There is now little dispute that percutaneous coronary intervention (PCI) has revolutionised the management of patients with acute coronary events such as heart attack.(1) Moreover, improvements in PCI in the past decade have greatly lowered the risk of life-threatening complications during the procedure, such that PCI is now regularly performed in lower-risk patients in hospitals without the support of a back-up cardiac surgery service.
However, what is still a matter of dispute is whether these stable coronary patients treated with PCI do as well in hospitals without a surgical service as those in hospitals with on-site surgical support. Now, the first randomised trial to resolve the question suggests that similarly comparable health status outcomes can be achieved from both services, thereby supporting the view that effective PCI programmes can be established in adequately equipped non-surgical, community hospitals.(2)
"From a patient's perspective," say the investigators, "receiving coherent specialty care at their local hospital instead of at a distant regional hospital may increase treatment satisfaction, perceived [quality of life] and better adherence to therapy."
The two hospitals in this study - the first prospective randomised trial to assess health outcomes after PCI in such different settings - were a community hospital in Norway (Stavanger University Hospital) and a regional cardiac centre with surgical provision (Haukeland University Hospital) 213 kilometres away. Prior to the establishment of a PCI service at the community hospital, all patients in need of revascularisation were treated at the distant regional specialist hospital.
"The primary aim of our study was to establish safety criteria for PCI in centres without on-site surgical back-up in non-emergency patients," said investigator Dr Tor Melberg from the Stavanger University Hospital in Norway. " "Outcomes were comparable at the two hospitals."
The study was a six-month follow-up of 609 consecutive coronary patients who were assessed by angiography at the community hospital and met the criteria for low-risk PCI. At baseline and following PCI at either the community or regional surgical hospital, the patients were assessed for changes in their health status (symptoms, physical capacity and quality of life). Results showed that at six months the extent of cardiac symptoms (angina) and exercise capacity were comparable in both groups. There was a substantial reduction in symptoms and in the use of anti-anginal drugs, and an increase in exercise time.
There were also marked improvements - in both groups - in quality of life scores, irrespective of where the PCI was performed. The greatest improvements were seen in physical functioning (statistically significant changes from baseline) and the lowest in mental health domains. The investigators report that these changes "were clearly related to angina symptom grade at both baseline and follow-up".
Commenting on the findings, Dr Melberg said: "In stable patients, relief of symptoms, improvement of functional capacity and bettered quality of life are the goals of the therapy. It was in important for us to show that these measures did not depend on whether the PCI was performed at a surgical or a non-surgical hospital. We believe that proximity to the treating hospital means a lot to patients and their relatives, who should be reassured that the quality of care is comparable to that of tertiary centres by comparisons of outcomes."