CORRESPONDENCE: LETTER TO THE EDITOR
Hubris Versus Evidence
Thomas P. Wharton, Jr, MD, FACC*
* Exeter Hospital, 3 Alumni Drive, Exeter, New Hampshire 03833 (Email: tom.wharton{at}comcast.net).
Yang et al. (1) from the Mayo Clinic have made a valuable contribution to the growing evidence supporting the current safety of percutaneous coronary intervention (PCI). Unfortunately, in the accompanying editorial, Bittl (2) digresses from this evidence to attribute "hubris" (arrogance resulting from excessive pride) to those who support PCI at qualified hospitals with off-site surgical backup.
Abundant recent data demonstrate the safety of PCI at qualified hospitals with off-site backup (3,4), which neither Bittl (2) nor the PCI guidelines evaluate. This steadily growing practice is supported by many thought-leaders with no perceived hubris (cited elsewhere [4]), including Singh, the senior author of the present report (5), by the guidelines of five other countries, and (tacitly) by the European Society of Cardiology (6). The only negative study cited by the guidelines is based on claims-coding Medicare data and pertains only to "non-primary/rescue" PCI at ultra-low volume sites (<50 Medicare PCIs/year) (7).
The speculation that emergency surgery after PCI would be more frequent at non-"premier" centers neglects the available data and is based on theoretical arguments. The notion that most hospitals cannot replicate the outcomes at the Mayo Clinic is unfounded. In fact, the Mayo Clinic itself supports PCI at off-site hospitals; these have had no surgical emergencies in 1,700 procedures (5). It should be recognized that satellite hospitals are inherently motivated to use the most careful case-selection (5) and generally do not perform the most complex procedures nor use higher-risk equipment. A fundamental paradox is built into the PCI guidelines themselves, in that they accept off-site backup only for primary PCI but not for nonemergent PCI despite their advocacy of higher procedural volumes to improve quality.
The assertion that the surgeon’s presence in the catheterization laboratory after a complication somehow lessens the patient’s risk compared to a direct telephone conversation between colleagues is only theoretical and ignores the reality that even on-site PCI complications may occur when the surgeon is occupied in the operating room, is in an off-site office, or is at home during off-hours.
Indeed, the very intensity of this debate over surgical backup, replete with inappropriate rhetoric, might suggest that there are other agendas being raised by this question that have little to do with the published data.
In this era when the importance of evidence-based medicine is universally recognized, proffering speculation as established conclusions while ignoring considerable data could itself be considered a form of "academic hubris." The advantages of increased access, increased procedural volumes, and the resultant shorter door-to-balloon times that are documented for PCI at nonsurgical hospitals (8) may far outweigh any proposed disadvantages of offering both primary and nonemergent PCI with off-site backup.
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1. Yang EH, Gumina RJ, Lennon RJ, Holmes Jr. DR, Rihal CS, Singh M. Emergency coronary artery bypass surgery for percutaneous coronary interventionschanges in the incidence, clinical characteristics, and indications from 1979 to 2003. J Am Coll Cardiol 2005;46:2004-2009.[Abstract/Free Full Text]2. Bittl JA. Reducing the risk of emergency bypass surgery for failed percutaneous coronary interventions J Am Coll Cardiol 2005;46:2010-2012.[Free Full Text] 3. Foster JK, Klein LW, Veledar E, et al. On-site surgical backup as a predictor of mortality among PCI patients with STEMI, NSTEMI, or No AMI (abstr) Circulation 2005;112:II737. 4. Wharton Jr TP. Nonemergent percutaneous coronary intervention with off-site surgery backupan emerging new path to access. Crit Pathways Cardiol 2005;4:98-106.[CrossRef] 5. Nainggolan L. Dramatic Decline in Emergency CABG Following Angioplasty. Available at: http://www.theheart.org. Accessed December 1, 2005.. 6. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary interventionsthe task force for percutaneous coronary interventions of the European Society of Cardiology. Eur Heart J 2005;26:804-847.[Free Full Text] 7. Wennberg DE, Lucas FL, Siewers AE, Kellett MA, Malenka DJ. Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery JAMA 2004;292:1961-1968.[Abstract/Free Full Text] 8. Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction JAMA 2005;294:803-812.[Abstract/Free Full Text]
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