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Same-Day Discharge After Percutaneous Coronary Intervention A Meta-Analysis
Abstract
Objectives:
This study sought to assess the safety of same-day discharge in patients undergoing percutaneous coronary intervention (PCI).
Background:
The safety of same-day discharge has previously been evaluated primarily in small, single-center studies.
Methods:
We conducted a meta-analysis of studies reporting outcomes of patients discharged on the same day as PCI. Demographic data, procedural characteristics, and adverse outcomes were collected. Two composite outcomes were pre-specified: 1) death, myocardial infarction (MI), or target lesion revascularization (TLR); and 2) major bleeding or vascular complications.
Results:
Data from 12,803 patients in 37 studies were collated, including 7 randomized controlled trials (RCTs) (n = 2,738) and 30 observational studies (n = 10,065). The majority of patients in both cohorts underwent PCI for stable angina. The vascular access site was predominantly transradial in the randomized cohort (60.8%) and transfemoral in the observational cohort (70.0%). In the RCTs, no difference was seen between same-day discharge and routine overnight observation with regard to death/MI/TLR (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.43 to 1.87; p = 0.78) or for major bleeding/vascular complications (OR: 1.69; 95% CI: 0.84 to 3.40; p = 0.15). In observational studies, the primary outcome of death/MI/TLR occurred at a pooled rate of 1.00% (95% CI: 0.58% to 1.68%), and major bleeding/vascular complications occurred at a pooled rate of 0.68% (95% CI: 0.35% to 1.32%).
Conclusions:
In selected patients undergoing largely elective PCI, same-day discharge was associated with a low rate of major complications and appeared to be as safe as routine overnight observation.
... This trend runs parallel with an increase in radial access PCI [1], which has shown a substantially lower rate of bleeding complications and adverse events [7] and is clearly preferred by patients [8]. Currently available data from predominantly nonrandomized or single-center studies show no adverse effects of SDD PCP on short-term or long-term outcome [9][10][11]. ...
... The most important doubt is the question if major complications can be detected with adequate precision, even including large registries, due to their very low event rate. As pointed out before [9,10], most single-center studies are underpowered to detect rare adverse events, therefore meta-analyses are of specific importance as a foundation for practice recommendations. Currently available metaanalyses have been published over a large time span [9][10][11][12], therefore incorporating a relatively heterogeneous group of technical, interventional and medication standards. ...
... As pointed out before [9,10], most single-center studies are underpowered to detect rare adverse events, therefore meta-analyses are of specific importance as a foundation for practice recommendations. Currently available metaanalyses have been published over a large time span [9][10][11][12], therefore incorporating a relatively heterogeneous group of technical, interventional and medication standards. Especially the fact that currently radial access is the clinical standard for diagnostic angiographies (DA) and coronary interventions (PCI) in Austria and many other European countries would make a review and meta-analysis with a focus on data from radial access SDD procedures especially valuable. ...
Introduction
Percutaneous coronary intervention is a well-established revascularization strategy for patients with coronary artery disease. The safety and feasibility of performing these procedures on a same-day discharge basis for selected patients has been studied in a large number of mostly nonrandomized trials. An up to date literature review should focus on trials with radial access, representing the current standard for coronary procedures in Austria and other European countries.
Methods
The aim of this consensus statement is to review the most recent evidence for the safety and feasibility of performing same-day discharge procedures in selected patients. A structured literature search was performed using prespecified search criteria, focusing on trials with radial access procedures.
Results
A total of 44 clinical trials and 4 large meta-analyses were retrieved, spanning 21 years of clinical evidence from 2001 to 2022. The outcome data from a wide range of clinical settings were unanimous in showing no negative effect on early (24 h) or late (30 day) major adverse events after same-day discharge coronary procedures. Based on nine prospective trials a comprehensive meta-analysis was compiled. Using 1‑month major adverse events data the pooled odds ratio of same-day discharge versus overnight stay procedures was 0.66 (95% confidence interval, CI 0.35–01.24; p = 0.19; I ² 0%), indicating a noninferiority in carefully selected patients.
Conclusion
Outcome data from same-day discharge coronary intervention trials with radial access confirm the robust safety profile showing no increase in the risk of major adverse events compared to overnight stay.
... [2][3][4] Most major, adverse events often occur within the first 6 hours after PCI. 5 In 2009, the Society for Cardiovascular Angiography and Interventions, endorsed by the American College of Cardiology Foundation, stated on their consensus documents that: after PCI, patients could be discharged within the same calendar day after the intervention. 6 After that, various studies also supported that same day discharge PCIs or day case PCIs are both feasible and safe. ...
... From systematic review, a randomized control trial by Brayton et al. 5 , reported factors related to vascular complications were patients with hypertension, receiving dual antiplatelet, coronary intervention, receiving heparin, introducer sheath size, and use of glycoprotein IIb/IIIa inhibitors during the procedure. 5 Although, the incidence of vascular complications after cardiac catherization were reported by studies in Thailand 11 and other countries [12][13][14][15] , the risk factors and criteria for selecting patients as a day case CAG/PCI has not been studied in the Thai population, and this in effect may be different from other countries. ...
... From systematic review, a randomized control trial by Brayton et al. 5 , reported factors related to vascular complications were patients with hypertension, receiving dual antiplatelet, coronary intervention, receiving heparin, introducer sheath size, and use of glycoprotein IIb/IIIa inhibitors during the procedure. 5 Although, the incidence of vascular complications after cardiac catherization were reported by studies in Thailand 11 and other countries [12][13][14][15] , the risk factors and criteria for selecting patients as a day case CAG/PCI has not been studied in the Thai population, and this in effect may be different from other countries. In so saying, we hypothesized vascular complications would not differ between the day case and inpatient CAG/PCI groups. ...
Objective: To compare the incidence along with risk factors of vascular complications between patients having undergone Coronary angiography/Percutaneous Coronary Interventions (CAG/PCIs); as day cases and those as inpatients.
Material and Methods: Our study is a retrospective cohort study. We performed a retrospective chart review of the patients, visiting a heart center of the hospital from October, 2014 to September, 2018. We included patients of a minimum 18 years of age, who had undergone CAG/PCIs. Excluded patients were those who had been referred from other hospitals. The main outcomes were vascular complications defined as: (1) bleeding with significant blood loss during the procedure. (2) Hematoma within 1 month after the procedure. Wilcoxon’s rank sum and chi-squared test were used to assess the risk factors.
Results: Of all 784 patients having undergone CAG/PCI, 387 were day cases and 397 were inpatients. Only 12 cases developed vascular complications. The incidence of vascular complications was not significantly different between either day case; whose incidence was 1.3% (95% confidence interval (CI), 0.72-1.87), and inpatients; whose incidence was 1.8% (95% CI, 1.10-2.42). We found that the risk factors of vascular complications were percutaneous coronary intervention, and using a vascular closure device to remove the introducer sheath.
Conclusion: Performing CAG/PCI as day cases did not increase the risks of complications post-procedure, as compare to the inpatients. However, due to the small numbers of patients with complications future studies with more patients are needed to ensure the safety of day case CAG/PCI. Patients undergoing PCI, or patients with vascular closure devices used should be closely observed before discharge.
... As stated above, the Austrian Society of Cardiology has performed a systematic literature review and metaanalysis to substantiate its practice recommendations [14]. In short, four large meta-analyses have published outcome data for SDD PCI [19][20][21][22], summarizing 38,785 patients with SDD and 256,049 patients staying overnight. All four meta-analyses are consistent in demonstrating no added risk of SDD practice assessed by MACE at 24 h and/or 30 days. ...
... The Austrian Society of Cardiology has considered recent publications from the ACC [3] and SCAI [4,5,13] and a wide scope of publications on radial access SDD PCI to develop an evidence base for its own individual position. Based on data from 4 expert consensus statements [3][4][5]13], 4 large meta-analyses [19][20][21][22], and a separate literature review performed by the AGIK [14], spanning 21 years of clinical evidence from 2001 to 2022, the practice of SDD DA and PCI can be considered safe and feasible for a subset of CAD patients carefully selected by the criteria detailed above ( Table 2). The SDD outpatient clinics provide additional value in fulfilling a well-documented patient preference towards shorter hospital stay following PCPs. ...
Introduction
Percutaneous coronary intervention is a well-established revascularization strategy for patients with coronary artery disease. Recent technical advances such as radial access, third generation drug-eluting stents and highly effective antiplatelet therapy have substantially improved the safety profile of coronary procedures. Despite several practice guidelines and a clear patient preference of early hospital discharge, the percentage of coronary procedures performed in an outpatient setting in Austria remains low, mostly due to safety concerns.
Methods
The aim of this consensus statement is to provide a practical framework for the safe and effective implementation of coronary outpatient clinics in Austria. Based on a structured literature review and an in-depth analysis of available practice guidelines a consensus statement was developed and peer-reviewed within the working group of interventional cardiology (AGIK) of the Austrian Society of Cardiology.
