Correspondence
Primary Percutaneous Coronary Intervention
N Engl J Med 2007; 356:1588-1590April 12, 2007
- Article
To the Editor:
In their review of primary percutaneous coronary intervention (PCI) for myocardial infarction with ST-segment elevation, Keeley and Hillis (Jan. 4 issue)1 cite the guidelines of the American College of Cardiology and American Heart Association (ACC–AHA): “Primary PCI is preferred if a . . . catheterization laboratory with surgical backup [is] available and if the procedure can be performed within 90 minutes after initial medical contact. . . .”2 Nationally, for 55% of patients who have myocardial infarction with ST-segment elevation, the door-to-balloon time is less than 90 minutes.3 Between January 2006 and July 2006, the hospital with the highest percentage of patients with myocardial infarction with ST-segment elevation meeting this criterion was a rural hospital that did not have surgical backup: 100% of the patients had door-to-balloon times of less than 90 minutes, and the average time was 55 minutes. Among these patients, there was no increase in complications.
Some rural areas have sufficient population to support a program in interventional cardiology but not a program in cardiac surgery. In rural communities, traffic congestion is rarely a problem, so that an interventional team could get to the hospital quickly. Primary PCI can be performed safely with superior results in rural settings without surgical backup.4 The ACC–AHA guidelines might compromise the care provided to patients with myocardial infarction with ST-segment elevation who live in rural communities.
4 ReferencesDaniel C. Brown, M.D.
St. Luke's Magic Valley Regional Medical Center, Twin Falls, ID 83301
dcbrown@mvrmc.org 1
Keeley EC ,Hillis LD . Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356:47-54
Full Text | Web of Science | Medline2
Antman EM ,Anbe DT ,Armstrong PW , et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction -- executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671-719[Erratum, J Am Coll Cardiol 2005;45:1376.]
CrossRef | Medline3
CathPCI Registry. American College of Cardiology, National Cardiovascular Data Registry (ACC–NCDR), 2007. (Accessed March 22, 2007, at http://www.accncdr.com/webncdr/DefaultCathPCI.aspx.)
4
Brown DC ,Mogelson S ,Harris R ,Kemp D ,Massey M . Percutaneous coronary interventions in a rural hospital without surgical backup: report of one year of experience. Clin Cardiol 2006;29:337-340
CrossRef | Web of Science | Medline
To the Editor:
In their article on primary PCI for patients who have myocardial infarction with ST-segment elevation, Keeley and Hillis describe the management of this potentially fatal coronary event, including medical treatment and mechanical therapy with primary PCI. However, some additional points should be addressed. The authors state that clopidogrel should be administered after it has been determined that emergency bypass surgery is not required. Recent study data indicate that the administration of clopidogrel before PCI significantly reduces the incidence of death from cardiovascular causes or from ischemic complications without a significant increase in bleeding.1,2 Furthermore, the addition of the selective aldosterone blocker eplerenone to optimal medical therapy has been shown to reduce morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure and thus should have been mentioned in this article.3 Finally, because of possible adverse effects on the clinical outcome, the risk of thrombocytopenia induced by treatment with heparin or glycoprotein IIb/IIIa inhibitors should also be noted.
3 ReferencesSebastian Szabo, M.D.
Thomas Oikonomopoulos, M.D.
Hans Martin Hoffmeister, M.D.
Städtisches Klinikum Solingen, 42653 Solingen, Germany
krisztinaszb@aol.com 1
Sabatine MS ,Cannon CP ,Gibson CM , et al. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA 2005;294:1224-1232
CrossRef | Web of Science | Medline2
Chen ZM ,Jiang LX ,Chen YP , et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005;366:1607-1621
CrossRef | Web of Science | Medline3
Pitt B ,Remme W ,Zannad F , et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-1321[Erratum, N Engl J Med 2003;348:2271.]
