Primary PCI in Masschusetts: Guidelines writers, how long must the rest of us suffer?

Romans 5; 3-4: "Suffering produces endurance and endurance produces character and character produces hope."

Indeed there is still "hope" for all of waiting to move primary PCI without surgery on-site forward in this country after this presentation. The data demonstrated (once again) that "among patients undergoing PCI, outcomes were almost identical in non-surgery-on-site and SOS (surgery on-site) hospitals. You would have thought the NCDR data would have been enough to push us to the point of expanding this lifesaving opportunity all across the US. Instead we still wait while many suffer.

 Felix Adler: "We stand, as it were, on the shore and see multitudes of our fellow beings struggling in the water, stretching forth their arms, sinking, drowning, and we are powerless to assist them."

It's no secret that I champion the cause of the lytic noneligible. I've related to many the untimely death of my uncle after I administered lytic therapy for a noncomplicated inferior wall MI around 10 years ago. That death was completely unnecessary and totally preventable. Had he lived just 70 miles south in the state of Tennessee, where PCI without SOS had been practiced for 12 years, he would have undergone a primary PCI and gone home in a couple of days. Instead, he resided in Kentucky where for six years we've battled to move primary PCI forward, and we are still battling.

We learned last month that the governor has unwittingly tied the primary-PCI program to the state health-plan amendment that will require a vote on an expensive pediatric psychiatry facility bill that will likely fail because it is viewed as unaffordable. This move will cost thousands of lives and dollars by producing yet another delay in expanding this life saving program to the other eight hospitals that stand ready, willing, but disallowed to perform this procedure.

Fritz Williams: "Suffering and joy teach us, if we allow them, how to make the leap of empathy, which transports us into the soul and heart of another person. In those transparent moments we know other people's joy and sorrows and we care about their concerns as if they were our own."

Dr Guyton, chief of cardiothoracic surgery at Emory, the discussant for the Massachusetts trial, gave a fair and very human response to this data. He said, "If I'm in an ambulance and am asked if I want to go to a hospital without surgery on-site or a surgery hospital, I'm going to go to a surgery hospital. But if I'm in a nonsurgery hospital and need a PCI, I'm going to stay at that hospital." He's a surgeon but he "gets it," and he "gets it" far better than some of our very own guidelines writers who are cardiologists. I guess it's difficult to feel hunger when your mouth is full and for some, very difficult to feel pain when those who are suffering are not your own.

Marcel Proust: "We are healed of a suffering only by experiencing it to the full."

I write of our trials and tribulations in the world of intervention or--lack thereof--"in order to draw attention to the need. Our efforts have resulted in marginal results at best but with the aid of results like those from the NRMI registry, combined with the NCDR data, we know that we will eventually prevail, but not until many more suffer and die from lack of access to primary PCI. We also know that the onus is on us to improve our adherence to guidelines and continue to improve our rates of revascularization as evidenced by this registry information. These are small but not insignificant issues when it comes to the race against the 90-minute clock that runs on every single patient with STs up.

George Eliot: "Deep unspeakable suffering may well be called a baptism, a regeneration, the initiation of a new state."

Perhaps if everyone had to walk down that long hall from the ICU and tell their mother that her only sibling and last remaining first-degree relative had died a horrible and preventable death, it might result in a more enthusiastic endorsement of primary PCI without surgery onsite. I implore our guidelines writers to convene to make this a priority in our country. I ask them to publish guidelines that would lead to the mapping of our country to find the shortest point from ST-elevation to a primary PCI. I ask that they insist that this become a leading platform for healthcare reform that this country so desperately needs. Let us overcome the unnecessary suffering of STEMI patients all over these US who die acutely from lack of access to primary PCI or costly pump failure from untimely delivery of this lifesaving procedure.

Helen Keller: "The world is full of suffering. It is also full of overcoming it."

