Cardiologists Say Patients Can Safely Get Angioplasty Without Surgeons on Site

"Surgical backup" isn't essential, but hospitals' outcomes should be tracked, made public.


The study lasted nine months, Aversano says, and full results will be released in March. At six weeks, the death rates were virtually identical for the two groups.

Opening up more hospitals to do angioplasty would likely push up the numbers for an already high-volume procedure. Each year, more than one million people undergo angioplasty, according to the AHA. During angioplasty, a doctor slips a thin tube into the femoral artery in the groin and guides it up to the heart and into one of the coronary arteries on the surface that supply blood to the organ itself. A tiny balloon is inserted into the blockage and inflated to restore blood flow. In most cases, a tiny mesh cylinder, a stent, is used to prop the artery open.

Relatively few angioplasties are elective procedures. Angioplasty's greatest benefit is in an emergency, to restore blood flow immediately after a heart attack. If done within 24 hours, it can cut the death rate by about one-third. About 70 percent of angioplasties are done on patients having a heart attack or other potentially life-threatening cardiovascular events, according to a report by a team headed by Paul Chan of Saint Luke's Mid America Heart Institute, Kansas City, in July in the Journal of the American Medical Association.

Little evidence shows that elective angioplasties prevent future heart attacks or prolong life. An analysis released by Judith Hochman of NYU Langone Medical Center and her team in the Archives of Internal Medicine last month found that doing angioplasty more than 24 hours after a heart attack offered no greater benefit than medication in 2,000 patients followed for three years. The two groups had essentially the same rates of hospitalizations, second heart attacks, and deaths.

What elective angioplasty can accomplish, however, is to relieve chest pain without major bypass surgery. That has skyrocketed its popularity over the last three decades. Safety concerns about 30 years ago about its rapid spread prompted many states to prohibit the procedure in hospitals that cannot provide emergency bypass surgery. About 30 states allow hospitals to use angioplasty to treat heart attacks without surgical backup, while 20 states allow such hospitals to provide elective angioplasty procedures. In states that still prohibit emergency angioplasty without on-site heart surgery, a patient suffering a heart attack may have to travel farther for life-saving treatment, especially in rural areas, doctors say.

Treatment guidelines released early last month by three professional heart groups reflect a new consensus that elective angioplasty is no longer too risky to be performed without surgical backup, says Ralph Brindis of Kaiser Permanente Oakland Medical Center, who's serving as an adviser to California regulators, who are considering approval of elective angioplasty without backup. The new guidelines fall short of full endorsement of the practice, but rule that it is reasonable. Non-backup angioplasty, says Brindis, "may be OK."

Advocates of expanding access to angioplasty to smaller hospitals without heart surgery suites say they must offer elective angioplasties if they're also going to treat heart attack patients. Only then, they say, will smaller hospitals generate sufficient revenue and cases to attract top-notch cardiologists and enable them to sustain their proficiency. Few cardiologists are eager to live in a small town, remain on-call to treat heart attacks, and commute to another hospital an hour away to perform elective procedures, says interventional cardiologist Shazib Khawaja of Tanner Medical Center in Carrollton, Ga., a 180-bed hospital about an hour from Atlanta that provides angioplasty but not heart surgery. "If you didn't have an elective program, you wouldn't be able to hire an [interventional cardiologist] for a 24-7 program," he says.

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