Full Text | Web of Science | Medline
To the Editor:
Keeley and Hillis ignore atheroembolic renovascular disease as a cause of nephropathy in patients who have undergone PCI. Atheroembolic disease accounts for approximately 5 to 10% of cases of acute renal failure1 and is an increasingly common cause of renal insufficiency in the elderly. A review of 372 autopsies identified cholesterol emboli in 2.4% of renal-tissue samples. Inciting events, including vascular surgery, arteriography, angioplasty, anticoagulation with heparin, and thrombolytic therapy, can be identified in 50% of cases of cholesterol embolization. Arteriographic procedures are the most common cause of cholesterol embolization.2 Showers of cholesterol emboli occur in about 50% of PCIs when a guiding catheter is passed through the aorta.3,4 Most of these showers are clinically silent. In approximately 1% of high-risk patients, an acute cholesterol emboli syndrome develops, which is manifested as acute renal failure, mesenteric ischemia, decreased microcirculation to the extremities, and, in some cases, embolic stroke.3 Since most cases of atheroembolic kidney disease are triggered by angiography, radiocontrast-induced nephropathy is easily invoked as an alternative diagnosis.1
4 ReferencesAjit Singh Kashyap, M.D.
Command Hospital (Central Command), Lucknow 226 002, India
kashyapajits@gmail.com Shekhar Kashyap, M.D.
Dhanvantri Hospital, Meerut 250 001, IndiaKuldip Parkash Anand, M.D.
Command Hospital (Eastern Command), Kolkata 700 027, India1
Polu KR ,Wolf M . Needle in a haystack. N Engl J Med 2006;354:68-73
Full Text | Web of Science | Medline2
Badr KF, Brenner BM. Vascular injury to the kidney. In: Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill, 2005:1706-10.
3
McCullough PA. Interface between renal disease and cardiovascular disease. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: W.B. Saunders, 2003:2161-72.
4
Meyrier A . Cholesterol crystal embolism: diagnosis and treatment. Kidney Int 2006;69:1308-1312
Web of Science | Medline
Author/Editor Response
We congratulate Brown et al.1 on their excellent outcomes with the use of primary PCI at a rural hospital without surgical backup, but we disagree that this procedure can be performed consistently in this setting and under these circumstances “safely with superior results.” The favorable results of primary PCI reported in selected community hospitals that do not have surgical backup, such as the data reported by Brown et al.,1 may not be achieved reliably at other facilities. Although urgent coronary-artery bypass grafting (CABG) is not commonly required for patients undergoing primary PCI, it is, in fact, necessary for an occasional patient, and the need often cannot be predicted. When CABG is required, the resultant delay incurred by the transfer of the patient to another facility can result in high morbidity and mortality.2 Primary PCI has been clearly shown to be safe and effective at high-volume centers with surgical backup, with supporting data from 23 randomized, controlled trials.3 In contrast, only one randomized trial comparing primary PCI and fibrinolytic therapy at community hospitals without surgical backup has been reported.4 As a result, according to the ACC–AHA guidelines,5 primary PCI without surgical backup is a class IIb indication.
As noted above, an occasional patient undergoing primary PCI requires urgent CABG. In such a patient, previous administration of clopidogrel substantially increases the risk of perioperative bleeding. For this reason, clopidogrel should not be given in the setting of primary PCI until it is clear that bypass surgery is not required. In some patients undergoing PCI, thrombocytopenia may develop after the administration of a combination of a platelet glycoprotein IIb/IIIa inhibitor and heparin; the risk is similar among those undergoing primary PCI for myocardial infarction with ST-segment elevation and those undergoing elective PCI. Currently, administration of the selective aldosterone blocker eplerenone is not considered a standard of care for patients who have myocardial infarction with ST-segment elevation.
Although an occasional patient undergoing an arteriographic procedure may have cholesterol embolization, most cholesterol emboli, as noted by Kashyap et al., are clinically silent. Only rarely do cholesterol emboli cause acute renal failure.
5 ReferencesEllen C. Keeley, M.D.
University of Virginia School of Medicine, Charlottesville, VA 22908L. David Hillis, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 753901
Brown DC ,Mogelson S ,Harris R ,Kemp D ,Massey M . Percutaneous coronary interventions in a rural hospital without surgical backup: report of one year of experience. Clin Cardiol 2006;29:337-340
CrossRef | Web of Science | Medline2
Lotfi M ,Mackie K ,Dzavik V ,Seidelin PH . Impact of delays to cardiac surgery after failed angioplasty and stenting. J Am Coll Cardiol 2004;43:337-342
CrossRef | Web of Science | Medline3
Keeley EC ,Boura JA ,Grines CL . Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20
CrossRef | Web of Science | Medline4
Aversano T ,Aversano LT ,Passamani E , et al. Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery: a randomized controlled trial. JAMA 2002;287:1943-1951[Erratum, JAMA 2002;287:3212.]
CrossRef | Web of Science | Medline5
Antman EM ,Anbe DT ,Armstrong PW , et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction -- executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004;110:588-636[Erratum, Circulation 2005;111:2013.]
CrossRef | Medline
