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The study by Grines et al. (1), which appeared recently in JACC,evaluated the safety and benefits of transfer of a high-risk patient suffering an acute myocardial infarction (AMI) to a regional interventional center for immediate angioplasty. The investigators concluded: “This trial demonstrated that patients with high-risk AMI at hospitals without percutaneous transluminal coronary angioplasty (PTCA) capabilities might have an improved outcome if transferred for emergency PTCA rather than being treated with thrombolytic therapy.” In the editorial (2)that accompanied the study, Cannon and Baim stated “it appears that there may be benefit in prompt and efficient transfer of patients from a community hospital that does not offer primary percutaneous coronary intervention (PCI) to a nearby one that does.” This begs an important question concerning the safety of transferring a patient with AMI. The investigators note that their study is underpowered to answer the question. The difficulty in recruitment of subjects and premature closure of the study suggest that the study group is a highly selective set of patients. Before the availability of immediate angioplasty it was believed that transfer was inappropriate for the AMI patient. This patient is at the greatest danger for extension of the infarction, serious arrhythmia, and congestive heart failure in the first hours after the infarction. Monitoring for and managing these complications are very difficult when the patient is transferring from one hospital to another.
Cannon and Baim (2)noted that success for PCI is related to the skill and experience of the interventionalist. Many hospitals with catherization laboratories have the availability of high-volume interventionalists. However, the majority of these physicians are unwilling to perform interventions at hospitals that do not routinely perform angioplasty. Because it is not a routine procedure, PTCA performed under emergency circumstances would represent a higher risk for the patient. As a solution to this problem, Cannon and Baim suggested a network of cardiac centers offering PCI around the clock.
Could immediate angioplasty be safely and effectively applied at the initial hospital? I believe that it is safer to bring the intervention to the patient rather than the patient to the interventionalist. For most patients with an AMI, this could be accomplished by expanding PTCA to any hospital with a catheterization laboratory. The use of routine PTCA at hospitals without back-up cardiovascular surgery would significantly extend PCI to the at-risk population and increase the availability of skilled interventionalists to provide the service.
- American College of Cardiology Foundation
- Grines C.L.,
- Westerhausen D.R. Jr.,
- Grines L.L.,
- et al.
- Cannon C.P.,
- Baim D.S.