CLINICAL STUDIES
Primary angioplasty for the treatment of acute myocardial infarction: experience at two community hospitals without cardiac surgery
Thomas P. Wharton, Jr., MD, FACC*  ,
Nancy Sinclair McNamara, RN, BSN*,
Frank A. Fedele, MD, FACC* ,
Mark I. Jacobs, MD, FACC* ,
Alan R. Gladstone, MD* and
Erik J. Funk, MD, FACC*
* Division of Cardiology, Exeter Hospital, Exeter, New Hampshire, USA
Division of Cardiology, Portsmouth Regional Hospital, Portsmouth, New Hampshire, USA
Manuscript received July 17, 1998;
revised manuscript received November 23, 1998,
accepted December 24, 1998.
Reprint requests and correspondence: Dr. Thomas P. Wharton, Jr, The Perry Medical Services Building, Suite 206, 3 Alumni Drive, Exeter, New Hampshire 03833
twharton{at}nh.ultranet.com
OBJECTIVES
We sought to establish the safety and efficacy of primary percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction (AMI) at two community hospitals without on-site cardiac surgery.
BACKGROUND
Though randomized studies indicate that primary angioplasty in AMI may result in superior outcomes compared with fibrinolytic therapy, the performance of primary angioplasty at hospitals without cardiac surgery is debated.
METHODS
Three experienced operators performed 506 consecutive immediate coronary angiograms with primary angioplasty when appropriate in patients with suspected AMI at two community hospitals without cardiac surgery, following established rigorous program criteria.
RESULTS
Clinical high risk predictors (Killip class 3 or 4, age  75 years, anterior AMI, out-of-hospital ventricular fibrillation) and/or angiographic high risk predictors (left main or three-vessel disease or ejection fraction <45%) were present in 69.6%. Angioplasty was performed in 66.2%, with a median time from emergency department presentation to first angiogram of 94 min and a procedural success rate of 94.3%. The in-hospital mortality for the entire study population was 5.3%. Of those without initial cardiogenic shock, the in-hospital mortality was 3.0%. Of 300 patients who were discharged after primary angioplasty, only four died within the first 6 months, with 97.7% follow-up. No patient died or needed emergent aortocoronary bypass surgery because of new myocardial jeopardy caused by a complication of the cardiac catheterization or angioplasty procedure.
CONCLUSIONS
Immediate coronary angiography with primary angioplasty when appropriate in patients with AMI can be performed safely and effectively in community hospitals without on-site cardiac surgery when rigorous program criteria are established.
|
Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | ECG | = electrocardiogram, electrocardiographic | | ED | = emergency department | | IABP | = intra-aortic balloon pump | | IRA | = infarct-related artery | | TIMI | = Thrombolysis in Myocardial Infarction |
|
This article has been cited by other articles:
|
|
|
|
 
M. Singh, B. J. Gersh, R. J. Lennon, H. H. Ting, D. R. Holmes Jr, B. J. Doyle, and C. S. Rihal
Outcomes of a System-Wide Protocol for Elective and Nonelective Coronary Angioplasty at Sites Without On-site Surgery: The Mayo Clinic Experience
Mayo Clin. Proc.,
June 1, 2009;
84(6):
501 - 508.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. W. Stone
Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part I: Primary Percutaneous Coronary Intervention
Circulation,
July 29, 2008;
118(5):
538 - 551.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. K. Jacobs, E. M. Antman, D. P. Faxon, T. Gregory, and P. Solis
Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Executive Summary
Circulation,
July 10, 2007;
116(2):
217 - 230.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Ellrodt, L. B. Sadwin, T. Aversano, B. Brodie, P. K. O'Brien, R. Gray, L. F. Hiratzka, and D. Larson
Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: The Non-Percutaneous Coronary Intervention-Capable (ST-Elevation Myocardial Infarction Referral) Hospital Perspective
Circulation,
July 10, 2007;
116(2):
e49 - e54.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. A de Belder
On-site surgical standby for percutaneous coronary intervention: a thing of the past?
Heart,
March 1, 2007;
93(3):
281 - 283.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Carlsson, S. N James, E. Stahle, S. Hofer, and B. Lagerqvist
Outcome of percutaneous coronary intervention in hospitals with and without on-site cardiac surgery standby
Heart,
March 1, 2007;
93(3):
335 - 338.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Singh, E. Yang, R. Gumina, R. J. Lennon, C. S. Rihal, and D. R. Holmes Jr
Reply
J. Am. Coll. Cardiol.,
July 18, 2006;
48(2):
416 - 417.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. H. Ting, G. Raveendran, R. J. Lennon, K. H. Long, M. Singh, D. L. Wood, B. J. Gersh, C. S. Rihal, and D. R. Holmes Jr
A Total of 1,007 Percutaneous Coronary Interventions Without Onsite Cardiac Surgery: Acute and Long-Term Outcomes
J. Am. Coll. Cardiol.,
April 18, 2006;
47(8):
1713 - 1721.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Moscucci and K. A. Eagle
Door-to-Balloon Time in Primary Percutaneous Coronary Intervention: Is the 90-Minute Gold Standard an Unreachable Chimera?
