Universal access to a percutaneous coronary intervention hospital: is it feasible or desirable?

D uring the past decade, advances in device technology (eg, drug-eluting stents), development of safer antico-agulants (eg, bivalirudin), and refinement in procedural techniques have led to a dramatic improvement in the effectiveness and safety of percutaneous coronary intervention (PCI), despite increasing clinical and anatomic complexity of treated patients. 1 As safety and effectiveness have been documented, the indications for PCI have expanded. In patients with ST-segment elevation myocardial infarction (STEMI), the superiority of primary PCI (when readily available) over thrombolytics is well established. 2 More recently, PCI has also become a viable alternative to coronary artery bypass grafting in select patients with coronary artery disease. 3 As appreciation of the effectiveness of PCI has grown, there has been rapid diffusion of PCI capability into US hospitals. Dissemination of PCI has been further augmented by generous hospital and physician reimbursement, reductions in federal regulatory policies, and accumulating evidence that PCI can be performed safely at hospitals without on-site cardiac surgical backup. 4,5 As a result, hospitals with PCI availability in the United States increased from 929 in 1993 to 1316 in 2004. 6 Despite the growth in capacity, PCI is not available at all hospitals at all times. In fact, most patients with STEMI initially present to hospitals without PCI capability, where treatment options may include on-site thrombolytics or transfer to the nearest PCI-capable hospital for primary PCI. Based on demonstration of the superiority of primary PCI over thrombolytics, 2 transfer to a PCI-capable hospital has been widely promoted as a treatment strategy for these patients. 7 However, reperfusion in patients transferred for primary PCI is frequently delayed because Ͻ10% of these patients achieve the recommended door-to-balloon (D2B) time of Ͻ90 minutes. 8 This is in sharp contrast to patients presenting directly to PCI-capable hospitals, where the astounding success of the D2B Alliance Program has led to a remarkable reduction in reperfusion delays and achievement of a median D2B time of 64 minutes. 9 Given this disparity in reperfusion times for direct-arrival and transferred patients with STEMI, it is important to assess whether new PCI programs have brought more patients closer to a PCI-capable hospital. To address this matter, in this issue of Circulation: Car-diovascular Quality and Outcomes, Concannon et al 10 provide interesting new data describing the growth of PCI capability in US hospitals between 2001 and 2006 and how this expansion has affected geographic access to PCI hospitals for …