Results
Based on the available literature same-day discharge coronary procedures show a favorable safety profile with no increase in the risk of major adverse events compared to an overnight stay. This document provides a detailed consensus in various clinical settings. The most important prerequisite for same-day discharge is, however, adequate selection of suitable patients and a structured peri-interventional and postinterventional management plan.
Conclusion
Based on the data analysis this consensus document provides detailed practice guidelines for the safe operation of daycare cathlab programs in Austria.
... Similarly, follow-up after 30 days was successfully completed for 574 patients with loss to follow-up rate of 4.3% (26). Cumulative MACE rate after 30 days was observed to be 4.9% (28) with 2.3% (13) allcause mortality, 1.4% (8) cerebrovascular events, 1.2% (7) unplanned coronary revascularization, 0.5% (3) unplanned hospitalization for unstable angina, and 0.3% (2) bleeding events. ...
... Similarly, many other studies conducted in various parts of the world showed evidence in favor of the early discharge (≤ 72 hours) strategy [11][12][13][14]23]. However, evidence regarding safety of same day (≤ 24 hours) discharge strategy in setting of primary PCI is very limited as safety of this strategy after successful ad hoc or elective PCI has been reported by only a few studies [24][25][26]. In this study very early (≤ 24 hours) discharge after primary PCI has been shown to be feasible and safe, subject to the careful risk assessment of patients. ...
... [5][6][7][8][9] Several meta-analyses have also shown that patients discharged on the same day had similar rates of major adverse cardiovascular events, repeat hospitalisations and overall complications as the patients who were observed overnight. [10][11][12] Patient heterogeneity, procedural characteristics and definitions of complications among the various studies are limitations of the meta-analyses. These studies provide the best evidence to date with regards to the safety of same-day discharge in PCI. ...
... 10 A similar analysis also showed that in selected patients undergoing PCI, same day discharge was not associated with a higher rate of major adverse events and this strategy appeared to be as safe as an overnight admission. 11 They also showed that patients who were excluded from same day discharge following PCI had worse short-and long-term outcomes however these likely represented a higher-risk group. More recently, a review of 8 randomised control trials showing that mortality, myocardial infarction (MI) and major adverse cardiac events (MACEs) were not significantly different between same day discharge versus overnight stay following PCI. ...
Background
Advances in percutaneous coronary intervention (PCI) has made the possibility of facilitating same day discharge (SDD) of patients undergoing intervention. We sought to investigate the feasibility, safety and economic impact of such a service.
Methods
We retrospectively collected data on all patients undergoing outpatient PCI at our institution over a 12-month period. We included in-hospital and 30-day major adverse cardiac events (MACE), vascular complications, acute kidney injury and any re-hospitalisations. We analysed the cost effectiveness of SDD compared to overnight admission post PCI and staged PCI following diagnostic angiography.
Results
A total of 147 patients undergoing PCI with 129 patients deemed suitable for SDD (88%). Mean age was 65.7 years. Most patients had type C lesions (60.3%); including 4 chronic total occlusions (CTOs). At 30-day follow-up there were no MACE events (0%). There were 10 (7.8%) re-hospitalisations of which majority (70%) were non cardiac presentations. We also included cost analysis for an elective PCI with SDD, which equated to $2090 per patient (total of $269 610 for cohort). Elective PCI with an overnight admission was $4440 per patient (total of $572 760 for cohort), an additional $2350 per patient (total $303 150). Total cost of an angiogram followed by a staged PCI with an overnight stay was $4700 per patient (total $606 300).
Conclusion
SDD is safe and feasible in the majority of patients that have elective coronary angiography that require PCI. SDD leads to a significant reduction in total cost and hospital stay of patients undergoing elective PCI.
... Similarly, follow-up after 30 days was successfully completed for 574 patients with loss to follow-up rate of 4.3% (26). Cumulative MACE rate after 30 days was observed to be 4.9% (28) with 2.3% (13) allcause mortality, 1.4% (8) cerebrovascular events, 1.2% (7) unplanned coronary revascularization, 0.5% (3) unplanned hospitalization for unstable angina, and 0.3% (2) bleeding events. ...
... Similarly, many other studies conducted in various parts of the world showed evidence in favor of the early discharge (≤ 72 hours) strategy [11][12][13][14]23]. However, evidence regarding safety of same day (≤ 24 hours) discharge strategy in setting of primary PCI is very limited as safety of this strategy after successful ad hoc or elective PCI has been reported by only a few studies [24][25][26]. In this study very early (≤ 24 hours) discharge after primary PCI has been shown to be feasible and safe, subject to the careful risk assessment of patients. ...
Background:
The strategy for early discharge after primary percutaneous coronary intervention (PCI) could have substantial financial benefits, especially in low-middle income countries. However, there is a lack of local evidence on feasibility and safety of the strategy for early discharge. Therefore, the aim of this study was to assess the safety of early discharge after primary PCI in selected low-risk patients in the population of Karachi, Pakistan.
Methods:
In this study 600 consecutive low-risk patients who were discharged within 48 hours of primary PCI were put under observation for major adverse cardiac events (MACE) after 7 and 30 days of discharge respectively. Patients were further stratified into discharge groups of very early (≤ 24 hours) and early (24 to 48 hours).
Results:
The sample consisted of 81.8% (491) male patients with mean age of 54.89 ± 11.08 years. Killip class was I in 90% (540) of the patients. The majority of patients (84%) were discharged within 24 hours of the procedure. Loss to follow-up after rate at 7 and 30 days was 4% (24) and 4.3% (26) respectively. Cumulative MACE rate after 7 and 30 days was observed in 3.5% and 4.9%, all-cause mortality in 1.4% and 2.3%, cerebrovascular events in 0.9% and 1.4%, unplanned revascularization in 0.9% and 1.2%, re-infarction in 0.3% and 0.5%, unplanned re-hospitalization in 0.5% and 0.5%, and bleeding events in 0.5% and 0.5% of the patients respectively.
Conclusion:
It was observed that very early (≤ 24 hours) discharge after primary PCI for low-risk patients is a safe strategy subjected to careful pre-discharge risk assessment with minimal rate of MACE after 7-days as well as 30-days.
... Patients undergoing an emergent PCI, patients > 70 years, patients prescribed IIb/IIIa inhibitor medications, and those with high-risk lesions (according to the ACC/AHA classi cation) [10] abnormal pre-catheterization laboratory investigations, severe left ventricular dysfunction, stroke, contrast allergy, or a glomerular ltration rate < 60 ml/min Results were excluded from the study. The induction of patients into the study was further guided by the criteria used by Brayton et al [11]. ...
... Most patients underwent PCI via bare metal stents because of economic feasibility. The decision regarding the type of the stent was based on the type, location, and characteristics of the lesion [11]. After completion of successful PCI, patients were moved to the coronary care unit for post-procedure monitoring and care. ...
Objective: Cardiovascular disease have a large disease burden in developing countries. Percutaneous coronary intervention (PCI) is one of the modalities used to restore the blood flow in atherosclerotic coronary vessels. The aim of this randomized controlled trial was to evaluate the safety of same-day discharge compared to overnight hospital stay after low-risk elective PCI in a tertiary care hospital in Pakistan.
Results: From September 2014 to September 2015, a total of 210 patients who underwent low-risk PCI were randomized to overnight stay or same-day discharge. Primary endpoint of the study was a major adverse event, a composite of death, myocardial infarction, repeat revascularization, rehospitalization, and any access site complications (major bleeding or hematoma) after the procedure. No major adverse events were noted within 24 hours in either group. The only reported adverse event was myocardial infarction secondary to stent thrombosis on the third day after PCI in the same-day discharge group. No mortality or access site complications occurred in either group. In our cohort, same-day discharge after low-risk PCI was safe and should be considered for certain patients to eliminate the cost of an overnight hospital stay.
clinical trial registry number: NCT02214082. Registered on 11th August 2014
... Few of the initial studies had enrolled only CSA [2,5] and simpler lesion for SDD ( [12,16] while we had 72% type C lesion in SDD patients, which was similar to the study by Amin, et al. [3]. Two meta-analyses of randomized and observations studies [17,18] had shown no difference in mortality, myocardial patients [11][12][13][14][15][16], whereas the study of Amin et al. had transradial access in 42% and 4.5% of SDD and NDD patients, respectively [3]. The present study had transradial access in 85% of SDD patients. ...
... We did not find a significant difference in safety outcomes of two groups at 6 weeks of followup, similar to other studies [12,14,16]. Two meta-analyses also confirmed the safety of SDD in terms of adverse events, such as mortality, myocardial infarction, major bleeding, blood transfusion, repeated revascularization, and rehospitalization [17,18]. None of the 187 SDD patients in the present study had local site vascular complications, stent thrombosis, rehospitalization, repeat PCI, or mortality. ...
