FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 342:1573-1580 May 25, 2000 Number 21 Next

	Full Text PDF Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background There is an inverse relation between mortality from cardiovascular causes and the number of elective cardiac procedures (coronary angioplasty, stenting, or coronary bypass surgery) performed by individual practitioners or hospitals. However, it is not known whether patients with acute myocardial infarction fare better at centers where more patients undergo primary angioplasty or thrombolytic therapy than at centers with lower volumes.

Methods We analyzed data from the National Registry of Myocardial Infarction to determine the relation between the number of patients receiving reperfusion therapy (primary angioplasty or thrombolytic therapy) and subsequent in-hospital mortality. A total of 450 hospitals were divided into quartiles according to the volume of primary angioplasty. Multiple logistic-regression models were used to determine whether the volume of primary angioplasty procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Similar analyses were performed for patients receiving thrombolytic therapy at 516 hospitals.

Results In-hospital mortality was 28 percent lower among patients who underwent primary angioplasty at hospitals with the highest volume than among those who underwent angioplasty at hospitals with the lowest volume (adjusted relative risk, 0.72; 95 percent confidence interval, 0.60 to 0.87; P<0.001). This lower rate, which represented 2.0 fewer deaths per 100 patients treated, was independent of the total volume of patients with myocardial infarction at each hospital, year of admission, and use or nonuse of adjunctive pharmacologic therapies. There was no significant relation between the volume of thrombolytic interventions and in-hospital mortality among patients who received thrombolytic therapy (7.0 percent for patients in the highest-volume hospitals vs. 6.9 percent for those in the lowest-volume hospitals, P=0.36).

Conclusions Among hospitals in the United States that have full interventional capabilities, a higher volume of angioplasty procedures is associated with a lower mortality rate among patients undergoing primary angioplasty, but there is no association between volume and mortality for thrombolytic therapy.

Source Information

From the Department of Medicine, Division of Cardiovascular Diseases (J.G.C., W.J.R., V.K.M.), and the Center for Outcomes and Effectiveness Research and Education (J.G.C., C.I.K.), University of Alabama at Birmingham, Birmingham; the University of Washington Cardiovascular Outcomes Research Center, Seattle (N.R.E., J.A.M., P.D.F.); Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle (N.R.E.); the Clinical Research Unit, Colorado Permanente Medical Group, Denver (D.J.M.); the Department of Preventive Medicine and Biometrics and the Division of Emergency Medicine, University of Colorado Health Sciences Center, Denver (D.J.M); Harbor UCLA Medical Center, Torrance, Calif. (W.J.F.); Washington University School of Medicine, St. Louis (A.J.T.); and the University of California at San Francisco, San Francisco, and Genentech, South San Francisco, Calif. (H.V.B.).

Address reprint requests to Dr. Canto at the University of Alabama at Birmingham, 363 BDB, 1808 7th Ave. S., Birmingham, AL 35294-0012.

Full Text of this Article

Related Letters:

Health Advice for Travelers
Abell L., Dumont L., Mardirosoff C., Tramer M. R., Ryan E. T., Kain K. C.
Extract | Full Text  
N Engl J Med 2000; 343:1045-1046, Oct 5, 2000. Correspondence

This article has been cited by other articles:

