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Primary coronary angioplasty in hospitals with and without surgery backup. MITI project investigators
W D Weaver1, L Parsons, N Every
1Division of Cardiology, University of Washington, Seattle, USA.
Insights
Primary angioplasty in hospitals without on-site surgery is safe and effective for acute myocardial infarction patients. Outcomes were similar to hospitals with surgery, indicating appropriate patient selection is key.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Acute myocardial infarction (AMI) management often involves primary percutaneous coronary intervention (PCI).
- The role of hospitals without on-site surgical backup for primary PCI is debated.
- The Myocardial Infarction Triage and Intervention (MITI) project provides data on AMI patient management.
Purpose of the Study:
- To compare outcomes of primary PCI in hospitals with and without on-site surgical capability.
- To identify factors influencing survival in patients undergoing primary PCI.
Main Methods:
- Observational study of 1,062 AMI patients treated with primary PCI.
- Comparison of outcomes between patients treated in hospitals with (n=592) and without (n=470) on-site surgery.
- Multivariable analysis to determine factors affecting survival.
Main Results:
- No significant difference in procedural success or mortality rates between the two hospital types.
- Discharge mortality was 7% in both groups.
- Factors influencing survival included age, prior myocardial infarction, and anterior ST-elevation MI, not on-site surgical availability.
Conclusions:
- Primary PCI can be safely performed in centers without on-site surgery.
- Appropriate patient selection, skilled operators, and transfer protocols are crucial for success.
- On-site surgical backup is not a prerequisite for acceptable outcomes in primary PCI.
Abstract:
In the Myocardial Infarction Triage and Intervention (MITI) project, a registry of acute myocardial infarction, 1,062 patients were treated for acute myocardial infarction using primary coronary angioplasty. Of those, 470 (44%) received the procedure in hospitals without coronary surgery capability on-site. These patients were compared to 592 (56%) other patients treated in hospitals with on-site surgery. Most baseline characteristics of patients treated by primary angioplasty were similar in the two types of centers. ST segment elevation was present in 76% of patients; time from admission to angiography averaged 100 +/- 71 minutes (median 77 minutes). There was no difference in procedural success rate nor initial and long-term mortality rates in patients treated by primary angioplasty in the two types of hospitals. The mortality rate at discharge for patients treated by primary coronary angioplasty was 7% in both types of hospitals. In the subset of patients with ST segment elevation and no evidence of shock and no prior bypass surgery, 30 day mortality rates were 7% and 8% (p = 0.46), respectively. In a multivariable analysis of those factors influencing survival, age, a history of prior myocardial infarction, and anterior ST elevation but not the availability of on-site surgical backup, was associated with outcome. In summary, this observational study suggests that with appropriate patient selection, trained operators, and a provision for hospital transfer, primary coronary angioplasty can be accomplished in centers without on-site surgery with acceptable outcomes.