Home > Interventional Cardiology, Journal Club > Journal Club 20 March 2013

Journal Club 20 March 2013

Paper

Nonemergency PCI at Hospitals with or without On-Site Cardiac Surgery

Presenter

PJS

Summary

Background

Emergency surgery has become a rare event after percutaneous coronary intervention
(PCI). Whether having cardiac-surgery services available on-site is essential for ensuring
the best possible outcomes during and after PCI remains uncertain.

Methods

We enrolled patients with indications for nonemergency PCI who presented at hospitals
in Massachusetts without on-site cardiac surgery and randomly assigned these
patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that
had cardiac surgery services available. A total of 10 hospitals without on-site cardiac
surgery and 7 with on-site cardiac surgery participated. The coprimary end points
were the rates of major adverse cardiac events — a composite of death, myocardial
infarction, repeat revascularization, or stroke — at 30 days (safety end point) and
at 12 months (effectiveness end point). The primary end points were analyzed according
to the intention-to-treat principle and were tested with the use of multiplicative
noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness).

Results

A total of 3691 patients were randomly assigned to undergo PCI at a hospital without
on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery
(917 patients). The rates of major adverse cardiac events were 9.5% in hospitals
without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at
30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for
noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98;
95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of
death, myocardial infarction, repeat revascularization, and stroke (the components
of the primary end point) did not differ significantly between the groups at either
time point.

Conclusions

Nonemergency PCI procedures performed at hospitals in Massachusetts without
on-site surgical services were noninferior to procedures performed at hospitals
with on-site surgical services with respect to the 30-day and 1-year rates of clinical
events.

Supplementary material

Important supplementary material is here.

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