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(Circulation. 2005;112:3509-3534.)
© 2005 American Heart Association, Inc.

Controversies in Cardiovascular Medicine

Should patients with acute myocardial infarction be transferred to a tertiary center for primary angioplasty or receive it at qualified hospitals in the community?

The Case for Community Hospital Angioplasty

Thomas P. Wharton, Jr, MD

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Primary percutaneous coronary intervention (PCI) has gained widespread acceptance as the preferred approach for treating ST-segment elevation acute myocardial infarction (STEMI) when it can be performed rapidly at qualified centers. Primary PCI is superior to fibrinolytic therapy in fibrinolytic-eligible patients with STEMI; it reduces the rates of death, reinfarction, cerebral bleeding, reocclusion of the infarct artery, and recurrent ischemia compared with fibrinolytic therapy.^1,2 It is much more effective than fibrinolytic therapy in restoring brisk coronary flow (>90% of patients). In addition, primary PCI is potentially applicable to a much broader spectrum of patients with STEMI than is fibrinolytic therapy. It reduces mortality 2-fold or more in the large group of patients inappropriate for fibrinolytic therapy.^3,4 It is particularly beneficial in women and the elderly.^5,6 A recent report of Medicare patients demonstrated that fibrinolytic therapy conferred a survival disadvantage in patients >75 years old, especially in women, compared with no reperfusion therapy.⁶ This population represents almost one third of patients with acute myocardial infarction (AMI).⁷ The editorial that accompanied this study noted that "a recent observational study...has shown a marked reduction in 30-day mortality for primary PCI relative to fibrinolytic therapy in the elderly. However, primary PCI is not available at the hospitals where most elderly patients present with AMI."⁷

	The Need to Improve Access to Primary PCI for Patients With AMI

 
Unfortunately, only a small minority of patients with STEMI are treated with primary PCI in the United States (Figure 1).^8,9 The National Registry of Myocardial Infarction (NRMI) reports that the utilization of primary PCI has increased only slowly from . . . [Full Text of this Article]

Ellen C. Keeley, MD; Cindy L. Grines, MD

Thomas P. Wharton, Jr, MD

Ellen C. Keeley, MD; Cindy L. Grines, MD

Correspondence to Thomas P. Wharton, Jr, MD, The Perry Medical Services Building, Suite 101, 3 Alumni Drive, Exeter, NH 03833 (e-mail tom.wharton@comcast.net); or Ellen C. Keeley, MD, UT Southwestern Medical Center, Division of Cardiology, 5323 Harry Hines Blvd, Dallas, TX 75390-8837 (e-mail Ellen.Keeley@UTSouthwestern.edu).

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