PCI Outcomes at Centers With and Without On-Site Cardiac Surgery

As more percutaneous coronary interventions (PCIs) are taking place at centers without on-site cardiac surgery facilities, mortality data suggest that this method of PCI may be safe. Researchers published their findings in JAMA Cardiology.

Charanjit S. Rihal, MD, of the Department of Cardiovascular Diseases at the Mayo Clinic in Rochester, Minnesota, and colleagues, used the National Inpatient Sample (NIS) database to analyze outcomes and trends in inpatient PCI at centers without on-site cardiac surgery.

Nearly 7 million inpatient PCI records were analyzed from 2003 to 2012; 66.2%% of patients were men (mean age: 64.5 years). The researchers found that 5.7% of PCI procedures were performed at hospitals without on-site cardiac surgery vs 94.3% performed at hospitals with on-site cardiac surgery facilities. Those centers with on-site cardiac surgery performed 34.4% of PCIs for ST-elevation myocardial infarction (STEMI), but performed a significantly lower proportion of elective PCI (24%).

Unadjusted in-hospital mortality was lower at PCI centers with on-site cardiac surgery (1.4% vs 1.9%; odds ratio [OR]: 0.74; 95% CI, 0.72-0.75). After multivariate adjustment, no significant in-hospital mortality difference was found between centers with and without on-site cardiac surgery (OR: 1.01; 95% CI, 0.98-1.03; P =.62). Rates of in-hospital transient ischemic attack and stroke were the same in both types of centers (0.8%; adjusted OR: 1.03; 95% CI, 0.99-1.07; P =.21).

While vascular injuries were more common at on-site cardiac surgery sites (1.1% vs 0.9%; adjusted OR: 1.31; 95% CI, 1.26-1.35; P =.001), no difference was noted in the frequency of incidence of hemorrhage requiring blood transfusion (0.7% vs 0.8%; adjusted OR: 1.02; 95% CI, 0.98-1.06; P =.28). At centers with on-site cardiac surgery, more patients were discharged home (91.2% vs 87.1%) vs discharged to a short-term hospital or skilled care facility (0.5% vs 3.6% and 3.6% vs 4.4%, respectively; P <.001).

While the number of PCIs performed annually declined from 776,000 to 535,000 between 2003 and 2012 (P <.001), the proportion of PCIs being performed at centers without on-site cardiac surgery increased significantly: 1.8% in 2003 to 12.7% in 2012 (P <.001 for trend). 

“This large study shows that it is safe to perform PCI at hospitals without on-site cardiac surgery for STEMI and NSTE-ACS [non-ST-elevation acute coronary syndromes],” the researchers wrote. “These results have important clinical and policy implications because they are applicable to the general US population requiring acute interventional care.”

“There was no significant difference in the adjusted in-hospital mortality after PCI for ACSs and elective procedures requiring inpatient hospitalization between centers with and without on-site CS [cardiac surgery],” the researchers concluded. “These data provide support for further thoughtful and careful expansion of centers without on-site CS.”

Study Limitations

• PCI data performed on outpatients were not available because the NIS only records inpatient hospitalizations.
• A possibility exists that the in-hospital mortality rate at centers without on-site cardiac surgery may have been underestimated since sicker patients may have been transferred out and therefore recorded as alive during that particular hospitalization.
• There is a lack of data on door-to-balloon time in patients with STEMI, procedural success, recurrent ischemia, target vessel revascularization, or long-term follow-up, since the NIS only includes in-hospital outcomes.

Disclosures: Dr Fonarow is the associate editor for Healh Care Quality and Guidelines, JAMA Cardiology, but was not involved in the editorial review or decision to accept this manuscript for publication. Dr Bhatt is a member of the advisory boards at Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences, among others. For Dr Bhatt’s complete disclosures, please visit jamacardiology.com.

Reference

Goel K, Gupta T, Kolte D, et al. Outcomes and temporal trends of inpatient percutaneous coronary intervention at centers with and without on-site cardiac surgery in the United States [Published online November 23, 2016]. JAMA Cardiol. doi: 10.1001/jamacardio.2016.4188.