• Stone, G. W. (2008). Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part I: Primary Percutaneous Coronary Intervention. Circulation 118: 538-551 [Full Text]  
• Stone, G. W. (2008). Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part II: Intervention After Fibrinolytic Therapy, Integrated Treatment Recommendations, and Future Directions. Circulation 118: 552-566 [Full Text]  
• Bates, E. R., Nallamothu, B. K. (2008). Commentary: The Role of Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction. Circulation 118: 567-573 [Full Text]  
• O'Brien, S. M., DeLong, E. R., Peterson, E. D. (2008). Impact of Case Volume on Hospital Performance Assessment. Arch Intern Med 168: 1277-1284 [Abstract] [Full Text]  
• Goodman, S. G., Menon, V., Cannon, C. P., Steg, G., Ohman, E. M., Harrington, R. A. (2008). Acute ST-Segment Elevation Myocardial Infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133: 708S-775S [Abstract] [Full Text]  
• Zahn, R, Gottwik, M, Hochadel, M, Senges, J, Zeymer, U, Vogt, A, Meinertz, T, Dietz, R, Hauptmann, K E, Grube, E, Kerber, S, Sechtem, U (2008). Volume-outcome relation for contemporary percutaneous coronary interventions (PCI) in daily clinical practice: is it limited to high-risk patients? Results from the Registry of Percutaneous Coronary Interventions of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). Heart 94: 329-335 [Abstract] [Full Text]  
• Le May, M. R., So, D. Y., Dionne, R., Glover, C. A., Froeschl, M. P.V., Wells, G. A., Davies, R. F., Sherrard, H. L., Maloney, J., Marquis, J.-F., O'Brien, E. R., Trickett, J., Poirier, P., Ryan, S. C., Ha, A., Joseph, P. G., Labinaz, M. (2008). A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction. NEJM 358: 231-240 [Abstract] [Full Text]  
• Brophy, J. M (2007). Has thrombolysis lost its mojo?. Heart 93: 1167-1169 [Full Text]  
• King, S. B. III, Aversano, T., Ballard, W. L., Beekman, R. H. III, Cowley, M. J., Ellis, S. G., Faxon, D. P., Hannan, E. L., Hirshfeld, J. W. Jr, Jacobs, A. K., Kellett, M. A. Jr, Kimmel, S. E., Landzberg, J. S., McKeever, L. S., Moscucci, M., Pomerantz, R. M., Smith, K. M., Vetrovec, G. W., Creager, M. A., Hirshfeld, J. W. Jr, Holmes, D. R. Jr, Newby, L. K., Weitz, H. H., Merli, G., Pina, I., Rodgers, G. P., Tracy, C. M. (2007). ACCF/AHA/SCAI 2007 Update of the Clinical Competence Statement on Cardiac Interventional Procedures: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures). J Am Coll Cardiol 50: 82-108 [Full Text]  
• de Villiers, J. S., Anderson, T., McMeekin, J. D., Leung, R. C.M., Traboulsi, M., for the Foothills Interventional Cardiology Servic, (2007). Expedited transfer for primary percutaneous coronary intervention: a program evaluation. CMAJ 176: 1833-1838 [Abstract] [Full Text]  
• Fernandez-Aviles, F., Alonso, J. J., Pena, G., Blanco, J., Alonso-Briales, J., Lopez-Mesa, J., Fernandez-Vazquez, F., Moreu, J., Hernandez, R. A., Castro-Beiras, A., Gabriel, R., Gibson, C. M., Sanchez, P. L., for the GRACIA-2 (Grupo de Analisis de la Cardiopa, (2007). Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial. Eur Heart J 28: 949-960 [Abstract] [Full Text]  
• Van Brabandt, H., Camberlin, C., Vrijens, F., Parmentier, Y., Ramaekers, D., Bonneux, L. (2006). More is not better in the early care of acute myocardial infarction: a prospective cohort analysis on administrative databases. Eur Heart J 27: 2649-2654 [Abstract] [Full Text]  
• Stenestrand, U., Lindback, J., Wallentin, L., for the RIKS-HIA Registry, (2006). Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction.. JAMA 296: 1749-1756 [Abstract] [Full Text]  
• Popescu, I., Vaughan-Sarrazin, M. S., Rosenthal, G. E. (2006). Certificate of need regulations and use of coronary revascularization after acute myocardial infarction.. JAMA 295: 2141-2147 [Abstract] [Full Text]  
• Hannan, E. L. (2006). Evaluating and improving the quality of care for acute myocardial infarction: can regionalization help?. JAMA 295: 2177-2179 [Full Text]  
• Rathore, S. S., Epstein, A. J., Nallamothu, B. K., Krumholz, H. M. (2006). Regionalization of ST-Segment Elevation Acute Coronary Syndromes Care: Putting a National Policy in Proper Perspective. J Am Coll Cardiol 47: 1346-1349 [Abstract] [Full Text]  
• Nallamothu, B. K., Bates, E. R., Wang, Y., Bradley, E. H., Krumholz, H. M. (2006). Driving Times and Distances to Hospitals With Percutaneous Coronary Intervention in the United States: Implications for Prehospital Triage of Patients With ST-Elevation Myocardial Infarction. Circulation 113: 1189-1195 [Abstract] [Full Text]  