The exponential increase in percutaneous coronary intervention (PCI) and increasing use of the transradial approach has set an ideal scenario for the cost-effective and relatively safe same-day discharge (SDD) policy in various institutes. We hereby report a single-center, prospective, observational study of 628 consecutive PCI patients, who had SDD or had overnight observation followed by next day discharge (NDD). Patients of chronic stable angina (CSA), unstable angina, and acute myocardial infarction (MI) were enrolled in the study. The baseline characteristics, safety, feasibility and 6 weeks of clinical outcomes were assessed in the two groups. Out of the 628 patients, 187 (30%) had SDD, and 358 (57%) had NDD. Transradial access was significantly more in SDD compared to NDD (P<0.001). The syntax score was significantly higher in NDD compared to the SDD (P<0.001). Five patients of NDD had clinical events at 6 weeks of follow-up, while none of SDD had any events. Patients with unstable angina (P = 0.024), MI (P≤0.001), prior PCI (P = 0.037), femoral access (P = 0.012), and high syntax score (P = 0.001) were more frequently discharged on next day. Factors such as CSA (P = 0.991), type of lesion (P = 0.984) and left ventricle ejection fraction (P = 0.535) were not the limiting factors for SDD. The present study demonstrated that SDD is safe and feasible in CSA patients, and a careful pre- and post-procedural risk assessment could enable SDD even in the complex cases.
... Moreover, practice gaps in patients' management have been noticed between hospitals with or without a catheterization laboratory (cath-lab) facility (hub centres vs. spoke centres) [4][5][6][7][8]. The service strategy is explained as the same-day transfer between the referring non-invasive spoke hospital and the hub centre with cath-lab facility; it has been shown to be a safe option and to minimise these inconsistencies [9][10][11][12][13][14]. The aim of this study was to retrospectively analyse the implementation of the service strategy and the 1-year outcomes of the elderly admitted in spoke hospitals of an Italian cardiology network. ...
Background:
Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility.
Purpose:
The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals.
Methods:
Observational-retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date.
Results:
From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82-89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25-87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7-27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0-4.0]; p < 0.001).
Conclusions:
An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.
... 5 However, with more widespread use of transradial vascular access, same-day discharge (SDD) after PCI has become safe and feasible with appropriate patient selection. [6][7][8][9] The American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) independently published consensus documents regarding appropriate length of stay following PCI and similarly advise that evidence strongly supports the safety of SDD after elective PCI. 8 , 10-13 Data regarding safety of SDD among patients presenting with NSTE-ACS are less robust and accrued during an era of widespread GP IIB/IIIA inhibitor use. 7 , 9 Current recommendations regarding safety of SDD for patients presenting with NSTE-ACS are understandably mixed. ...
Background and Aim
: Timing of discharge after percutaneous coronary intervention (PCI) is a crucial aspect of procedural safety and patient turnover. We examined predictors and outcomes of same-day discharge (SDD) after non-elective PCI for non-ST elevation acute coronary syndromes (NSTE-ACS) in comparison with next-day discharge (NDD).
Methods
: Baseline demographic, clinical, and procedural data were as well as in-hospital outcomes and post-PCI length of stay (LOS) were collected for all patients undergoing non-elective PCI for NSTE-ACS between 2011 and 2014 at a central tertiary care center. Thirty day and 1-year mortality and bleeding as well as 30-day readmission rates were determined from social security record and medical chart review. Logistic regression was performed to identify predictors of SDD, and propensity-matched analysis was done to examine the differences in outcomes between NDD and SDD.
Results
: Out of 2,529 patients who underwent non-elective PCI for NSTE-ACS from 2011-2014, only 1,385 met the inclusion criteria (mean age = 63 years; 26% women) and were discharged either the same day of (N=300) or the day after (N=1085). Thirty-day and one-year mortality and major bleeding rates were similar between the two groups. Logistic regression identified male sex, radial access, negative troponin biomarker status, and procedure start time as predictors of SDD. In propensity-matched analyses, there was no difference in 30-day mortality and readmission between SDD and NDD groups.
Conclusions
: SDD after non-elective PCI for NSTE-ACS may be a reasonable alternative to NDD for selected low-risk patients with comparable mortality, bleeding, and readmission rates.
... Safety and feasibility of same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) in low-risk patients have been established in various randomized controlled trials and meta-analysis [1,2,3,4,5,6,7,8,9]. The data about SDD after PCI in acute coronary syndrome (ACS) is scarce [10,11]. ...
Background
The literature about the safety and feasibility of same-day discharge (SDD) following complex percutaneous coronary intervention (PCI) and in acute coronary syndrome (ACS) is scarce. The economic impact of SDD has not been evaluated in this geographical region. We in the present study evaluated the safety, feasibility, and economic impact of SDD following PCI at a tertiary care centre of north India.
Methods
It was a single-centre, non-randomized, prospective study, in which all consecutive PCI patients during the study period of 15 months were evaluated for SDD using a “patient-centred” approach. The patients who were discharged on the next calendar day were included in the next day discharge (NDD) group. The baseline demographic data including coronary risk factors, clinical presentation, and management details were noted for all patients. All patients were followed up for 6 weeks. The Indian health system is only partially insured, hence most of the expendable costs are borne by patients. In the present study, we computed the total societal expenditure of each PCI which includes both the health system costs and the expenditure borne by the patients. A standardized tool and bottoms up costing method were used for recording out-of-pocket expenditure (OOPE) by the patients and health care expenditure respectively.
Results
Out of a total of 675 PCI patients, 617 patients were enrolled in the study, and 132/617 (21.39%) patients were discharged the same day. Sixty-five % of patients (86/132) in the SDD cohort and 70% of patients (337/485) in the NDD cohort presented with ACS. Baseline characteristics in the two cohorts were identical. A higher syntax score, greater number of stents, and longer stented segment predicted the NDD. The mean length of stay after PCI in patients with SDD and NDD was 8.71 ± 2.48 and 21.76 ± 2.42 h, respectively. In the SDD group, there were no readmissions or adverse events after discharge till 6 weeks of follow-up. The total mean cost of PCI (health care system and OOPE) for SDD and NDD was Indian Rupees (INR) 129,322.14 [United States dollar (US$) 1810.51] and INR 165500.71 [US$ 2317.01] respectively. An amount of INR 36178.57 (health system cost: INR 10242.76 and OOPE: INR 25935.71 was saved for each SDD. Besides 100 cardiac unit bed days including 85 intensive cardiac care bed days were saved with 21% SDD in the present cohort.
Conclusion
Post PCI SDD is safe and feasible in selected ACS/chronic stable angina patients using the “patient-centred” approach. Besides, decreasing OOPE for the patients, SDD also helps in the efficient use of scarce health system resources.
... A recently published meta-analysis did not find difference in MACE between SDD and overnight stay. 20,29 Furthermore, in the group of patients hospitalized, there was a 8% of in-hospital-related infections or fall-related injuries. 30,31 From the institution operational perspective, the SDD for elective-PCI may offers a myriad of benefits. ...
... Three meta-analyses consistently demonstrated the safety of SDD for patients after uncomplicated PCI. [4][5][6] Recent studies have examined the safety profile of SDD among patients with complex lesions, 7,8 and the evidence to date has not indicated an additional risk associated with SDD relative to an overnight hospital stay. Moreover, SDD is associated with higher patient satisfaction and lower costs incurred by both patients and healthcare systems. ...
Background
Despite an evidence-based protocol to facilitate same-day discharge (SDD) of patients undergoing elective intracoronary procedures, overnight hospitalization remains a routine practice.
Objectives
This study aimed to determine the frequency of SDD after intracoronary procedures among patients treated before and during the COVID-19 pandemic, and identify factors predictive of a decision for SDD.
Methods
This retrospective cohort study (N = 680) was based on registry data of a cardiac ambulatory center.
Results
The frequency of SDD was significantly higher in 2020 relative to 2019 (p <0.001). No complication were identified during the next-day follow-up among SDD cohort. Compared to those who stayed overnight, SDD patients had a lower 30-day readmission rate (p<0.001), but not 30-day mortality (p=1.000). Radial access, some procedural-related and comorbidities of patients significantly predicted SDD.
Conclusions
SDD is safe and feasible when a dedicated protocol has been implemented. The findings support the routine use of this practice.
... In this context, the appropriateness of both TRI and SDD as candidate approaches to PCI care is self-evident. Both approaches are safe (as shown by several previous studies and meta-analyses) [33,[72][73][74][75] effective as demonstrated by the associated cost savings shown here; efficient (as demonstrated by studies on time demands of PCI options) [43,[76][77][78] and patientcentered (since they both target patient satisfaction) [66]. In this context, it is encouraging to note that the use of TRI in the United States is rapidly increasing. ...
Transradial access for PCI (TRI) along with same day discharge (SDD) is
associated with varying estimates of cost savings depending on the population
studied, the clinical scenario and application to low-risk vs high-risk patients.
