Coronary angioplasty safe and effective at facilities without on-site cardiothoracic surgery

1. Rates of procedural complications, one-year mortality, and myocardial infarction were equivalent between individuals undergoing coronary angioplasty at facilities with and without on-site cardiothoracic surgery.

2. Patients undergoing coronary angioplasty at facilities without on-site cardiothoracic surgery were at a higher risk for subsequent unplanned revascularization within one year of a surgery.

Evidence Rating Level: 2 (Good)           

Study Rundown: Recent randomized clinical trials have demonstrated that coronary angioplasty, also known as percutaneous coronary intervention (PCI), can be performed in facilities without onsite cardiothoracic (CT) surgery without adverse effects on the procedure. However, concern remains over the level of oversight required to maintain equivalent safety and efficacy standards. This study objectively compared the outcomes of PCI performed with on-site CT surgery to those without. The authors found equivalent rates of procedural complications, one-year mortality, and one-year myocardial infarction (MI). This supports the safety and long-term effectiveness of PCI performed at facilities without on-site CT surgery. Notably, a higher number of patients treated at a facility without CT surgery underwent unplanned revascularization within one year. Although initially concerning, a higher rate of high-risk stenosis and complete total occlusion (CTO) patients were treated at facilities without on-site CT surgery, which may help to explain this trend. A limitation of this study is that the patient population is from the VA healthcare delivery system, a relatively homogeneous population, which restricts the generalizability of its findings.

Click to read the study in Circulation

Relevant Reading: Percutaneous Coronary Intervention at Centers With and Without On-site Surgery: A Meta-analysis

In-Depth [retrospective cohort]: A total of 24,387 patients at 59 VA facilities underwent PCI between October 2007 and September 2010. 6,616 patients underwent PCI at facilities without on-site CT surgery and 17,771 at facilities with on-site CT surgery. Patients undergoing PCI at facilities without on-site CT surgery had lower rates of past MI, cardiac risk factors, and non-cardiac co-morbidities as well as higher rates of high-risk (Type C) stenosis and CTO. These patients (40.2%) were also more likely to undergo PCI for elective indications than those at facilities with on-site CT surgery (37.8%). No change in rates of procedural complications and in-lab death were noted across both groups (p = 0.382, p = 0.618, respectively). There was no difference one year mortality (HR 0.96, 95% CI 0.78-1.18) or MI (HR 1.11, 95% CI 0.91-1.34) between facilities with and without on-site CT surgery. This equivalence in risk for one year mortality and MI was maintained when patients were stratified on the basis for their indication for surgery: elective, ST elevation MI (STEM) and non-ST elevation (STEMI). Patients undergoing PCI at facilities without CT surgery were at increased risk of a subsequent PCI (HR 1.27, 95% CI 1.05-1.51) within one year.

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