Cardiology Section
Department of Medicine
King Abdul Aziz Medical City
PO Box 9515
Jeddah 21423
Kingdom of Saudi Arabia
E-mail address: kholeifm{at}ngha.med.sa
The guidelines on primary percutaneous coronary intervention (PCI) published in the April issue of the European Heart Journal recommend early PCI for most of the clinical spectrum of acute coronary syndromes (ACSs).1
In a recent editorial, the issue of thrombolysis vs. primary PCI for ST-elevation myocardial infarction is raised again by Townend and Doshi.2 They suggest adopting a strategy of early, pre-hospital thrombolysis, followed by early PCI.
The merits of early PCI are deemed to be established and are incorporated in recent guidelines from the European Society of Cardiology as well as the American College of Cardiology and the American Heart Association.35
These recommendations are based on meta-analysis of randomized controlled trials and do not incorporate the results from registries reflecting what happens in the real world. Van de Werf et al.6 reported for the GRACE Investigators on this subject recently. This registry of 28 825 in 14, mostly developed, countries showed that the risk of death at 6 months, and bleeding complications and stroke in hospital, was higher among patients who were admitted first to hospitals with facilities for angioplasty. Although part of the excess risk may be procedure related, the excess mortality at 6 months suggests that other mechanisms may be involved, including under-reported peri-procedural infarcts, which will adversely affect longer term outcome. In their report, they refer to concordant results from other investigators.
Moreover, guidelines recommend that skilled support staff should be available for all such angioplasties.1 This usually means an experienced cardiac surgeon, cardiac anaesthesiologist, perfusionist, theatre nurses, and other support staff on site, with a theatre available and ready. In the real world, this probably does not happen.
Recent reviews of guidelines have not incorporated information from registries reflecting what actually happens when these guidelines are implemented. This information should perhaps influence the revision of guidelines as much as, if not more than, meta-analysis of randomized trials.
CVD will be the leading cause of death worldwide by the year 2020. In the 1999 World Health Report, the then Director General, Gro Harlem Brundtland, states that we are halfway through a two century transition in which CVD will dominate as the major cause of death and disease.7
In the UK, the British Cardiac Society studied the number of PCI procedures needed per million population based on current evidence. The estimate is 20003000 procedures per million.8
Implementing a strategy of early PCI will carry enormous costs worldwide for decades.
Uncertainties about the consequences of implementing this approach in the real world should be addressed before embarking on such a policy.
References
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