A summary estimate of the true cost savings of TRI and SDD are unknown. We
searched the PubMed, EMBASE®, CINAHL® and Google
Scholar® databases for published studies on hospitalization costs
of TRI and SDD. Primary outcome of interest in all included studies was the cost
saving with TRI (or SDD), inflation-corrected US$ 2018 values using the medical
consumer price index. For meta-analytic synthesis, we used Hedges’ summary
estimate (g) in a random-effects framework of the DerSimonian and Laird model,
with inverse variance weights. Heterogeneity was quantified using the I2
statistic. The cost savings of TRI from four US studies of 349,757 patients
reported a consistent and significant cost saving associated with TRI after
accounting for currency inflation, of US$ 992 (95% CI US$ 850–1,134). The
cost savings of SDD from six US studies of 1,281,228 patients, after
inflation-correcting to the year 2018, were US$ 3,567.58 (95% CI US$
2,303–4,832). In conclusion, this meta-analysis demonstrates that TRI and SDD
are associated with mean cost reductions of by approximately US$ 1,000/patient
and US$ 3,600/patient, respectively, albeit with wide heterogeneity in the cost
estimates. When combined with the safety of TRI and SDD, this meta-analysis
underscores the value of combining TRI and SDD pathways and calls for a
wide-ranging practice change in the direction of TRI and SDD.
... Therefore, potential post-discharge complications should be carefully monitored with both SDD protocol and usual discharge protocols. As proposed in the previous meta-analysis on safety of SDD protocol among patients receiving percutaneous coronary intervention [23], the implementation of this strategy which only selected patients with low risk of complications will be allowed to discharge same-day after PVI and patients at high risk will be followed up for at least one night would be better in the first period. The presence of congestive heart failure, intraprocedural complications, high burden of comorbidity, and low AF ablation hospital volume have been known as prognostic factors of early mortality following AF ablation [4,24]. ...
PurposeThe purpose of this systematic review and meta-analysis was to evaluate the feasibility and safety of a same-day discharge protocol following pulmonary vein isolation (PVI).Methods
PubMed and Embase were systematically investigated from the inception to 20 July 2020. Studies on safety and feasibility of PVI for atrial fibrillation (AF) were included. Study-specific estimates were combined using one-group meta-analysis with a random-effects model.ResultsSeven observational studies investigating the safety and feasibility of same-day discharge protocols were identified. Of a total of 3656 patients who have undergone PVI for AF, the overall complication rate was 0.80% (95% confidence interval [CI], 0.20–1.40%). The readmission within 30-day following same-day discharge protocol occurred at a pooled rate of 3.6% (95% CI, 0.0–8.4%). Frequent complications following the procedure were complications related to vascular access (0.38%; 95% CI, 0.18–0.58%), and phrenic nerve injury (0.19%; 95% CI, 0.05–0.33%). The reported complications in SDD group were mainly based on results among patients without perioperative complications.Conclusions
The introduction of same-day discharge strategies might be safe and feasible in selected patients given the reported complication and re-admission rates in the current practice. Further prospective studies are needed to confirm these findings.
... The impetus for SDD for PCI reflects not only patient preference and satisfaction, but also safety. In terms of major adverse cardiovascular events, meta-analyses have found no difference between same-and next-day discharge following PCI (6,7). However, data suggest that approximately 8% of hospitalizations are associated with highly undesirable events such as hospital-acquired infections or falls leading to injury (8,9). ...
... A meta-analysis of these studies revealed that in selected patients undergoing largely elective PCI, same-day discharge was associated with a low rate of major complications and appeared to be as safe as routine overnight observation. 27 36 have shown that same-day discharge after radial coronary intervention in certain low-risk patients is a safe and feasible strategy because it enables immediate ambulation. Largest study of same day discharge which included 2400 patients done by Mehul Patel et al. has shown that when appropriately selected, with strict adherence to the set protocol, sameday discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients. ...
Background: In conventional coronary angiography (CAG) by transfemoral approach patients usually need to stay at least one night in hospital. CAG by transradial approach gives the opportunity for same day hospital discharge. The objective of this study was to assess the safety and feasibly of day case CAG in Bangladesh. Methods: This is a single operator observational study where patients admitted for CAG through transradial (conventional and distal radial) approach were included. Patients were admitted at least 2 hours before the procedure. Hemostasis was done with manual compression followed by tight gauge-rolled bandage. Predischarge criteria had been set and applied to all patients. An emergency telephone number was given to the patient and they were contacted on the next day over telephone. Results: 30 (30%) female and 70 (70%) male were included with mean age 53±9SD years. Patients were discharged from the hospital on an average after 3.3±1.1 hours of the procedure. Only 4(4%) patients contacted to the emergency number. No bleeding complication was noted and 16(16%) patients complained about of some puncture site pain. Radial artery patency was was maintained in 96% of the patient on subsequent follow up. Conclusion: Same day hospital discharge is a feasible and safe alternative with similar radial artery patency rate. It will reduce the hospital cost and bed occupancy rate in a busy center in Bangladesh. Cardiovasc. j. 2019; 11(2): 152-158
... Same-day discharge has been proved to be safe for uncomplicated PCI in patients with stable ischemic heart disease [10][11][12][13][14][15][16][17]. In a single-center experience on stable coronary syndromes over a period of 10 years, the SDD was found to be safe with no additional mortality or morbidity concerns. ...
Purpose of review:
Shorter hospital stay after percutaneous coronary intervention (PCI) can provide economic advantage. Same-day discharge (SDD) after transradial PCI is thought to reduce the cost of care while maintaining the quality and safety. This review summarizes the current knowledge of the benefits and safety of this concept.
Recent findings:
Increase in rate of transradial PCI over the last two decades has resulted in recent growth in rate of acceptance of SDD after a successful procedure. SDD is shown to result in savings of $3500 to $5200 per procedure with comparable adverse event rate of traditional discharge processes. SDD after PCI is shown to be safe and results in cost advantage maintaining the safety profile. The acceptance rate of SDD is still not optimum, and further market penetration of SDD practice would be achieved only if the institutional and operator preference barriers are addressed.
... 3,4 Three main drivers for prolonged length of stay include postprocedure bleeding, acute stent thrombosis, or potentially fatal arrhythmic/conduction system disorder events. The use of radial access, small sheath size, and modification of the antiplatelet and anticoagulation protocols have reduced access-related vascular and bleeding complications [5][6][7] ; however, the prevalence and impact of arrhythmias on the safety of such protocols is unknown. In addition, potentially fatal arrhythmic complications dissuade early discharge planning and keep the patient with continuous electrocardiographic monitoring. ...
Background:
The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied.
Methods:
We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed.
Results:
Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non-ST-segment-elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [P<0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population.
Conclusions:
AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.
... Contemporary techniques and pharmacotherapy strategies have improved the safety of PCI, thus reducing risk of major adverse cardiovascular events (MACE) and the requirement for overnight stay in elective cases. Published data have demonstrated that the majority of post-procedural complications occur within the initial 6 hours, and that patients can be safely discharged after a period of observation (3). Implementation of these recommendations into clinical practice has the potential to provide significant healthcare cost savings. ...
Introduction
In 2016, 100,483 patients in the United Kingdom underwent PCI (1). PCI is a guideline recommended treatment for coronary artery disease (2). Contemporary techniques and pharmacotherapy strategies have improved the safety of PCI, thus reducing risk of major adverse cardiovascular events (MACE) and the requirement for overnight stay in elective cases. Published data have demonstrated that the majority of post-procedural complications occur within the initial 6 hours, and that patients can be safely discharged after a period of observation (3). Implementation of these recommendations into clinical practice has the potential to provide significant healthcare cost savings.
Objectives
This study aimed to evaluate the clinical outcomes of patients undergoing elective PCI at a tertiary cardiac centre, determine rates of elective SDD PCI, and identify potential areas for service improvement.
Methods
Elective PCI procedures over a 12-month period (October 2016 – September 2017) were electronically retrieved from our trust’s TOMCAT cardiovascular information system. Incidence of MACE at 30 days after PCI was recorded following review of procedure reports, discharge summaries and hospital re-admission data. NHS numbers were used as unique identifiers to ensure robust data collection. Our data was subsequently compared with the British Cardiovascular Intervention Society (BCIS) 2016 audit results.
Results
306 patients underwent elective PCI during the study period. 1.3% incidence of MACE was recorded (death 0.32% [n=1]; MI 0.32% [n=1]; urgent revascularisation 0.65% [n=2]; stroke [n=0]; emergency CABG [n=0]). 55% (168/306) of elective PCI was performed as a SDD. 34 patients were admitted overnight, despite undergoing uncomplicated single-vessel PCI. Applying published criteria, SDD would have been appropriate in this group. View this table:
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Abstract 66 Table 1
Conclusion
This study demonstrates that elective PCI at our centre is safe and results in low rates of MACE, with clinical outcomes comparable to national audit data. 55% of elective PCI at our centre is SDD, considerably higher than BCIS figures. Patients suitable for SDD were identified and will be the focus of future pathway and service improvement.