Your comments

	Primary PCI in Masschusetts: Guidelines writers, how long must the rest of us suffer?
	# 1 of 8	November 16, 2009 10:47 (EST)
	Goran Olivecrona, MD, PhD.	very well stated Melissa. I completely agree with you. In Europe there are a multitude of sites without on site surgery doing a great job in treating STEMI patients with PCI. The issue is not surgery on site or not, I think we are way past that issue. The remaining issue is volume and experience. As such, any high volume operator will do a great job with STEMI patients regardless if there is surgery or not on site, in my opinion.
	# 2 of 8	November 17, 2009 02:50 (EST)
	Burt Cohen	Melissa -- this is an important issue that needs constant repeating -- on of the earliest discussion forums on Angioplasty.Org was about C-Port and the question of PCI without surgical backup -- and that was 12 years ago! Yes, one would think more progress would have been made. Speaking of "the old days", a historical note about Dr. Guyton from Emory. He was a close collaborator of Andreas Gruentzig's in the early days of balloon angioplasty at Emory and has told me that he always appreciative of Gruentzig's ability to explain to patients the difference between CABG and PCI -- and to offer them the choice, if it was feasible. He greatly admired Gruentzig's intellectual honesty about what did and did not work.
	# 3 of 8	November 17, 2009 06:41 (EST)
	John Reynolds	It is interesting to read this commentary when many times the writer does not practice all what is preached.
	# 4 of 8	November 23, 2009 09:56 (EST)
	Burt Cohen, Angioplasty.Org	Melissa -- this is an important issue that needs constant repeating -- on of the earliest discussion forums on Angioplasty.Org was about C-Port and the question of PCI without surgical backup -- and that was 12 years ago! Yes, one would think more progress would have been made. Speaking of "the old days", a historical note about Dr. Guyton from Emory. He was a close collaborator of Andreas Gruentzig's in the early days of balloon angioplasty at Emory and has told me that he always appreciative of Gruentzig's ability to explain to patients the difference between CABG and PCI -- and to offer them the choice, if it was feasible. He greatly admired Gruentzig's intellectual honesty about what did and did not work.
	# 5 of 8	December 1, 2009 09:05 (EST)
	melissa	Burt, I could not agree more.   I thought 12 years ago that we  would have been light years ahead of where we are now.  Since the inception of primary PCI without surgery onsite at our hospital, we've been engaged in a constant back and forth in trying to move our state forward.  So many hospitals are still begging for the opportunity.  Finally, in the Kentucky hospital assocation journal, they published our data and found that our mortality was NO DIFFERENT than the national data for hospitals WITH surgery onsite. Until this month, not one single word was uttered publicly about what we were doing (exactly mirroring the NCDR data) for our population in medical political circles.  Now that we have been published, along with Ephraim McDowell hospital in Danville, other hospitals may finally get the opportunity.  We'll just have to see if it takes another 6 years to get anywhere.   Melissa
	# 6 of 8	December 10, 2009 10:59 (EST)
	Zoran Stanic	Things can be taken to an illogical extreme however. In my practice area we have a "C-port" hospital performing unsupported elective and primary PCI with a total annual volume <300 cases 1 mile away from a supported high volume center doing 3000 PCI's per year and 50 primary PCI's per month (with DTB times median under 70 minutes). Just because it makes sense for rural and underserved areas, doesn't mean that this should apply to all situations across the board.
	# 7 of 8	December 18, 2009 11:05 (EST)
	Mary	great post. I would love to follow you on twitter. By the way, did you guys learn that some Iranian hacker had busted twitter yesterday. Mary
	# 8 of 8	January 24, 2010 05:31 (EST)
	Melissa	Zoran, Though I understand your concerns, in theory, every hospital with a cath program and an interventionalist should be offering PCI.  The elective programs stand on the shoulders of the acute PCI programs.  My partner, Jim Whiteside always said, "the absolute worst place in the world to start having an MI is while you are admitted to the hospital (with something else).  If you are a non-PCI capable hospital, you must get your MI recognized, then get packaged, then get transported.  I recall seeing an interesting study that looked at D2B times for patients who were transported just across the street to PCI capable hospitals.  No matter if the doors were facing each other, the packaging, transporting and unpackaging the patient still cost around 60 minutes of D2B time.  It's time we take all of the angst and the awe out of this procedure.  It's a procedure like anything else.  Since we don't whine and complain about a <1% risk of doing an appendectomy in a non PCI capable hospital, we don't need to whine about the <0.5% risk of doing a PCI in a non surgical hospital.  We just need to have our systems ready in case of an emergency and save the other 40% who arrive at our ER doors who are inelegible for lytic with an MI or be prepared to care for those admitted with other primary diagnoses who get into trouble.  We should be FAR MORE WORRIED and more vocal  about the 4% who will die of an intracranial bleed from lytic therapy than we are the <0.05% who will need an emergent transfer for a pci complication. Contact your local guidline writer today for a frank discussion about getting the guidelines up to speed to save a nation of people who are suffering.    Melissa

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