A majority of heart specialists say it's safe to clear blocked coronary arteries with angioplasty at hospitals that lack backup heart surgery, according to an exclusive survey by theheart.org and U.S. News & World Report—so long, that is, as the hospitals meet key criteria for proficiency. Their responses echo a study released last month at an American Heart Association meeting concluding that patients who had elective angioplasty at hospitals without a heart surgeon on tap fared as well as patients treated at hospitals with heart surgery suites.
The AHA study, led by Johns Hopkins cardiologist Thomas Aversano, found that death rates for nonemergency angioplasty procedures were just under 1 percent both at hospitals with and without backup heart surgery. The findings prompted U.S. News and theheart.org, a leading online source of cardiology news and views, to explore how heart specialists nationwide view the issue.
The news organizations together surveyed more than 17,000 cardiologists who are recognized as Top Doctors by U.S. News and Castle Connolly Medical Ltd. or who subscribe to theheart.org. About 5,200 cardiologists are board-certified as interventional cardiologists, who perform angioplasties and other heart procedures through thin tubes threaded through a blood vessel, according to the Society for Cardiovascular Angiography and Interventions. A total of 350 cardiologists responded to the 10-question survey; two-thirds responded that angioplasty can be done safely and effectively without surgical backup. (For a breakdown of the questions and responses, see Behind the U.S. News Doctors Survey on Angioplasty.)
Of those who rejected the idea of permitting hospitals without cardiac surgery to do nonemergency angioplasties, most cited more than one reason—66 percent because of safety concerns, more than 60 percent because angioplasty programs that spring up at dozens of smaller hospitals will prompt doctors to send patients for procedures "to keep their institutional volume up."
The suspicion that the real issue was money was clear. Of all the cardiologists who responded to the survey, only a third said they believe the goal is to expand access to areas where angioplasty isn't available. Nearly half said it's about the bottom line.
"I believe that much of this is fueled by greed, not need," says University of Michigan cardiologist Kim Eagle, especially with fewer patients seeking angioplasty because cholesterol-lowering drugs and other preventive therapies have reduced the need. "By making angioplasty available at every hospital in the nation, we will not only drive up costs, we will reduce quality due to exposing patients to unnecessary, risky procedures."
Virtually all of the cardiologists who responded to the survey said it would be a mistake to take angioplasty's safety for granted. For instance, 96 percent said each hospital's angioplasty performance should be tracked and the results publicly reported. The cardiologists were also nearly unanimous in their view that hospitals with poor results should be required to improve, or lose their state certification to perform angioplasty.
"I think that's exactly right," says Aversano. "It validates what New Jersey and New York have been doing for years—monitoring and reporting outcomes for angioplasty and bypass surgery. It helps to rein in the cowboys."
His study involved more than 18,000 elective angioplasty patients who were assigned at random to centers with and without on-site heart surgery. Three-fourths of the patients were treated at centers without heart surgery to make sure each center treated enough patients to provide high quality care. All of the hospitals performed at least 200 angioplasties a year. (Current American Heart Association-American College of Cardiology guidelines recommend that hospitals performing angioplasties do more than 400 cases a year.) With few exceptions, the patients were typical of those who generally get angioplasty.
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.