References
• British Cardiovascular Intervention Society. BCIS Audit 2016. http://www.bcis.org.uk/wp-content/uploads/2018/03/BCIS-Audit-2016-data-ALL-excluding-TAVI-08-03-2018-for-web.pdf BCIS Audit (Accessed 27th February 2019).
• Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40(2):87–165.
• Brayton KM, Patel VG, Stave C, de Lemos JA, Kumbhani DJ. Same-day discharge after percutaneous coronary intervention: a meta-analysis. J Am Coll Cardiol 2013;62(4):275–85.
Conflict of Interest
None
... Similarly, we found marked variation of more than 16% in SDD across hospitals in Victoria (Figure 2). A systematic review assessing this variation found that deferral of SDD was related to access site complications (33%), physician preference (30%), patient preference (13%) and medical reasons [29]. Herman et al. demonstrated within their single centre study that an increasing percentage of patients was discharged home the same day post elective PCI as greater experience was gained [30]. ...
Background:
Despite international growth in the use of same day percutaneous coronary intervention (PCI), its widespread use remains limited. This study sought to determine the prevalence, clinical outcomes and cost implications of same day discharge (SDD) amongst Australian patients undergoing elective PCI.
Methods:
This is a retrospective, observational cohort study of patients who underwent elective PCI in Victoria between January 2014 and December 2017. Data from this study was obtained from the Victorian Cardiac Outcomes Registry (VCOR). The primary outcome measured was the incidence of 30-day major adverse cardiac events (MACE) and secondary outcomes included in hospital complications and 30-day readmissions, between SDD patients and those observed as inpatients overnight (ON). Propensity score matching for key clinical factors were used to compare both groups.
Results:
We studied 18,101 patients, with a mean age of 68±11years and 13,935 (77%) were male. The rate of SDD was 586 (3.2%) and 17,515 (96.8%) patients stayed in hospital overnight. Radial access was performed in 393 (67.1%) and 7,967 (45.5%) among SDD and ON patients respectively (p<0.001). At 30 days, unplanned cardiac re-hospitalisation occurred in 9.6% (n=56) amongst SDD and 11.6%, (n=2,033) amongst ON patients (p=0.173). Propensity matching highlighted SDD to be non-inferior to overnight, with no significant difference in 30-day MACE (0.5%, 95% CI: 0.34, 1.35) but SDD was associated with reduced average length of stay by 2.06 days (95% CI: 1.94, 2.19). We observed substantial hospital variation for SDD from 0% to 16.6% of elective PCI procedures.
Conclusions:
Same day discharge after elective PCI is performed infrequently in Victoria. Despite this, SDD appears to be safe and feasible. Given significant benefits in cost and bed utilisation, a more consistent use of SDD could markedly improve the value of PCI care in Australia.
... Contemporary techniques and pharmacotherapy strategies have improved the safety of PCI, thus reducing risk of major adverse cardiovascular events (MACE) and the requirement for overnight stay in elective cases. Published data have demonstrated that the majority of post-procedural complications occur within the initial 6 hours, and that patients can be safely discharged after a period of observation (3). Implementation of these recommendations into clinical practice has the potential to provide significant healthcare cost savings. ...
Introduction
NHS England announced a new nurse angiographer role with the purpose of reducing hospital waiting lists for elective angiography.
Methods
Development of a standardised operating procedure for training in Radial Arterial Access (RAA), guidance on how to minimise the risk and recognise complications and post procedural limb management. Obtaining approval at the new procedures committee. Training program 50 consultant supervised nurse led procedures for (RAA), establishing expertise in 100 further procedures, followed by roll out of the program to other nursing staff.
Results
During training (RAA) cannulation was successful on 1st attempt in 42 out of 50 (success rate allowing for two attempts 84%), with no complications recorded. Successful access by a more experienced operator N = 7, failed (RAA) N = 1. The following 100 were performed independently on unselected patients (success rate 81%; (1st pass 70)), with no complications, need for alternate access routes, N = 1. The following table details the success rate and patient comfort score recorded during 104 procedures performed by a nurse specialist and trainee registrars.
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Abstract 65 Table 1
Conclusion
Nurse-led (RAA) is safe and feasible and has the potential to improve catheter laboratory efficiency, patient satisfaction, standardise procedure training and improve staff retention. Our next steps will be to train more nurses in radial access and progress to nurse led angiography.
Conflict of Interest
None
... We were unable to fully understand the reasons for this variation, but these differences were unlikely to be related to patient characteristics because patients from each center are quite similar with respect to baseline demographics and clinical characteristics. 13 Instead, we observed variation in SDD PCI rates for factors that included radial access and hospital characteristics. Such observations show that the practice of PCI was highly dependent on the hospital culture and the ability to embrace changes in clinical practice. ...
Background
To manage overcrowding and bed shortages in Canadian hospitals, same‐day discharge ( SDD ) after percutaneous coronary intervention ( PCI ) has emerged as a solution to improve resource utilization. However, limited information exists regarding current trends, hospital variation, and safety of SDD PCI in Canada.
Methods and Results
We evaluated outpatients undergoing elective PCI in Ontario, Canada, from October 2008 to March 2016. SDD was defined when patients were discharged on the day of PCI , and non‐ SDD was defined as those patients who had 1 overnight stay. The primary outcome was 30‐day all‐cause death or hospitalization for acute coronary syndrome. Inverse probability of treatment weighting with propensity score was used to account for differences in baseline and clinical characteristics between SDD and non‐ SDD groups. Among 35 972 patients who underwent elective PCI at 17 PCI centers in Ontario, 10 801 patients (30%) had SDD PCI and 25 121 patients (70%) had non‐ SDD PCI . Substantial hospital variation for SDD PCI was observed, ranging from 0% to 87% during the study period. In the propensity‐weighted cohort, SDD patients had no significant difference in 30‐day rates of death or hospitalization for acute coronary syndrome (1.3% versus 1.6%; hazard ratio: 0.84 [95% CI, 0.65–1.08]; P =0.17) compared with non‐ SDD patients. SDD and non‐ SDD patients also had no significant difference in 30‐day rates of mortality or coronary revascularization.
Conclusions
In this large population‐based cohort of elective PCI patients, we demonstrated the safety of SDD PCI . Increased adoption of this strategy could lead to improved bed‐flow efficiency and substantial savings for the Canadian healthcare system without comprising outcomes.
... Since gaining substantial popularity in the past 10-15 years, the TRA was shown to improve outcomes in both randomized controlled trials and observational studies [2,3,5,6,17]. However, despite this abundance of literature, there has been a slow adoption rate by many operators. ...
Objective:
The transradial approach (TRA) has increasingly been adopted for the use of percutaneous coronary interventions (PCI), with reported clinical benefits. Little is known regarding the change in outcomes over time.
Patients and methods:
From our large single-center PCI registry, we have analyzed 15 429 patients in two periods - 2008-2012 (period 1) and 2013-2017 (period 2). We examined the proportions of use of TRA, the influence on in-hospital outcomes, and adjusted long-term effects.
Results:
The rate of TRA rose from 15.9% in period 1 to 69.1% in period 2, including in specific situations such as acute coronary syndrome, chronic total occlusion, bifurcation, calcified lesions, and unprotected left main PCI. In-hospital rates of bleeding were lower for TRA versus. Transfemoral artery (1.8 vs. 5.1%, overall, P<0.001), as were rates of additional bleeding events in the following 12 months (1.3 vs. 2.4%, P<0.001). Following multivariate analysis, use of TRA was associated with a lower 30-day and 4-year rate of the composite outcomes of death, myocardial infarction, target vessel revascularization, or coronary artery bypass surgery [at 4 years, hazard ratio (HR)=0.86; 95% confidence interval (CI): 0.77-0.96; P=0.007, during period 1 and HR=0.62; 95% CI 0.55-0.7; P<0.0001 during period 2]. Interaction analysis showed a stronger effect at the latter period (HR=0.69, 95% CI: 0.59-0.81, P<0.001).
Conclusion:
Over a decade of follow-up, TRA has gained acceptance for different PCI scenarios, including complex patients - a course which is associated with consistent short and long-term clinical benefits.
... A meta-analysis which compared SDD versus overnight stay in the hospital following PCI showed the former not to be associated with major complications, and the authors stated that SDD appeared safe in selected patients undergoing elective PCI. [23] Moreover, even if the femoral access was more delicate in comparison to the radial or ulnar access for intervention, a retrospective study which was carried out with participants assigned to elective PCI at the Mount Sinai Hospital in New York, showed that if the respective protocol was correctly followed, SDD was completely safe in uncomplicated elective PCI via the femoral access. [24] Eleven hundred ninety elective PCI were retrospectively reviewed at the Red Cross General Hospital to assess for the feasibility and safety of SDD for selected patients undergoing complex PCI using the forearm approach. ...
