State Study Supports Stand-Alone Primary PCI


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 American College of Cardiology/American Heart Association 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 ACC/AHA guidelines as the reperfusion therapy of choice for STEMI when it can be accomplished in a timely manner. But most STEMI patients present to hospitals that don't perform primary PCI because they lack 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 improve access to the procedure, explained Dr. Anis of Boston University at the annual scientific sessions of the AHA. He reported on 3,018 Massachusetts STEMI patients who had primary PCI during 2005-2007, including 977 treated at non-SOS hospitals through a state department of health pilot program.

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

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, observed, “You can't say a well-run primary PCI program without surgery on-site isn't as good as one with surgery on-site.”

However, Dr. Robert A. Guyton, professor of surgery and chief of cardiothoracic surgery at Emory, said that the data “don't really give you comfort” that STEMI patients have the same outcomes whether they present to hospitals with or without SOS, 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 does not 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%), less use of guideline-recommended medications, and a trend for less use of primary PCI (44% versus 56%). “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 as a class IIb recommendation. “What would it take to actually move the needle from class IIb to a class I recommendation? Our rules of evidence 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.

Dr. Anis reported no financial conflicts.

Elsevier Global Medical News

Recommended Reading

Doubling Clopidogrel Aids Stented ACS Patients : In CURRENT-OASIS7, 600-mg loading dose cut ischemic and thrombotic events, increased bleeding.
MDedge Cardiology
Initiative Speeds Reperfusion Treatment Time
MDedge Cardiology
Sulfonylureas Tied to Mortality in MI Survivors
MDedge Cardiology
Heart Defect Screening Indicated in Turner's
MDedge Cardiology
Fractional Flow Reserve as PCI Guide Costs Less
MDedge Cardiology
Phone Calls Improve Post-CABG Depression
MDedge Cardiology
Off-Pump CABG Bests PCI in Cognitive Scores
MDedge Cardiology
Diabetes No Liability in Endovascular AAA Repair
MDedge Cardiology
Revascularization Boosts Cognitive Function, at a Price
MDedge Cardiology
Link Between RA, Carotid Disease Questioned
MDedge Cardiology