Circulation,
February 28, 2006;
113(8):
1048 - 1050.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. P. Wharton Jr, E. C. Keeley, C. L. Grines, T. P. Wharton Jr, E. C. Keeley, and C. L. Grines
The Case for Community Hospital Angioplasty
Circulation,
November 29, 2005;
112(22):
3509 - 3534.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. E. Wennberg, F. L. Lucas, A. E. Siewers, M. A. Kellett, and D. J. Malenka
Outcomes of Percutaneous Coronary Interventions Performed at Centers Without and With Onsite Coronary Artery Bypass Graft Surgery
JAMA,
October 27, 2004;
292(16):
1961 - 1968.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. D. Weaver
Is Onsite Surgery Backup Necessary for Percutaneous Coronary Interventions?
JAMA,
October 27, 2004;
292(16):
2014 - 2016.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. C. Keeley and C. L. Grines
Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way?
Ann Intern Med,
August 17, 2004;
141(4):
298 - 304.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. P. Wharton Jr, L. L. Grines, M. A. Turco, J. D. Johnston, J. Souther, D. C. Lew, A. Z. Shaikh, W. Bilnoski, S. K. Singhi, A. E. Atay, et al.
Primary Angioplasty in Acute Myocardial Infarction at Hospitals With No Surgery On-Site (the PAMI-No SOS study) versus transfer to surgical centers for primary angioplasty
J. Am. Coll. Cardiol.,
June 2, 2004;
43(11):
1943 - 1950.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. J. Ryan
Primary Percutaneous Coronary Intervention Without Nearby Surgical Capability: A Reassuring Response From Rural America
Mayo Clin. Proc.,
June 1, 2004;
79(6):
731 - 732.
[PDF]
|
|
|
|
|
|
|
M. Singh, H. H. Ting, B. J. Gersh, P. B. Berger, R. J. Lennon, D. R. Holmes Jr, and K. N. Garratt
Percutaneous Coronary Intervention for ST-Segment and Non-ST-Segment Elevation Myocardial Infarction at Hospitals With and Without On-site Cardiac Surgical Capability
Mayo Clin. Proc.,
June 1, 2004;
79(6):
738 - 744.
[Abstract]
[PDF]
|
|
|
|
|
|
|
G. J. Dehmer and D. S. Gantt
Coronary intervention at hospitals without on-site cardiac surgery: are we pushing the envelope too far?
J. Am. Coll. Cardiol.,
February 4, 2004;
43(3):
343 - 345.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Singh, H. H. Ting, P. B. Berger, K. N. Garratt, D. R. Holmes Jr, and B. J. Gersh
Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal
J. Am. Coll. Cardiol.,
June 19, 2002;
39(12):
1881 - 1889.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. L. Grines, D. R. Westerhausen Jr, L. L. Grines, J. T. Hanlon, T. L. Logemann, M. Niemela, W. D. Weaver, M. Graham, J. Boura, W. W. O'Neill, et al.
A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: The air primary angioplasty in myocardial infarction study
J. Am. Coll. Cardiol.,
June 5, 2002;
39(11):
1713 - 1719.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. P. Cannon
Primary Percutaneous Coronary Intervention for All?
JAMA,
April 17, 2002;
287(15):
1987 - 1989.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. M. Bashore, E. R. Bates, P. B. Berger, D. A. Clark, J. T. Cusma, G. J. Dehmer, M. J. Kern, W. K. Laskey, M. P. O'Laughlin, S. Oesterle, et al.
American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents endorsed by the American Heart Association and the Diagnostic and Interventional Catheterization Committee of the Council on Clinical Cardiology of the AHA
J. Am. Coll. Cardiol.,
June 15, 2001;
37(8):
2170 - 2214.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al.
ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions
J. Am. Coll. Cardiol.,
June 15, 2001;
37(8):
2239 - 2239.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L.K. Michalis, C.S. Stroumbis, K. Pappas, E. Sourla, D. Niokou, J.A. Goudevenos, C. Siogas, and D.A. Sideris
Treatment of Refractory Unstable angina in geographically isolated areas without Cardiac Surgery. Invasive versus conservative strategy (TRUCS Study)
Eur. Heart J.,
December 1, 2000;
21(23):
1954 - 1959.
[Abstract]
[PDF]
|
|
|
|
|
|
|
D. J. Kereiakes, S. C. Smith, A. K. Jacobs, M. J. Kern, and D. P. Faxon
Angioplasty for acute myocardial infarction in community hospital without surgical back-up: Response to Wharton and Angelini publications "should guidelines be changed?: Not whether but when"
J. Am. Coll. Cardiol.,
July 1, 2000;
36(1):
299 - 300.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. P. Wharton Jr., N. Sinclair McNamara, F. A. Fedele, M. I. Jacobs, A. R. Gladstone, and E. J. Funk
Reply
J. Am. Coll. Cardiol.,
July 1, 2000;
36(1):
301 - 303.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Primary Angioplasty at Community Hospitals
Journal Watch Cardiology,
July 9, 1999;
1999(709):
5 - 5.
[Full Text]
|
|
|
|
|
|
|
PTCA for MI Without Cardiac Surgery Backup
Journal Watch (General),
May 4, 1999;
1999(504):
1 - 1.
[Full Text]
|
|
|
|