Background:
Nowadays 57% of the cardiologists based in the United Kingdom and 32% of the cardiologists based in Canada utilize same day discharge (SDD) following elective percutaneous coronary intervention (PCI) as a routine practice. In this analysis, we aimed to systematically assess early versus late clinical outcomes following SDD after elective PCI.
Methods:
The Medical Literature Analysis and Retrieval System Online, the Cochrane Central, the Resources from the United States National Library of Medicine (www.ClinicalTrials.gov: http://www.clinicaltrials.gov) and EMBASE were carefully searched for relevant English publications which reported early versus late clinical outcomes in patients who were discharged on the same day following revascularization by PCI. Relevant clinical outcomes which were reported in the original studies were considered as the endpoints in this analysis. Odd ratios (OR) and 95% confidence intervals (CI) were used to represent the data, and RevMan 5.3 was used as the statistical software.
Results:
A total number of 21, 687 participants (enrollment time period from the year 1998 to the year 2015) were assigned to this analysis. When early versus late clinical outcomes were compared in patients who were discharged on the same day following elective PCI, major adverse cardiac events (OR: 0.75, 95% CI: 0.31-1.79; P = .51), mortality (OR: 0.26, 95% CI: 0.06-1.06; P = .06), stroke (OR: 1.46, 95% CI: 0.72-2.94; P = .29), arrhythmia (OR: 1.30, 95% CI: 0.64-2.63; P = .47), hematoma (OR: 1.00, 95% CI: 0.60-1.66; P = 1.00) and major bleeding from access site (OR: 1.68, 95% CI: 0.22-12.85; P = .62) were not significantly different. Post-procedural myocardial infarction (OR: 2.01, 95% CI: 0.71-5.70; P = .19) and minor bleeding from access site (OR: 6.61, 95% CI: 0.86-50.66; P = .07) were also similarly manifested. However, re-hospitalization was significantly higher in those patients with late clinical outcomes (OR: 0.18, 95% CI: 0.07-0.44; P = .0002).
Conclusions:
In those patients who were discharged from the hospital on the same day following elective PCI, no significant difference was observed in the assessed early versus late clinical outcomes. However, late clinical outcomes resulted in a significantly higher rate of re-hospitalization. Larger studies should confirm this hypothesis.
... Recent evidence demonstrates that same-day discharge is safe in selected patients and is associated with significant cost savings, improved patient satisfaction, and increased bed availability. [32][33][34] With respect to PCI patients who are observed overnight, an analysis of the NCDR CathPCI registry demonstrated that from 2009 to 2014, the proportion of outpatients not admitted to a hospital after PCI increased from 32.8% to 66.3%, with admitted patients being older, having more comorbidities, and having experienced post-PCI compli- cations. 35 However, of the patients who were not admitted, those who were at high risk for predicted mortality increased significantly from 17.0% to 19.8% during the time period. ...
The present‐day cardiac catheterization laboratory (CCL) is home to varied practitioners who perform both diagnostic, interventional, and complex invasive procedures. Invasive, non‐interventional cardiologists are performing a significant proportion of the work as the CCL environment has evolved. This not only includes those who perform diagnostic‐only cardiac catheterization but also heart failure specialists who may be involved in hemodynamic assessment and in mechanical circulatory support and pulmonary hypertension specialists and transplant cardiologists. As such, the training background of those who work in the CCL is varied. While most quality metrics in the CCL are directed towards evaluation of patients who undergo traditional interventional procedures, there has not been a focus upon providing these invasive, noninterventional cardiologists, hospital/CCL administrators, and CCL directors a platform for quality metrics. This document focuses on benchmarking quality for the invasive, noninterventional practice, providing this physician community with guidance towards a patient‐centered approach to care, and offering tools to the invasive, noninterventionalists to help their professional growth. This consensus statement aims to establish a foundation upon which the invasive, noninterventional cardiologists can thrive in the CCL environment and work collaboratively with their interventional colleagues while ensuring that the highest quality of care is being delivered to all patients.
... p = 0.78) and low rate of major complications among the observational cohort (95% CI: 0.35%-1.32%). 80 Recently, a study conducted by Amin et al. showed an average total cost savings of approximately $3689 per patient using TRI with SDD in comparison to patients using TFI with non-SDD. 81 Recommendations Early discharge after 2-3 h of observation is feasible and safe in stable patients who undergo TR diagnostic procedures without complications. ...
Radial access for cardiac catheterization and intervention in India has been growing steadily over the last decade with favorable clinical outcomes. However, its usage by interventional cardiologists varies greatly among Indian operators and hospitals due to large geographic disparities in health care delivery systems and practice patterns. It also remains unclear whether the advantages, as well as limitations of transradial (TR) intervention (as reported in the western literature), are applicable to developing countries like India or not. An evidence-based review involving various facets of radial procedure for cardiac catheterization, including practical, patient-related and technical issues was conducted by an expert committee that formed a part of Advancing Complex CoronariES Sciences through TransRADIAL intervention (ACCESS RADIAL™) Advisory Board. Emerging challenges in redefining TR management based on evidence supporting practices were discussed to formulate these final recommendations through consensus.
... Three systematic reviews and meta-analyses have been performed to assess differences between SDD and overnight observation from randomized trials alone [19,20] and randomized trials plus observational studies [3]. Each of these analyses demonstrated no difference in acute or medium-term mortality, myocardial infarction and MACE between groups (Figure 2). ...
Since the publication of the 2009 SCAI Expert Consensus Document on Length of Stay Following percutaneous coronary intervention (PCI), advances in vascular access techniques, stent technology, and antiplatelet pharmacology have facilitated changes in discharge patterns following PCI. Additional clinical studies have demonstrated the safety of early and same day discharge in selected patients with uncomplicated PCI, while reimbursement policies have discouraged unnecessary hospitalization. This consensus update: (1) clarifies clinical and reimbursement definitions of discharge strategies, (2) reviews the technological advances and literature supporting reduced hospitalization duration and risk assessment, and (3) describes changes to the consensus recommendations on length of stay following PCI (Supporting Information Table S1). These recommendations are intended to support reasonable clinical decision making regarding postprocedure length of stay for a broad spectrum of patients undergoing PCI, rather than prescribing a specific period of observation for individual patients.
Background:
Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown.
Objective:
To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area.
Methods:
There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Area codes 4-10 were used to define rural status.
Results:
A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes.
Conclusions:
SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.
Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.
Background:
Most previous studies on outpatient cardiac catheterization have been conducted in Western countries, but Japanese studies are rare. We aimed to describe patient characteristics and short-term clinical outcomes of outpatient cardiac catheterization compared to those of inpatient cardiac catheterization in Japan.
Methods:
We conducted a retrospective cohort study using data from the JMDC Claims Database. We identified all adult patients aged ≥18 years who underwent cardiac catheterization between April 2012 and October 2021. We investigated patient characteristics and clinical outcomes (i.e. all-cause mortality, stroke, acute kidney injury, bleeding, vascular complications, percutaneous coronary intervention, and total healthcare costs) within 2, 7, and 30 days between patients who underwent outpatient cardiac catheterization (outpatient group) and those who underwent inpatient cardiac catheterization (inpatient group).
Results:
Of the 37,002 eligible patients (57.6 % <60 years old, and 80.2 % male), 1853 (5.01 %) underwent outpatient cardiac catheterization. The outpatient group was more likely to be male, have more comorbidities, and be performed at non-university hospitals than the inpatient group. The proportion of patients who underwent right heart catheterization and imaging was lower in the outpatient group. There were no significant differences in 7-day major complications between the two groups (all-cause mortality, 0.0 % versus 0.0 %, p = 0.57; acute kidney injury, 0.0 % versus 0.1 %, p = 0.10, bleeding, 0.5 % versus 0.9 %, p = 0.052; vascular complication, 0.0 % versus 0.1 %, p = 0.23, respectively). The 30-day total healthcare costs were lower in the outpatient group than in the inpatient group (mean 3212 US dollars versus 3955 US dollars, p = 0.003).
Conclusions:
Approximately 5 % of cardiac catheterizations were performed in an outpatient setting. Given the low adverse event risk observed in this study, it may be a reasonable option to widen outpatient cardiac catheterization to include potential populations in Japan, warranting further studies.
Aims:
To assess the effects on outcomes and hospital revenues (societal cost) of a by default strategy of same day discharge (SDD) in patients undergoing a cardiac catheterization procedure in a Belgian Hospital.
Methods and results:
Outcome and complete financial data were obtained in all consecutive patients with a cardiac catheterization performed in 2019 (n=5237) and in 2021 (n=5377). Patient-reported experience, patient satisfaction and Net promotor score were obtained prospectively for the SDD cohort in 2021. The proportion of patients receiving catheterization procedure in SDD increased from 28 to 44 % (p<0.001). This translates to the saving of 889 conventional hospitalizations in 2021. All-cause death and readmission rate remained unchanged (0,17% vs 0,15% (p=0,004); and 0,7% vs 1,8% (p>0,05)) in 2019 and 2021, respectively. Patients satisfaction top box score was 91% and the Net Promotor Score was 89,5. The by default SDD strategy was associated with reduction in in-hospital health care spending, on average 3206€ per procedure is saved. This means a 57% decrease in hospital revenues and translates into an important decrease in physician income.
