Angioplasty Safe at Hospitals Without On-Site Surgery: Review
In-hospital death, emergency bypass no more likely in non-specialty centers, researchers say
By Denise Mann
TUESDAY, Dec. 13 (HealthDay News) -- Despite current guidelines, many people who have angioplasty to open blocked heart arteries can safely undergo these procedures in hospitals that don't have on-site cardiac surgery capabilities, according to a new review of 15 studies.
The review found no heightened risk for death or conversion to emergency bypass surgery in individuals who have angioplasty at centers that don't have teams that are ready to perform emergency coronary artery bypass grafting in a pinch.
The findings are published in the Dec. 14 issue of the Journal of the American Medical Association.
Angioplasty can be done urgently after a heart attack or electively to reduce the risk of a heart attack. The new study included more than 120,000 people who had angioplasty immediately following a heart attack. In this setting, timing is of the essence. The risk of dying was 7.2 percent at hospitals where there was on-site surgery and 4.6 percent at centers that did not have this capability. The risk of needing emergency bypass surgery was low for urgent and elective angioplasty patients at centers with and without on-site surgery capabilities, the study showed.
According to guidelines from the American College of Cardiology and American Heart Association, elective angioplasties should only be performed in centers with on-site surgery capabilities. But "for the most part, elective or non-urgent angioplasty can safely be performed at all centers," said study author Dr. Mandeep Singh, a cardiologist at the Mayo Clinic in Rochester, Minn.
"Patients who need primary, emergency angioplasty should be sent to the hospital nearest to where they live," he said. "For elective angioplasty procedures which can wait, it can be decided on a case-by-case basis."
Dr. Scott Kinlay, who wrote an accompanying journal editorial, agreed. "Patients should know that coronary revascularization by [angioplasty] is relatively safe regardless of whether there is on-site [surgery]," he said. If on-site surgery is not available, "patients should know if there are systems in place to transfer them quickly to a hospital if this is required," said Kinlay, director of the cardiac catheterization laboratory and vascular medicine of the VA Boston Healthcare System.
This discussion is not essential following a heart attack. "However, in the non-heart attack setting, it would be reasonable to ask this question," Kinlay said. "At the time the guidelines were written, there was still some doubt about whether on-site [surgery] is a necessity," he added.
Many of the studies only recruited and included patients who are considered low risk. If ongoing trials "come to the same conclusion as this paper, future guidelines may suggest that patients with high-risk features" should have their angioplasty in a hospital with on-site bypass, whereas "[angioplasty] without on-site [bypass] may be more acceptable for the majority of average and low-risk patients," Kinlay noted.
"We should wait for further confirmation by the randomized trials before giving the absolute green light on this," Kinlay said, particularly as these studies may also help define who should have angioplasty in hospitals with on-site bypass surgery.
Visit the U.S. National Heart, Lung, and Blood Institute to learn more about angioplasty.SOURCES: Mandeep Singh, M.D., M.P.H., cardiologist, Mayo Clinic, Rochester, Minn.; Scott Kinlay, M.D., MBBS, Ph.D., director, cardiac catheterization laboratory and vascular medicine, VA Boston Healthcare System, West Roxbury, Mass.; Dec. 14, 2011, Journal of the American Medical Association Related Articles
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