I can go two weeks and not find anything stimulating to comment on, then there’s a day like today.
Decline seen at Mayo Clinic even as physicians expanded angioplasty to sicker patients
When life-threatening problems occur during angioplasty procedures, doctors may perform emergency coronary artery bypass graft surgery, but data from the Mayo Clinic indicates that need to send patients to emergency surgery has dropped sharply, according to a new study in the Dec. 6, 2005, issue of the Journal of the American College of Cardiology.
‘Our review of almost 25 years of data on angioplasty suggests that there has been a dramatic reduction of almost 90 percent in the incidence of coronary artery bypass graft surgery following angioplasty; and this is despite the fact that more recently we are performing angioplasty on very high risk patients,’ said Mandeep Singh, M.D., F.A.C.C., from the Mayo College of Medicine in Rochester, Minnesota.
‘We knew there had been a reduction, but the magnitude of the reduction was a surprise to us,’ Dr. Singh said. ‘The bypass surgery rates, which were close to 3 percent, came down to 0.3 percent in the most recent time period.’
Dr. Singh said the fact that angioplasty is being offered to sicker patients now makes the reduction even more remarkable. Patients requiring emergency surgery in the most recent study period had a higher prevalence of high blood pressure and heart failure, and they were more likely to have undergone previous procedures, compared to patients in the earlier study periods.
Dr. Singh said he believes stents may be responsible for much of the reduction in the rate of life-threatening problems during angioplasty procedures.
However, among patients who did suffer serious problems during angioplasty and had to be sent into emergency surgery, the researchers did not see an improvement in survival. Death rates were statistically similar in all three study periods, ranging between 10 percent and 14 percent. Dr. Singh pointed out that there were only 41 deaths among patients who underwent emergency bypass surgery, including just two during the 2000 to 2003 study period. He said such small numbers make it difficult to calculate useful statistical comparisons.
‘The assessment of elective PCI without on-site bypass surgery underway in some states is a step in the right direction. But, choosing the right metrics is challenging. The only meaningful comparison between hospitals with and without on-site surgery is the rate of death or urgent transfer to another facility within a pre-specified period of time after PCI. One proposal that mixes acute events with late endpoints like repeat revascularizations is manipulative and misleading,’ he added.
This is really good news for everyone, cardiac surgeons included (they don’t want to be operating emergently anyway, and especially not on people who are already super-sick with vessels so bad they can’t be opened in the cath lab). I, for instance, really hope that when I have my MI (family probability) they can get me opened and stented in the lab, and not spend an hour in the lab then go and have my chest cracked for a bypass.
Also, this study going on with emergency caths in hospitals without in-house emergency bypass surgery is going to be very interesting to watch. Personally I hope it’s shown to have an acceptable risk/benefit ratio, but that study is only starting.
Good news, and progress, all around.
Stent picture from St. Michael’s Hospital, Tononto, Canada.