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Percutaneous Coronary Intervention at Centers With and Without On-site Surgery A Meta-analysis

Mandeep Singh, MD, MPH; David R. Holmes, MD; Gregory J. Dehmer, MD; Ryan J. Lennon, MS; Thomas P. Wharton, MD; Michael A. Kutcher, MD; Thomas Aversano, MD; Charanjit S. Rihal, MD
JAMA. 2011;306(22):2487-2494. doi:10.1001/jama.2011.1790.
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Published online

Context Percutaneous coronary interventions are performed at centers without onsite surgery, despite current guidelines discouraging this.

Objective To assess literature comparing rates of in-hospital mortality and emergency coronary artery bypass grafting surgery at centers with and without on-site surgery.

Data Sources A systematic search of studies published between January 1990 and May 2010 was conducted using MEDLINE, EMBASE, and Cochrane Review databases.

Study Selection English-language studies of percutaneous coronary intervention performed at centers with and without on-site surgery providing data on in-hospital mortality and emergency bypass were identified. Two study authors independently reviewed the 1029 articles originally identified and selected 40 for analysis.

Data Extraction Study title, time period, indication for angioplasty, and outcomes were extracted manually from all selected studies, and quality of each study was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.

Data Synthesis High-quality studies of percutaneous coronary interventions performed at centers with and without on-site surgery were included. Pooled-effect estimates were calculated with random-effects models. Analyses of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction of 124 074 patients demonstrated no increase in in-hospital mortality (no on-site surgery vs on-site surgery: observed risk, 4.6% vs 7.2%; odds ratio [OR], 0.96; 95% CI, 0.88-1.05; I2 = 0%) or emergency bypass (observed risk, 0.22% vs 1.03%; OR, 0.53; 95% CI, 0.35-0.79; I2 = 20%) at centers without on-site surgery. For nonprimary percutaneous coronary interventions (elective and urgent, n = 914 288), the rates of in-hospital mortality (observed risk, 1.4% vs 2.1%; OR, 1.15; 95% CI, 0.93-1.41; I2 = 46%) and emergency bypass (observed risk, 0.17% vs 0.29%; OR, 1.21; 95% CI, 0.52-2.85; I2 = 5%) were not significantly different at centers without or with on-site surgery.

Conclusion Percutaneous coronary interventions performed at centers without on-site surgery, compared with centers with on-site surgery, were not associated with a higher incidence of in-hospital mortality or emergency bypass surgery.

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Figure 1. Study Flow
Graphic Jump Location

PCI indicates percutaneous coronary intervention. Abstracts were excluded because they do not provide enough information.

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Figure 2. Forest Plots Comparing In-hospital Mortality Following Percutaneous Coronary Intervention at Sites With and Without Surgery
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Odds ratio (OR) estimates with 95% CIs of all studies for the outcomes of death by indication for percutaneous coronary intervention. In the case of 0 counts, ORs were calculated by adding 0.5 to all cell counts from the study to avoid division by 0. STEMI indicates ST-elevation myocardial infarction.

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Figure 3. Funnel Plot to Evaluate Publication Bias
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Studies comparing in-hospital mortality and emergency coronary artery bypass grafting (CABG) surgery after nonprimary (elective for patients without ST elevation myocardial infarction [STEMI]) and primary (patients with STEMI) percutaneous coronary intervention. Trim-and–based estimates of unpublished studies are also shown.

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Figure 4. Forest Plot Comparing Emergency Coronary Bypass Graft Surgery Rates Following Percutaneous Coronary Intervention at Sites With and Without Surgery
Graphic Jump Location

Odds ratio (OR) estimates with 95% CIs of studies for the outcomes of emergency coronary artery bypass grafting (CABG) surgery by indication for percutaneous coronary intervention (PCI). In the case of 0 counts, ORs were calculated by adding 0.5 to all cell counts from the study to avoid division by 0.

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