Heart experts at Johns Hopkins have evidence that
life-saving coronary angioplasty at community hospitals is
safer when physicians and hospital staff have more
experience with the procedure.
In a report presented Nov. 12 at the American Heart
Association's annual Scientific Sessions in New Orleans,
researchers found that among 5,737 men and women who had
emergency, so-called primary, angioplasty for treatment of
sudden heart attack, all at community hospitals with no
on-site cardiac surgery backup, hospitals performing 83 or
more procedures per year had the lowest death rates at the
time of hospital discharge, at 2.2 percent.
Angioplasty consists of threading a thin tube into the
main blood vessels near the heart and using it to inflate a
tiny balloon to widen an artery blocked or narrowed from
the buildup of cholesterol-laden plaque. A metal cylinder
stent is often deployed to keep the blood vessel open.
Researchers say their findings, collected over seven
years from a diverse group of 31 hospitals across the
country, none of which have elective angioplasty programs,
suggest that patient safety and survival rates for primary
angioplasty could be improved by easing restrictions on the
use of elective angioplasty so that such hospitals can get
Under present guidelines from the American Heart
Association and the American College of Cardiology,
community hospitals are limited to offering angioplasty
only in emergency situations, such as during a heart
attack. In all other nonemergency or elective surgical
cases, patients must be transferred to a hospital that has
on-site specialized heart surgery backup.
"The results reinforce what we have known for a long
time with many other technical procedures, such as organ
transplantation or specialized heart surgery: From an
institutional and physician perspective, the more
procedures performed, the better the outcomes for the
patient," said senior study investigator and interventional
cardiologist Thomas Aversano. According to the American
Heart Association, in 2005 an estimated 1,265,000
angioplasty procedures were performed on 640,000 Americans.
This amounts to a 324 percent increase in volume since
In this study, one of a number being conducted by the
Cardiovascular Patient Outcomes Research Team, or C-PORT,
all participants had primary angioplasty in response to a
heart attack caused by a blocked artery. Mortality rates
were adjusted to account for factors that heighten risk,
such as age, ability to tolerate clot-busting drugs,
diabetes and the extent of blockages in coronary blood
The research is part of several C-PORT projects
investigating the safety of performing angioplasty in
hospitals without heart surgery backup, all led by
Aversano, an associate professor at the Johns Hopkins
University School of Medicine and its
Heart and Vascular Institute.
Aversano noted that even in lower-volume hospitals,
those conducting no more than 46 procedures per year, the
death rate is 4 percent. Previous research by Aversano,
published in the Journal of the American Medical
Association in 2002, showed that heart attack patients who
were treated with a clot-busting drug to open up the
artery, the alternative to primary angioplasty, had a 6.7
percent death rate.
"Even in low-volume community hospitals, survival
rates are better for primary angioplasty than thrombolytic
therapy," he said.
"Our results serve as one potential motivation for
expanding elective angioplasty to community hospitals
without on-site cardiac surgery so that institutional
volume is not restricted to emergency cases," he said.
For the last two decades, surgical backup has been
required for nonemergency angioplasty because, in rare
instances, the procedure leads to a tear in a vessel or
closing of an artery rather than opening it. The risk that
angioplasty patients will need emergency heart bypass
surgery is less than 1 to 2 in every 1,000 cases.
But Aversano and other researchers say that medical
advances have led to nonsurgical means of treating many of
these complications, including the use of stents to keep
arteries open, thus minimizing the need for on-site cardiac
Funding for the study was provided by participating
hospitals in Alabama, Connecticut, Maryland, New Jersey,
New York, Ohio and other states.
Additional statistics from the AHA show that 69
percent of angioplasties are performed on men and half on
people 65 and older. According to reimbursement schedules
available from Medicare, the federal program that funds
health care for the elderly, the cost of angioplasties
ranges from $11,000 to $18,000.