Nonprimary PCI at hospitals without cardiac surgery on-site: Consistent outcomes for all?

Am Heart J. 2018 Mar:197:18-26. doi: 10.1016/j.ahj.2017.10.023. Epub 2017 Nov 6.

Abstract

Background: The CPORT-E trial showed the noninferiority of nonprimary percutaneous coronary intervention (PCI) at hospitals without cardiac surgery on-site (SoS) compared with hospitals with SoS for 6-week mortality and 9-month major adverse cardiac events (MACE). However, target vessel revascularization (TVR) was increased at non-SoS hospitals. Therefore, we aimed to determine the consistency of the CPORT-E trial findings across the spectrum of enrolled patients.

Methods: Post hoc subgroup analyses of 6-week mortality and 9-month MACE, defined as the composite of death, Q-wave myocardial infarction, or TVR, were performed. Patients with and without 9-month TVR and rates of related outcomes were compared.

Results: There was no interaction between SoS status and clinically relevant subgroups for 6-week mortality or 9-month MACE (P for any interaction=.421 and .062, respectively). In addition to increased 9-month rates of TVR and diagnostic catheterization at hospitals without SoS, non-TVR was also increased (2.7% vs 1.9%, P=.002); there was no difference in myocardial infarction-driven TVR, non-TVR, or diagnostic catheterization. Predictors of 9-month TVR included intra-aortic balloon pump use, any index PCI complication, and 3-vessel PCI, whereas predictors of freedom from TVR included SoS, discharge on a P2Y12 inhibitor, and stent implantation.

Conclusions: The noninferiority of nonprimary PCI at non-SoS hospitals was consistent across clinically relevant subgroups. Elective PCI at an SoS hospital conferred a TVR benefit which may be related to a lower rate of referral for diagnostic catheterization for reasons other than myocardial infarction.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Cardiac Catheterization* / methods
  • Cardiac Catheterization* / statistics & numerical data
  • Cardiac Surgical Procedures* / methods
  • Cardiac Surgical Procedures* / statistics & numerical data
  • Coronary Artery Disease* / complications
  • Coronary Artery Disease* / diagnosis
  • Coronary Vessels* / diagnostic imaging
  • Coronary Vessels* / surgery
  • Elective Surgical Procedures / methods
  • Elective Surgical Procedures / statistics & numerical data
  • Female
  • Hospitals* / classification
  • Hospitals* / standards
  • Hospitals* / statistics & numerical data
  • Humans
  • Intra-Aortic Balloon Pumping / statistics & numerical data
  • Male
  • Middle Aged
  • Mortality
  • Myocardial Infarction* / diagnosis
  • Myocardial Infarction* / etiology
  • Myocardial Infarction* / mortality
  • Myocardial Infarction* / therapy
  • Myocardial Revascularization* / adverse effects
  • Myocardial Revascularization* / methods
  • Myocardial Revascularization* / statistics & numerical data
  • Outcome Assessment, Health Care
  • Severity of Illness Index