• Nallamothu, B. K., Wang, Y., Magid, D. J., McNamara, R. L., Herrin, J., Bradley, E. H., Bates, E. R., Pollack, C. V. Jr, Krumholz, H. M., for the National Registry of Myocardial Infarction, (2006). Relation Between Hospital Specialization With Primary Percutaneous Coronary Intervention and Clinical Outcomes in ST-Segment Elevation Myocardial Infarction: National Registry of Myocardial Infarction-4 Analysis. Circulation 113: 222-229 [Abstract] [Full Text]  
• Smith, S. C. Jr, Feldman, T. E., Hirshfeld, J. W. Jr, Jacobs, A. K., Kern, M. J., King, S. B. III, Morrison, D. A., O'Neill, W. W., Schaff, H. V., Whitlow, P. L., Williams, D. O., Antman, E. M., Smith, S. C. Jr, Adams, C. D., Anderson, J. L., Faxon, D. P., Fuster, V., Halperin, J. L., Hiratzka, L. F., Hunt, S. A., Jacobs, A. K., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B. (2006). ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 47: 216-235 [Full Text]  
• Smith, S. C. Jr, Feldman, T. E., Hirshfeld, J. W. Jr, Jacobs, A. K., Kern, M. J., King, S. B. III, Morrison, D. A., O'Neill, W. W., Schaff, H. V., Whitlow, P. L., Williams, D. O., Antman, E. M., Smith, S. C. Jr, Adams, C. D., Anderson, J. L., Faxon, D. P., Fuster, V., Halperin, J. L., Hiratzka, L. F., Hunt, S. A., Jacobs, A. K., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B. (2006). ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 113: 156-175 [Full Text]  
• (2005). Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation 112: IV-89-IV-110 [Full Text]  
• de Belder, A (2005). Should primary angioplasty be available for all patients with an ST elevation myocardial infarction?. Heart 91: 1509-1511 [Abstract] [Full Text]  
• Wharton, T. P. Jr, Keeley, E. C., Grines, C. L., Wharton, T. P. Jr, Keeley, E. C., Grines, C. L. (2005). The Case for Community Hospital Angioplasty. Circulation 112: 3509-3534 [Full Text]  
• (2005). Part 5: Acute Coronary Syndromes. Circulation 112: III-55-III-72 [Full Text]  
• Al-Khatib, S. M., Lucas, F. L., Jollis, J. G., Malenka, D. J., Wennberg, D. E. (2005). The Relation Between Patients' Outcomes and the Volume of Cardioverter-Defibrillator Implantation Procedures Performed by Physicians Treating Medicare Beneficiaries. J Am Coll Cardiol 46: 1536-1540 [Abstract] [Full Text]  
• Andersen, H R, Terkelsen, C J, Thuesen, L, Krusell, L R, Kristensen, S D, Botker, H E, Lassen, J F, Nielsen, T T (2005). Myocardial infarction centres: the way forward. Heart 91: iii12-iii15 [Abstract] [Full Text]  
• Authors/Task Force Members, , Silber, S., Albertsson, P., Aviles, F. F., Camici, P. G., Colombo, A., Hamm, C., Jorgensen, E., Marco, J., Nordrehaug, J.-E., Ruzyllo, W., Urban, P., Stone, G. W., Wijns, W. (2005). Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26: 804-847 [Full Text]  
• Rathore, S. S., Epstein, A. J., Volpp, K. G. M., Krumholz, H. M. (2005). Regionalization of Care for Acute Coronary Syndromes: More Evidence Is Needed. JAMA 293: 1383-1387 [Full Text]  
• Nallamothu, B. K., Bates, E. R., Herrin, J., Wang, Y., Bradley, E. H., Krumholz, H. M., for the NRMI Investigators, (2005). Times to Treatment in Transfer Patients Undergoing Primary Percutaneous Coronary Intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 Analysis. Circulation 111: 761-767 [Abstract] [Full Text]  
• Heuschmann, P. U., Kolominsky-Rabas, P. L., Roether, J., Misselwitz, B., Lowitzsch, K., Heidrich, J., Hermanek, P., Leffmann, C., Sitzer, M., Biegler, M., Buecker-Nott, H.-J., Berger, K., for the German Stroke Registers Study Group, (2004). Predictors of In-Hospital Mortality in Patients With Acute Ischemic Stroke Treated With Thrombolytic Therapy. JAMA 292: 1831-1838 [Abstract] [Full Text]  
• Brophy, J. M., Bogaty, P. (2004). Primary Angioplasty and Thrombolysis Are Both Reasonable Options in Acute Myocardial Infarction. ANN INTERN MED 141: 292-297 [Abstract] [Full Text]  
• Keeley, E. C., Grines, C. L. (2004). Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way?. ANN INTERN MED 141: 298-304 [Abstract] [Full Text]  
• Waters, R. E. II, Singh, K. P., Roe, M. T., Lotfi, M., Sketch, M. H. Jr, Mahaffey, K. W., Newby, L. K., Alexander, J. H., Harrington, R. A., Califf, R. M., Granger, C. B. (2004). Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 43: 2153-2159 [Abstract] [Full Text]  
• Montalescot, G, Andersen, H R, Antoniucci, D, Betriu, A, de Boer, M J, Grip, L, Neumann, F J, Rothman, M T (2004). Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction. Heart 90: e37-e37 [Abstract] [Full Text]