December 14, 2011

Percutaneous Coronary Intervention at Centers With and Without On-site SurgeryA Meta-analysis

Author Affiliations

Author Affiliations: Division of Cardiovascular Diseases (Drs Singh, Holmes, and Rihal) and Division of Biomedical Statistics and Informatics (Mr Lennon), Mayo Clinic, Rochester, Minnesota; Division of Cardiology, Scott & White Healthcare, Temple, Texas (Dr Dehmer); Cardiovascular Medicine, Exeter Hospital, Exeter, New Hampshire (Dr Wharton); Department of Cardiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina (Dr Kutcher); and Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland (Dr Aversano).

JAMA. 2011;306(22):2487-2494. doi:10.1001/jama.2011.1790

Context Percutaneous coronary interventions are performed at centers without onsite surgery, despite current guidelines discouraging this.

Objective To assess literature comparing rates of in-hospital mortality and emergency coronary artery bypass grafting surgery at centers with and without on-site surgery.

Data Sources A systematic search of studies published between January 1990 and May 2010 was conducted using MEDLINE, EMBASE, and Cochrane Review databases.

Study Selection English-language studies of percutaneous coronary intervention performed at centers with and without on-site surgery providing data on in-hospital mortality and emergency bypass were identified. Two study authors independently reviewed the 1029 articles originally identified and selected 40 for analysis.

Data Extraction Study title, time period, indication for angioplasty, and outcomes were extracted manually from all selected studies, and quality of each study was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.

Data Synthesis High-quality studies of percutaneous coronary interventions performed at centers with and without on-site surgery were included. Pooled-effect estimates were calculated with random-effects models. Analyses of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction of 124 074 patients demonstrated no increase in in-hospital mortality (no on-site surgery vs on-site surgery: observed risk, 4.6% vs 7.2%; odds ratio [OR], 0.96; 95% CI, 0.88-1.05; I2 = 0%) or emergency bypass (observed risk, 0.22% vs 1.03%; OR, 0.53; 95% CI, 0.35-0.79; I2 = 20%) at centers without on-site surgery. For nonprimary percutaneous coronary interventions (elective and urgent, n = 914 288), the rates of in-hospital mortality (observed risk, 1.4% vs 2.1%; OR, 1.15; 95% CI, 0.93-1.41; I2 = 46%) and emergency bypass (observed risk, 0.17% vs 0.29%; OR, 1.21; 95% CI, 0.52-2.85; I2 = 5%) were not significantly different at centers without or with on-site surgery.

Conclusion Percutaneous coronary interventions performed at centers without on-site surgery, compared with centers with on-site surgery, were not associated with a higher incidence of in-hospital mortality or emergency bypass surgery.