The ABCs of the impact of the C-PORT E study

Dr Melissa Walton-Shirley


November 14, 2011

A: All patients deserve a safe and timely coronary intervention.

B: Because this technology is still not evenly distributed throughout the US, patients are dying without a timely primary PCI. Nonprimary centers must be sustained in order to provide lifesaving interventions for those suffering from an acute event. TheC-PORT E trial is about the one-millionth piece of evidence that shows that PCI without surgery on site, with regard to both primary and nonprimary PCI is safe. We are so late in promoting access that it's embarrassing.

C: Congestive heart failure continues to be our most costly and lethal DRG. Until our guidelines writers convene often enough with the goal of maintaining and creating more PCI centers in underserved areas, patients will continue to die while others will be discharged with a poor EF. This translates into higher drug bills, more devices, and greater disability enrollment. At the same time, those centers that are operating under the radar, without adequate reporting, and quality measures should be sanctioned and reimbursements cut if after a grace period they are not willing to comply with monitoring.

Dr Ralph Brandis spoke to Managing Editor Shelley Wood of heartwire in June 2009 on the subject:

"We've actually had some outside people doing some analysis of our paper [the NCDR data] and . . . they think that, based on the data we have collected, the clinical-practice-guidelines team should look long and hard about changing their class 3 recommendations and making them either a 2a or 2b" for elective PCI, Brindis commented. That said, he continued, "I can't anticipate what they are actually going to do, and I suspect they are going to wait for C-PORT Elective before making their final recommendations."

Well, it's way past showtime, folks. Can anyone really look me straight in the eye and tell me that primary PCI without surgery on site for STEMI should really be a 2b indication? If so, I think intubation as a 2b indication makes just as much sense. There isn't much difference between dying now and dying three years from now after years of poor quality life while suffering from preventable primary pump failure. (Some argue that dying early on is more merciful.) As much as I revere, respect, and appreciate my friends and colleagues who are interventionalists, pulling this off in a nonsurgical center is not rocket science, or maybe I should more appropriately insist it is at least the same rocket science that makes it so feasible in a surgery-on-site center.

The 30-year-long warm-up performed by such groups such as Dr Gabriel Stegg and the "daring lifesavers" in downtown Paris, who have performed PCI safely with no in-house safety net for three decades, should be our template. For the life of me, I don't know why it has taken so long to upgrade these guidelines. Or, let me rephrase that: In the name of so many lives cut short or lost because of our reluctance to promote this lifesaving procedure full on, why, on this side of God's green earth, has it taken so long?




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