Conclusion:
Implementing a by default SDD cardiac catheterization strategy results in a reduction of societal cost, excellent patient satisfaction and unchanged clinical outcome. Yet, in the given context this approach negatively impacts hospital and physician revenues precluding the sustainability of such protocol.
Objective Knowledge regarding the short-term outcomes after same-day discharge (SDD) post primary percutaneous coronary intervention (PCI) is lacking. In this study, we evaluated 1-year major adverse cardiovascular events (MACE) among SDD patients after primary PCI.
Design 1-year follow-up analysis of a subset of patients from an existing prospective cohort study.
Setting Tertiary care cardiac hospital in Karachi, Pakistan.
Participants Consecutive patients, from August 2019 to July 2020, with ST segment elevation myocardial infarction who had undergone primary PCI with SDD (within 24 hours) after the procedure by the treating physician and with at least one successful follow-up up to 1 year.
Outcome measure Cumulative MACE during follow-up at the intervals of 1 week, 1 month, 6 months and 1 year.
Results 489 patients were included, with a gender distribution of 83.2% (407) male patients and a mean age of 54.58±10.85 years. Overall MACE rate during the mean follow-up duration of 326.98±76.71 days was 10.8% (53), out of which 26.4% (14/53) events occurred within 6 months of discharge and the remaining 73.6% (39/53) occurred between 6 months and 1 year. MACE was significantly higher among patients with a Zwolle Risk Score (ZRS) ≥4 at baseline, with an incidence rate of 21.9% (16/73) vs 8.9% (37/416; p=0.001) in patients with ZRS≤3 (relative risk 2.88 (95% CI 1.5 to 5.5)).
Conclusion A significant burden of short-term MACE was identified among SDD patients after primary PCI; most of these events occurred after 6 months of SDD, mainly among patients with ZRS≥4. A systematic risk assessment based on risk stratification modalities such ZRS could be a viable option for SDD patients with primary PCI.
Background:
Same day discharge (SDD) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.
Methods:
We evaluated the clinical, angiographic, and procedural characteristics of patients discharged the same day versus those kept for overnight observation in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436).
Results:
Of the 7181 patients who underwent CTO PCI, 943 (13%) had SDD. The SDD rate increased from 3% in 2015 to 21% in 2022. Patients with SDD were less likely to have a history of heart failure (21% vs. 26%, p = 0.005), chronic lung disease (10% vs. 15%, p = 0.001), or anemia (12% vs. 19%, p < 0.001). Technical success (87% vs. 88%, p = 0.289) was similar, but in-hospital major adverse cardiovascular events (0.0% vs. 0.4%, p = 0.041) were lower in SDD. In multivariable logistic regression analysis, prior myocardial infarction odds ratio (OR): 0.71 (95% confidence interval [CI]: 0.59-0.87, p = 0.001), chronic lung disease OR: 0.64 (95% CI: 0.47-0.88, p = 0.006), and increasing procedure time OR: 0.93 (95% CI: 0.91-0.95, p < 0.001, per 10-min increase) were associated with overnight observation, while radial-only access OR: 2.45 (95% CI: 2.03-2.96, p < 0.001) had the strongest association with SDD. In the SDD, 2 (0.4%) of 514 patients were readmitted, due to retroperitoneal bleeding (n = 1) and ischemic stroke (n = 1).
Conclusion:
The overall frequency of SDD after CTO PCI was 13% and has been increasing over time. SDD is feasible in select patients following CTO PCI, and radial-only access had the strongest association with SDD.
Conventionally, patients have been admitted overnight after atrial fibrillation (AF) catheter ablation. Several centers have recently adopted a same-day discharge (SDD) protocol for patients undergoing AF catheter ablation. We aimed to systematically review the current evidence for the safety and efficacy of SDD after AF catheter ablation. A systematic search was performed in PubMed, Embase, Scopus, Web of Science, and the Cochrane library until August 21, 2021. The risk of bias was assessed with the "Methodological Index for Non-Randomized Studies" (MINORS). The pooled efficacy rate of SDD protocol (defined as the proportion of patients discharged the same day of ablation among the patients who were planned for SDD) was calculated. Meanwhile, pooled major complication rates and early readmission or emergency department (ED) visit rates were evaluated in successful and planned SDD groups separately. Overall, 12 observational studies consisting of 18,065 catheter ablations were included, among which 7320 (40.52%) were discharged the same-day after ablation. The pooled efficacy was 90.3% (95% confidence interval [CI] [82.7-96.0]). The major complication rates were 1.1% (95%CI [0.5-1.9]), and 0.7% (95% CI [0.0-3.1]) in planned SDD and successful SDD groups, respectively. In addition, readmission/ED visit rate were 3.0% (95%CI [0.9-6.1]), and 3.1% (95% CI [0.8-6.5]) in the same groups. There were no significant differences between planned SDD and overnight groups with respect to major complication rate (risk ratio = 0.70, 95%CI [0.35-1.42], p-value = .369). The available data indicates that SDD after AF ablation is safe and efficient. Further prospective and randomized studies are warranted to elucidate the safety of SDD after AF ablation and develop a standardized SDD protocol.
Aims: The effectiveness and safety of same-day discharge (SDD) for catheter ablation (CA) for atrial fibrillation (AF) has not been fully elucidated using a large nationwide database. This study aimed to evaluate the all-cause readmission rates within 30-days among patients receiving CA for AF with an SDD protocol compared with a conventional overnight stay (ONS).
Methods and results: We performed a retrospective cohort study using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission following discharge in patients receiving CA and a secondary outcome was requiring total healthcare cost. A 1 : 3 propensity score matching was conducted to compare the safety and efficacy within both SDD and ONS group. Among 30 776 patients [mean 67.2 ± 11.4 years, 12 590 female (41.5%)] who received CA from 2016 through 2018, 440 (1.42%) patients were discharged on the same-day following CA (SDD group), and the remaining 30 336 patients stayed at least one night in the hospital (ONS group). A propensity score analysis generated 1751 matched pairs (440 in the SDD group; 1311 in the ONS group). The 30-day readmission following discharge was not significantly higher in the SDD group than the ONS group (SDD vs. ONS: 12.7% vs. 9.7%; hazard ratio: 1.17, 95% confidence interval: 0.76-1.81, P = 0.47). Healthcare cost was significantly higher in the ONS group ($25 237 ± 14 036 vs. $30 749 ± 16 383; P < 0.01).
Conclusion: In this nationwide database study, there was no significant difference in the all-cause 30-day readmission following SDD for CA compared with ONS.
Objectives:
The Zwolle risk score (ZRS) has been considered to be a useful tool for the systematic evaluation of patients for early discharge after primary percutaneous coronary intervention (PCI). Therefore, aim of this study was to evaluate the clinical utility of ZRS for the same-day discharge strategy after primary PCI at a tertiary care cardiac center of Karachi, Pakistan.
Methods:
This study was conducted at a tertiary care cardiac center between August 2019 and July 2020. Patients discharged within 24 h (same-day) of the primary PCI procedure were included. Patients were stratified as high- and low-risk based on ZRS score; low-risk (≤3) and high-risk (≥4). All patients were followed during 30-days post-procedure period for major adverse cardiac events (MACE).
Results:
Out of 487 patients, 83.2% (405) were male and mean age was 54.6 ± 10.87 years. Mean ZRS was 2.34 ± 1.64 with 16.0% (78) patients in high-risk (≥4) group. 30-days MACE rate was observed to be 5.3% (26) with significantly higher rate among high-risk patients as compared to low-risk patients 12.8% (10) vs. 3.9% (16); p = 0.004 respectively with OR of 3.61 [1.57-8.29]. The area under the curve (AUC) of ZRS for prediction of 30-day MACE was 0.67 [95% CI: 0.58-0.77], ZRS ≥4 had sensitivity of 38.5% and specificity of 85.2% with AUC of 0.62 [95% CI: 0.50-0.74] for prediction of 30-day MACE.
Conclusion:
ZRS showed moderate discriminating potential in identifying patients with high-risk of MACE at 30-day after same-day discharge after primary PCI.
Objectives:
The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes.
Background:
Insights on contemporary use of same-day discharge following elective PCI are limited.
Methods:
In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed.
Results:
A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction <0.001).
Conclusions:
In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes.
Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.
Introduction and objectives
Elective percutaneous coronary intervention (PCI) has become an increasingly safe procedure. However, same day discharge (SDD) has yet to become standard practice. Our aim is to characterize the patients who underwent elective PCI and compare outcomes between the overnight stay (ONS) patient group and the group that was discharged on the same day at 24 hours and at 30 days.
