Minor heart procedures can be performed safely even at hospitals that can't do emergency heart surgery in case of complications, a fresh look at past studies suggests.
As more of the procedures, called stenting, are being done outside of big hospitals in urban centers, more patients have fast access to what can be a life-saving treatment. And others simply have a convenient place to get non-emergency surgery, researchers said.
During stenting, a blocked heart artery is cleared and propped open with a small mesh tube called a stent.
Because artery-opening has become safer as techniques and technology have improved, researchers say that for emergency stent procedures and many non-emergency ones as well, local hospitals that don't also perform bypass surgeries are a good option.
"We used to have cardiac or operation rooms on standby in case something went wrong," said Dr. Scott Kinlay, who wrote a commentary published with the study in the Journal of the American Medical Association.
Stents, he said, "revolutionized the success and safety" of those more minor procedures.
"But there's still a need to make sure ... there are clear plans and arrangements to ship patients to centers that do have cardiac surgery if something goes wrong," Kinlay, a cardiologist at VA Boston Healthcare System, told Reuters Health.
Recommendations from national organizations including the American Heart Association once called for non-emergency stenting to be done only at hospitals that were able to perform emergency bypass surgery because of the risk of complications.
But last month, those groups updated their guidelines to say that non-emergency stenting "might be considered" in hospitals without on-site bypass surgery options, as long as there's a proven plan to transport patients to another hospital that does do heart surgery in case of emergency.
For people having a heart attack and needing emergency treatment, guidelines say it's "reasonable" to send patients to local hospitals that perform artery-opening procedures, also called angioplasty, but not surgery.
"It is very safe for any patient with a heart attack to go to the nearest hospital that has angioplasty capability. The sooner we can get the artery open, the better the prognosis is," study author Dr. Mandeep Singh, from the Mayo Clinic in Rochester, Minnesota, told Reuters Health.
"For elective (non-emergency) angioplasty, it is more of a convenience issue. For the most part (procedures for) any low- to medium-risk patients can be done safely at places without on-site surgery."
He and his colleagues analyzed 15 studies that compared the rate of in-hospital deaths and emergency surgery in patients getting a stent inserted at hospitals that did or didn't have the capabilities to perform bypass surgery.
Those included more than 900,000 people getting emergency and non-emergency stenting.
Only two or three in every 1,000 of them needed emergency bypass surgery, regardless of where they were treated. The chance of dying in the hospital was 1.4 percent in patients who had the procedures done at hospitals without on-site heart surgery, compared to 2.1 percent at hospitals that did do the more complicated operations.
There was also no extra risk of death or transport for bypass surgery in 120,000 patients getting emergency stenting for heart attacks who were treated at hospitals without heart surgery teams and facilities.
"The complication rates have dwindled to a very low level ... regardless of where you get the angioplasty done," Singh said.
Dr. Steven Marso, a cardiologist at Saint Luke's Health System in Kansas City, Missouri, and the senior author of one of the studies included in the new analysis, said that more and more smaller hospitals have started performing angioplasties in recent years.
"There's a strong drive to distribute care. We'd like to take services that can be done safely and effectively and that can be replicated out into areas where it's just more challenging to get patients to come to the major center," he told Reuters Health.
Marso pointed out, though, that it can be difficult to know how prepared a smaller hospital is to transfer patients in need of emergency surgery — a process that he said should take less than half an hour.
Singh and Kinlay both said that patients who are at high risk of complications, such as those with fully blocked arteries, should probably still get non-emergency procedures done at bigger hospitals that can perform heart surgery. And Singh added that the next step will be to establish guidelines on exactly which types of patients can be safely treated at hospitals with and without those capabilities.
Marso concluded, "I think that patients can have angioplasty at large or small centers with or without surgery backup safely, as long as hospitals, whether they have surgery or not, have best practices in place."
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