Nonemergent percutaneous coronary intervention with off-site surgery backup: an emerging new path to access

Nonemergent primary coronary intervention (PCI) at hospitals with off-site cardiac surgery backup is currently given a "Class III" indication by the American College of Cardiology/American Heart Association (ACC/AHA) PCI Guidelines on the basis of "consensus opinion of experts," not on trials or studies (Level of Evidence C). Yet the evidence is mounting, both in the US and abroad, that urgent and elective PCI can be performed safely and effectively at qualified nonsurgical hospitals in controlled circumstances. As the need for PCI grows, especially in the large population with high-risk acute coronary syndromes (ACS), the lack of local access to and underutilization of timely PCI can demonstrably result in inferior outcomes. The multiple clinical, performance, and economic advantages of the broader availability of PCI are discussed extensively in this paper. Removing the requirement for on-site cardiac surgery from nonemergent PCI can also increase procedural volumes at the growing numbers of primary angioplasty programs at hospitals with off-site backup, while also reducing the pressure to build new low-volume cardiac surgery programs merely to support PCI programs. The many US hospitals that are already participating in this growing movement to provide PCI with off-site backup are encouraged to enroll in the ACC National Cardiovascular Data Registry to assure that this strategy is fairly assessed and monitored on a national level. We anticipate that state regulations and national guidelines will continue to evolve and keep pace with this growing movement and with the already-evolving guidelines from abroad.