary PCI is recommended in the American College of Cardiology/American Heart Association guidelines as the reperfusion therapy of choice for STEMI when it can be accomplished in a timely manner. But the majority of U.S. patients with STEMI present to hospitals that lack the capacity to perform primary PCI because they don't have surgery on-site (SOS). Performing primary PCI in STEMI patients at non-SOS hospitals—provided that it can be done safely—would be a strategy to increase the number of STEMI patients getting primary PCI, explained Dr. Anis of Boston University.

At the annual scientific sessions of the American Heart Association, he reported on 3,018 Massachusetts STEMI patients who underwent primary PCI during 2005–2007, including 977 treated at non-SOS hospitals.

One-year mortality and most other key outcomes were similar regardless of the type of hospital in which patients were treated. (See box.) The exceptions were 30-day all-cause mortality, which was significantly lower at non-SOS hospitals, and 30-day and 1-year repeat revascularization rates, which were significantly higher at non-SOS hospitals.

However, the results seem unlikely to change many physicians' established views on performing primary PCI in non-SOS facilities.

“You can't say a well-run primary PCI program without surgery on-site isn't as good as one with surgery on-site,” said Dr. Spencer B. King III, president of the Saint Joseph's Heart and Vascular Institute and professor of medicine emeritus at Emory University, both in Atlanta.

On the other hand, Dr. Robert A. Guyton, professor of surgery and chief of cardiothoracic surgery at Emory, said that the Massachusetts data “don't really give you comfort” that STEMI patients have the same outcomes regardless of whether they present to hospitals with or without SOS. That's because the registry collected data only on the STEMI subgroup undergoing primary PCI, not on all comers with STEMI.

“We do this all too often in medicine, talking about results in patients in whom we choose to perform an intervention,” Dr. Guyton said. “What the patient—and the state of Massachusetts—wants to know is, 'What is my outcome if I am taken with my STEMI to a hospital without surgery on-site versus my outcome if I am taken to a hospital with SOS?'”

Although the Massachusetts registry study doesn't address that question, a new report from the National Registry of Myocardial Infarction does, he said. The NRMI study included 58,821 STEMI patients who presented to PCI-capable hospitals during 2004–2006. The 8.1% of patients presenting to non-SOS hospitals had 9.8% mortality, significantly higher than the 7.0% mortality in patients presenting to SOS hospitals. The patients at non-SOS hospitals also had a significantly lower rate of reperfusion (71% vs. 81%). “If I'm in the ambulance with a STEMI, I'm going to request to be taken to an SOS hospital,” Dr. Guyton concluded.

In an interview, Dr. Elliott M. Antman pointed out that ACC/AHA guidelines already support primary PCI for STEMI at non-SOS hospitals. It has a class IIb recommendation, meaning the benefit is deemed greater than or equal to the risk. A change in classification “would require a randomized trial,” said Dr. Antman, a member of the ACC/AHA guidelines-writing committee and professor of medicine at Harvard Medical School, Boston.

The PCI registry study was funded through the Massachusetts Department of Public Health. Dr. Anis reported no financial conflicts.

Source Elsevier Global Medical News