More Hospitals Can Use Angioplasty, Study Finds

Community hospitals can safely perform balloon angioplasties to unclog blocked arteries, and the procedure is as big a lifesaver in such facilities as in major medical centers, according to a new study.

Angioplasty involves threading a catheter through an artery in the groin to the artery feeding the heart, then expanding a balloon to compress the clot or other blockage. It reduces the death rate from heart attacks by about 40% compared with the administration of clot-busting enzymes.

But currently, an estimated 70% of heart attack victims in the United States are taken to local hospitals that cannot perform angioplasties. Medical guidelines restrict the procedure to hospitals that have cardiac surgery units to deal with possible complications.

But the new study, reported in today’s issue of the Journal of the American Medical Assn., demonstrates that such complications are extremely rare. The benefits of angioplasty far outweigh any risks, the study shows.

Dr. Thomas Aversano of Johns Hopkins Hospital and his colleagues concluded that 20 lives will be saved for every 1,000 patients who undergo angioplasty rather than receiving clot-busting drugs, also called thrombolytics. The incidence of nonfatal second heart attacks and bleeding in the brain, which affect about 1% of patients receiving the drugs, was also sharply reduced.

“It’s becoming less tenable for us as a society to accept two standards of care” for heart attacks: angioplasties for patients who go to major medical centers and drugs for those who do not, Aversano said. “It is incumbent on us to adjust our health-care policy so that the greatest number of patients with heart attacks have access to the better form of therapy.”

In an editorial in the same journal, Dr. Christopher P. Cannon of Brigham and Women’s Hospital in Boston wrote that, while having more hospitals perform angioplasty is clearly beneficial, it is not the only solution.

“We need to change our emergency treatment and transport patients to a cardiac center” for angioplasty rather than simply send patients to the nearest hospital, he wrote.

Boston, he added, is implementing a program that will ensure heart attack victims are taken to a center where they can receive the lifesaving procedure.

Patients have options as well, said Dr. Alex Durairaj of County-USC Hospital. If they think they are having a heart attack, they can insist that the responding ambulance take them to a major medical center where angioplasty is routinely performed.

“It’s the patient’s option where to go, ultimately,” he said.

Angioplasty was first performed in 1979. At the time, “it was unthinkable to do it in a hospital that did not have a cardiac surgery program because, if there were complications, it was necessary to crack the chest open and take care of it right away,” Durairaj said.

The technology has improved so much since then and the complication rate is so low that the requirement for a cardiac surgery program “is probably overkill,” he added, but the guidelines have never changed. Patients who once were required to stay in the hospital for nearly a week after elective angioplasty now go home the next day, or sometimes even the same day.

To test the safety and efficacy, Aversano and his colleagues organized a trial in 11 community hospitals in Massachusetts and Maryland. All of the hospitals already had a cardiac surgeon on call who was certified to perform angioplasties, but those specialists performed their elective procedures at larger medical centers.

The hospital staffs received three months of training in the care of patients who underwent the procedure. Each hospital also received a waiver from local governing bodies to perform angioplasty even though they did not have a cardiac surgery program.

The hospitals ultimately enrolled 451 heart attack victims who were randomly assigned to receive either thrombolytics or angioplasty.

At six weeks after their heart attacks, 10.7% of those receiving angioplasty had died, suffered a second heart attack or had a stroke, compared with 17.7% of those receiving thrombolytics. At six months, the comparable figures were 12.4% and 19.9%.

No complications requiring surgery occurred in any of the angioplasty patients. Nearly three-quarters of those receiving thrombolytics eventually had to have angioplasty as well because they had blockages in their arteries that were not improved by the destruction of a clot.

The study has some limitations. The most important was the relatively small sample size. Aversano had initially planned to enroll 2,550 patients, but the Hopkins group was unable to obtain the $6 million that would have been necessary to complete the study.

The American Heart Assn. and the American College of Cardiology are unlikely to alter their guidelines for angioplasty any time soon, said Dr. Ishmael Muno of USC University Hospital.

Those groups, he said, “believe that the best chance a patient has is to put them in a situation where . . . should they get in trouble, they can be referred to a surgeon for repair, a bypass” or other corrective measures.

The possibility of performing angioplasty in a hospital that doesn’t have such an option, he concluded, will be an “ongoing controversy.”