PCI still performed at low-volume facilities with no back-up

Facilities that have no on-site cardiac surgery capabilities still sometimes perform interventional cardiology procedures. That was among the findings in the CathPCI registry report detailing the current state of interventional cardiology practice in the U.S. The report was published online Oct. 17 in the Journal of the American College of Cardiology.

Data in the CathPCI registry is collected from 1,488 facilities, which perform approximately 85 percent of PCI procedures in the U.S. The report presents data collected for the six consecutive calendar quarters beginning Jan. 1, 2010 and ending June 30, 2011, and includes information on procedures and outcomes for 1.1 million patients who underwent diagnostic cardiac catheterization procedures and 941,248 patients who underwent PCI.

According to Gregory J. Dehmer, MD, of the Texas A&M Health Science Center, and colleagues, "These data provide a contemporary snapshot of diagnostic cardiac catheterization and PCI ... and thus provide an important perspective on many aspects of invasive cardiac procedures, including their current use outcomes."

Almost half of the reporting facilities (49 percent) reported performing 400 or fewer PCIs annually and 13 percent performed more than 1,000 PCIs annually. However, 26 percent of reporting facilities performed 200 or fewer PCIs annually, accounting for 4 percent of the total number of PCIs. On-site cardiac surgery was not available in 83 percent of facilities performing fewer than 200 PCIs annually.

The authors pointed out that 2011 PCI guidelines "recommend that low-volume operators (fewer than 75 cases annually) not perform PCI procedures at low-volume facilities (fewer than 400 procedures annually) and that facilities performing fewer than 200 procedures annually, unless geographically isolated, carefully consider whether to continue to offer this service."

The data indicate that 56 percent of patients who underwent diagnostic catheterization were male, and 67 percent of patients who underwent PCI were male. Twenty-six percent of the diagnostic catheterization patients were under age 55 and 10 percent were aged 80 or older. Among the PCI patients, 23 percent were under age 55 and 12 percent were 80 or older. Approximately 80 percent of the patients were overweight and more than 43 percent were obese. Eighty percent had dyslipidemia and 27.6 percent were current or recent smokers.

Among patients who underwent only diagnostic catheterization, 43.5 percent had an acute coronary syndrome at presentation, compared with 70 percent of the patients who underwent PCI.  Diagnostic catheterization and PCI were performed with femoral access over 90 percent of the time.

Among PCI patients, 87.8 percent received aspirin within 24 hours before and during the procedure, while by time of discharge "nearly all patients without a contraindication were receiving aspirin," the report stated. Similarly, the mean rate of thienopyridine use was 98.9 percent at the time of discharge, and the mean for statin use at the time of discharge was 90.5 percent.

Among patients undergoing only diagnostic procedures, post-procedure recommendations were: medical therapy, 69.2 percent; CABG, 13 percent; no therapy or other therapy, 15.5 percent; and PCI without CABG, 2.1 percent. 

Among PCI patients, 69.8 percent received at least one drug eluting stent (DES), 21.5 percent of patients received a bare metal stent without DES and 8.7 percent of patients received balloon angioplasty and no stent. 

The median time from hospital arrival to PCI in nontransfer STEMI patients was 64.5 minutes, which the authors termed "a marked reduction in door-to-balloon times over a few years that reflects the success of focused improvement initiatives."