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February
9, 2009
Study Proves That Practice Makes Perfect in PCI for Heart
Attack
Patients treated by experienced doctors in experienced
hospitals most likely to survive
When it comes to treating heart attacks, experience matters.
New research shows that patients have a much better chance
of survival when both their hospital and their physician have
a strong track record in treating heart attack with angioplasty
and stenting.
The new research, published in the February 17, 2009, issue
of the Journal of the American College of Cardiology (JACC),
found that the risk of dying was cut by nearly half when interventional
therapy was performed by an experienced physician in a hospital
with plenty of practice in providing the rapid, intense attention
that heart attack patients need.
“Even in this day of advanced technology and advanced
training, physician and hospital volume still matter, and
they matter most in high-risk patients,” said V.S. Srinivas,
M.B.B.S., an associate professor of clinical medicine at Montefiore
Medical Center in New York City. “In coronary interventions,
nothing is higher risk than a heart attack.”
The study focused on the effect of physician and hospital
experience on patients who were treated with primary percutaneous
coronary intervention (PCI). In this procedure, a heart attack
is treated by inflating a tiny balloon that clears away a
blood clot that is cutting off the blood supply to the heart.
Usually the interventional cardiologist also places an expandable
metal mesh tube, or stent, inside the artery to prop it open.
Today it is widely acknowledged that primary PCI is the safest
and most effective treatment for heart attack—provided
it can be accomplished quickly. As a result, many communities
are establishing primary PCI programs to provide rapid, local
care. This trend is raising questions, however. For example,
in large cities that already have a primary PCI program, are
more programs better for patients, if it means that each hospital
and physician performs fewer cases? In smaller communities,
can the benefit of having an experienced interventional cardiologist
on staff overcome the inexperience of a fledgling primary
PCI program that treats only a small number of heart attack
patients each year?
The new research provides unique insight into such questions.
Although previous studies have looked separately at the influence
of physician and hospital experience on survival after primary
PCI, this is the first study to evaluate the combined effect
of these two factors since stent placement came into common
use.
The interaction between physician and hospital experience
is critically important, particularly in the case of an unforeseen
complication, said James Jollis, M.D., an associate professor
of medicine at Duke University in Durham, NC. Dr. Jollis did
not participate in the study but was invited to write an editorial
in the same issue of JACC.
“In most hospitals with angioplasty facilities, highly
trained teams are on call 24 hours a day, 7 days a week,”
Dr. Jollis said. “These teams are composed of interventional
cardiologists, nurses and technicians who work in a coordinated
fashion to rapidly open blocked arteries. When rare but severe
complications arise, a team experienced in its recognition
and treatment may be the difference between life and death.”
For the study, researchers analyzed data from the New York
State PCI registry, a database that all New York hospitals
are required to participate in. The data came from 7,321 patients
treated with primary PCI by 266 physicians at 41 medical centers
between 2000 and 2002.
Hospitals performing an average of more than 50 primary PCIs
each year were defined as high-volume centers, while those
performing 50 cases or fewer each year were defined as low-volume
centers. Similarly high-volume physicians were defined as
those performing more than 10 primary PCIs each year, while
low-volume physicians were defined as those performing 10
or fewer cases each year.
Patients who were treated at low-volume hospitals and by
low-volume physicians tended to be older and sicker, and to
have other characteristics that placed them at higher risk.
But even when these factors were taken into account, being
treated by an experienced physician in an experienced hospital
was clearly associated with better survival after primary
PCI.
Overall, in high-volume hospitals, the risk of dying in the
hospital was 42 percent lower when compared to low-volume
hospitals. Among patients treated by high-volume physicians,
the risk of in-hospital death was 34 percent lower overall
when compared to patients treated by low-volume physicians.
Researchers also examined the relationship between hospital
volume and physician volume. In high-volume hospitals, the
risk of in-hospital death was significantly lower among high-volume
physicians when compared to low-volume physicians (3.8 percent
vs. 6.5 percent, odds ratio: 0.58). In low-volume hospitals,
there was a trend showing a lower risk of death among patients
treated by high-volume physicians, as compared with low-volume
physicians (4.8 percent vs. 8.4 percent, odds ratio: 1.44),
but the difference was not statistically significant, due
to the small numbers cases in this category.
These findings suggest that even in the most experienced
hospitals, it is important that primary PCI be performed by
experienced physicians, Dr. Srinivas said. As for low-volume
community hospitals, the study’s findings offer indirect
guidance.
“Even in high-volume hospitals, higher-volume physicians
did better than lower-volume physicians. We would expect the
same effect in low-volume hospitals,” Dr. Srinivas said.
“Therefore, it’s all the more important that community
hospitals that are developing primary PCI programs have experienced
physicians.”
Dr. Jollis advised outlying communities to also consider
the alternatives to developing primary PCI programs, including
establishing ambulance diversion plans to immediately take
heart attack patients to the closest angioplasty hospital,
if the travel distance is not too great. Use of clot-busting
drugs is another alternative.
“All hospitals, including those lacking angioplasty
teams, are capable of rapidly opening coronary arteries using
clot-dissolving medicines. Thus, the closest hospital is the
safest and best place to proceed,” he said.
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The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 36,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
the American College of Cardiology as a service to physicians,
the media, the public and other interested parties. However,
statements or opinions expressed in these reports reflect
the view of the author(s) and do not represent official policy
of the ACC unless stated so.
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