CORRESPONDENCE: LETTER TO THE EDITOR
Reply
John A. Bittl, MD*
* Ocala Heart Institute, Munroe Regional Medical Center, 13013 Highway 475, Ocala, Florida 34480 (Email: jabittl{at}aol.com).
I am grateful to Dr. Wharton for his interest in the editorial (1) about the declining need for emergency bypass surgery for failed percutaneous coronary interventions (PCIs) at the Mayo Clinic (2).
The Mayo report (2) and the current PCI guidelines raise the issue of what constitutes adequate evidence to perform elective PCIs in community hospitals without on-site bypass surgery. Although Wharton et al. (3) showed that direct PCI is superior to fibrinolytic therapy for ST-segment elevation myocardial infarction in a broad range of hospital settings, this level of evidence is currently lacking for elective PCIs without on-site bypass surgery in the U.S. The Mayo report (2) does not prove that it is safe to perform elective PCIs without on-site surgery in Exeter, New Hampshire, or anywhere else.
The assessment of elective PCIs without on-site bypass surgery underway in some states (4) is a step in the right direction. However, choosing the right metrics is challenging. An observational matched cohort analysis constitutes a good start, but results from a single pair of closely linked hospitals within one health care delivery system are not broadly generalizable (5), and statistical tests for non-inferiority require larger comparison groups.
The motivation to perform an elective PCI without on-site bypass surgery needs clarification. "During its  28-year-history, elective PCI has never been shown to extend life or prevent death" (4). The recent proliferation of cardiac procedures in North America has not been explained by an increased prevalence of disease but has generated serious questions about the value to individual patients and society (6). Costs will increase further in the absence of safeguards to limit the inevitable expansion in the number of hospitals performing PCIs.
Finally, the term "hubris" in the editorial (1) has rankled some readers. The medical meaning, based on the classical character flaw of arrogantly flaunting natural law and suffering tragic consequences, connotes more than the dictionary definition. Even the most gifted physicians can be humbled by unforeseeable twists and turns in the response to treatment. But I digress.
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1. 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]2. 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] 3. Wharton Jr. TP, Keeley EC, Grines CL. The case for community hospital angioplasty Circulation 2005;112:3509-3534.[Free Full Text] 4. Kuntz RE, Normand S-LT. Measuring percutaneous coronary intervention quality by simple case volume Circulation 2005;112:1088-1091.[Free Full Text] 5. Ting HH, Raveendran G, Lennon RJ. A total of 1,007 percutaneous coronary interventions without onsite cardiac surgeryacute and long-term outcomes. J Am Coll Cardiol 2006;47:1713-1721.[Abstract/Free Full Text] 6. Ayanian JZ. Rising rates of cardiac procedures in the United States and Canadatoo much of a good thing?. Circulation 2006;113:333-335.[Free Full Text]
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