Primary Angioplasty in Community Hospitals without On-Site Cardiac Surgery

Abstract

It is now firmly established that primary angioplasty is superior to fibrinolytic therapy for the treatment of acute myocardial infarction (AMI) in lytic-eligible patients (1–3) when the procedure is performed at qualified centers. Compared with fibrinolytic therapy, primary angioplasty has been demonstrated to reduce rates of death, stroke, recurrent ischemia, and reinfarction (1). In the current era of newer generation stents and glycoprotein (GP) IIb/IIIa platelet inhibitors, the advantage of primary angioplasty over fibrinolytic therapy is even more clear. One recent randomized trial of 140 patients showed that the combined incidence of death, reinfarction, and stroke at 6 mo was almost three times greater in patients treated with fibrinolytics than with coronary stenting and abciximab (8.5% vs 23.2%, p = 0.02; relative risk, 0.34; 95% confidence interval, 0.13– 0.88)(2). Recently pooled “real world” outcomes of 9906 patients with AMI in two current German registries demonstrated that primary angioplasty was independently associated with lower hospital mortality compared with fibrinolytic therapy in all subgroups, whether high or low risk: 6.4% vs 11.3%, respectively (odds ratio [OR] 0.54, 95% confidence interval [C I] 0.43–0.67) (3). Other reports indicate that patients with low-risk AMI treated with primary angioplasty have very low rates of in-hospital mortality (1%) (4,5), fewer reinfarctions, and decreased hospital costs as a result of safe early discharge (3–4 d) and avoidance of both intensive care and in-hospital exercise testing (4). The benefits of primary angioplasty over fibrinolytic therapy have been shown to be sustained over 5 yr (6). Moreover, early knowledge of the coronary anatomy gained from the initial angiogram enables greater diagnostic precision and more informed therapeutic decisions and enhances risk stratification (4).