Contrary to current guidelines, Mayo Clinic researchers have found that elective or primary (in patients who have had heart attacks) angioplasties performed at centers without on-site cardiac surgery capabilities pose no increased risk for patient death or emergency bypass surgery. Results of the study were published in today's Journal of the American Medical Association and have implications for how care can be delivered to heart attack patients and for performance of angioplasties at centers without on-site surgery.
For the study, researchers systematically searched papers about angioplasties performed at centers with and without on-site surgery; the papers were published between 1990 and 2010 in several medical databases. Fifteen studies met the inclusion criteria and included thousands of patients. For the 124,074 patients who had primary angioplasties performed to unblock their coronary arteries in the setting of heart attack where timely treatment is crucial and lifesaving, the mortality rate was 4.6 percent for sites without on-site surgery and 7.2 percent for sites with on-site surgery.
"More than 900,000 patients had angioplasty done in an elective or urgent setting," says Mandeep Singh, M.D., Mayo Clinic cardiologist and lead author of the study. "Again, we did not find any higher risk of in-hospital death in patients who had their angioplasties performed at centers with on-site surgery compared to centers without. This study demonstrates that any type of angioplasty can be safely performed at centers that do not have on-site surgical capability."
The researchers also found that the incidence of emergency coronary artery bypass surgery for both classifications of patients was low at centers without on-site surgery capabilities. For primary angioplasty done in patients with heart attacks, the observed rate of emergency cardiac surgery was 0.22 percent at centers without on-site surgery compared to 1.03 percent at centers with on-site surgery; for all other patients, the rates of emergency heart surgery were 0.17 percent and 0.29 percent, at centers without and with on-site surgery.
Guidelines published by the American College of Cardiology and American Heart Association (ACC/AHA) recently revised their recommendations favorably toward the performance of angioplasty at centers without on-site surgery, and "our study that combines the results of a large number of more recent studies with similar outcomes of angioplasties at centers with and without on-site surgery provides further evidence in support of safety of angioplasty procedures at centers without on-site surgical facilities," Dr. Singh says.
Other Mayo Clinic co-authors of the study are David Holmes, Jr., M.D.; Gregory Dehmer, M.D.; Ryan Lennon; Thomas Wharton, M.D.; Michael Kutcher, M.D.; Thomas Aversano, M.D.; and Charanjit Rihal, M.D.