Methods
One-year registry of patients who underwent an elective PCI. The possibility of SDD was established by the operator. Appropriate candidates were discharged at least four hours after the end of the intervention. The primary endpoints were defined as: Major adverse cardiac and cerebrovascular events (MACCE) — death, myocardial infarction (MI) stroke or transient ischemic attack (TIA), non-planned re-intervention — and vascular complications. Secondary endpoints were any unplanned hospital visit, readmission and re-catheterization.
Results
We performed 155 elective PCIs. One patient was admitted to the coronary care unit; 111 patients stayed overnight (ONS Group); 43 patients were discharged the same day (SDD Group). Three patients had early (<4 hours) post procedure complications: two TIAs and one vascular access site complication. There were no MACCE between four and 24 hours, nor at 30 days. At 24 hours, two patients from the SDD group had unplanned visits. Between one and 30 days, more patients from the SDD group had unplanned visits (9.3% vs. 0.9%. p=0.02). One patient from the ONS group had a recatherization. There were no readmissions or reinterventions.
Conclusion
Same day discharge of selected patients who undergo elective PCIs is feasible and safe.
Objectives
To assess the feasibility and safety of same day discharge (SDD) after chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
Background
CTO PCI has been associated with higher complication rates and procedural and hospitalization costs. Shortening post‐PCI hospitalization length not only increases the patients' comfort but at the same time it consists an important part of cost reduction policies.
Methods
We retrospectively compared the 30‐day outcomes of patients who underwent CTO PCI at the Red Cross Hospital, Greece between January 2016 and June 2019 and underwent SDD versus non‐SDD. Major adverse cardiovascular events (MACE) were defined as the composite of death, myocardial infarction, urgent repeat target vessel revascularization, tamponade, and stroke.
Results
A total of 173 patients (mean age 63.7 ± 8.9 years) were included, of whom 51 (30%) underwent SDD. SDD patients were less likely to have diabetes mellitus (51 vs. 31%, p = .015), arterial hypertension (89 vs. 67%, p < .001), and acute coronary syndrome presentation (39.7 vs. 21.6%, p = .022), compared with non‐SDD patients. Forearm access was used in all SDD patients and in 83% of the non‐SDD patients. The 30‐day incidence of MACE was 0% in the SDD group and 1.6% in the non‐SDD group. Multivariable analysis showed that diabetes mellitus and longer procedural time were associated with lower probability of SDD (OR: 0.34, 95% CI: 0.15, 0.73 and OR: 0.29, 95% CI: 0.12, 0.71, respectively).
Conclusions
SDD appears to be feasible and safe in selected patients undergoing an uncomplicated CTO PCI through forearm approach.
Introduction and objectives
Elective percutaneous coronary intervention (PCI) has become an increasingly safe procedure. However, same day discharge (SDD) has yet to become standard practice. Our aim is to characterize the patients who underwent elective PCI and compare outcomes between the overnight stay (ONS) patient group and the group that was discharged on the same day at 24 hours and at 30 days.
Methods
One-year registry of patients who underwent an elective PCI. The possibility of SDD was established by the operator. Appropriate candidates were discharged at least four hours after the end of the intervention. The primary endpoints were defined as: Major adverse cardiac and cerebrovascular events (MACCE) — death, myocardial infarction (MI) stroke or transient ischemic attack (TIA), non-planned re-intervention — and vascular complications. Secondary endpoints were any unplanned hospital visit, readmission and re-catheterization.
Results
We performed 155 elective PCIs. One patient was admitted to the coronary care unit; 111 patients stayed overnight (ONS Group); 43 patients were discharged the same day (SDD Group). Three patients had early (<4 hours) post procedure complications: two TIAs and one vascular access site complication. There were no MACCE between four and 24 hours, nor at 30 days. At 24 hours, two patients from the SDD group had unplanned visits. Between one and 30 days, more patients from the SDD group had unplanned visits (9.3% vs. 0.9%. p=0.02). One patient from the ONS group had a recatherization. There were no readmissions or reinterventions.
Conclusion
Same day discharge of selected patients who undergo elective PCIs is feasible and safe.
Background:
Same-day discharge of patients undergoing percutaneous coronary intervention (PCI) may challenge preparation of patients for discharge.
Objective:
The objective of this study was to investigate whether nurse-led telephone follow-up influenced patients' self-management post-PCI.
Methods:
We performed a randomized study with an allocation rate of 1:1. A standardized nurse-led motivational telephone consultation was conducted between 2 and 5 days after PCI to support adherence to medical therapy, follow-up activities, emotional well-being, and healthy lifestyle. The control group received usual care and discharge procedures. Primary outcome was adherence to use of P2Y12 inhibitor (clopidogrel or ticagrelor) therapy at 30 days of follow-up.
Results:
We consecutively included 294 elective patients (83%) undergoing PCI and with planned same-day discharge. Adherence to P2Y12 inhibitors was not influenced by the intervention (intervention vs control, 95% vs 93%, respectively; P = .627). However, the proportion of patients readmitted (8% vs 16%, P = .048), as well as self-initiated contacts to general practitioners (29% vs 42%, P = .020), was lower in the intervention group compared with the control group. Patients in the intervention group were more likely to know how to manage symptoms of angina pectoris (90% vs 80%, P = .015), and a higher proportion of patients in the intervention group commenced healthy physical activities (53% vs 41%, P = .043).
Conclusion:
Nurse-led motivational telephone follow-up did not influence adherence to antiplatelet medical therapy after PCI. However, the intervention positively influenced self-management of angina pectoris and reduced hospital readmissions and self-initiated contacts to general practitioners and hospitals.
Importance
Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown.
Objective
To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers.
Design, Setting, and Participants
This observational cross-sectional cohort study included 672 470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up.
Exposures
Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge.
Main Outcomes and Measures
Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals’ perspective, inflated to 2016.
Results
Among 672 470 elective PCIs, 221 997 patients (33.0%) were women, 30 711 (4.6%) were Hispanic, 51 961 (7.7%) were African American, and 491 823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates.
Conclusions and Relevance
Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
Background：Recent advances of percutaneous coronary intervention (PCI) and transradial coronary interven-tion (TRI) have made it possible to reduce the local complication rate and the time until a return to ambulation. The aim of this study is to assess the safety and the patient satisfaction of the TRI-based one-day admission program for PCI. Methods：Total 230 consecutive patients underwent TRI on the day of admission, according to pre-determined inclusion criteria, from May 2001 to October 2003. The subjects were examined for clinical and angiographic characteristics. The patients having a same-day discharge were telephone-interviewed one day and seven days after discharge to assess late complications and the patients' satisfaction. Results：The mean age of the subjects was 59±9 years and 77.4% were male patients. 169 (73.4%) had stable angina and 37 (16.1%) had unstable angina. Stents were implanted in 178 cases (69.3%). Of the 230 patients who underwent TRI, 206 patients (89.6%) could discharge on the same day after the procedure. The procedure was successful in 98.5%. The average hospital stay for them was 9.4±1.4 hours. Two subjects reported hematoma near the puncture site within 24 hours after discharge, and one reported this problem 7 days after discharge. During the follow-up, there were no cases reporting chest pain needing rehospitalization or such complications as subacute vessel closure. No deaths, myocardial infarctions or revascularization were noted during the follow-up period. The majority of the patients (n=197, 95.6%) were satisfied with the same-day admission and discharge. Conclusions：Same-day admission and discharge after TRI seems to be safe as well as satisfactory for not low-risk patients. (Korean Circulation J 2004 ; 34 (7) : 647-654) KEY WORDS：Coronary disease；Angioplasty；Radial artery.
Because of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers.
Twenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention.
We conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods.
From the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed.
The proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.
day discharge after percutaneous coronary intervention in light of the society for cardiovascular angiography and intervention's proposed guidelines: A single-center experience.
The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice. Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein. In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force (1). The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current [GRAPHICS] practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of "no benefit" or is associated with "harm" to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only. In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines. Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation. The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate. Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benefit-to-risk ratio may be lower. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are asked to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must recuse themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members' comprehensive disclosure information-including RWI not pertinent to this document-is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-TaskForces. aspx. The work of the writing committee was supported exclusively by the ACCF, AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) without commercial support. Writing committee members volunteered their time for this activity. In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed) and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference. In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust (2,3). It is noteworthy that the ACCF/AHA guidelines were cited as being compliant with many of the standards that were proposed. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated. The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.
Patients undergoing elective percutaneous coronary intervention (PCI) are generally observed overnight in the hospital. The association between same-day discharge of older patients and death or readmission is unclear.
To evaluate the prevalence and outcomes of same-day discharge among older patients undergoing elective PCI in the United States.
Multicenter cohort study. Data were from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008 and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay.
Death or rehospitalization occurring within 2 days and by 30 days after PCI.
The prevalence of same-day discharge was 1.25% (95% CI, 1.19%-1.32%; n = 1339 patients) with significant variation across facilities. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures with less multivessel intervention. There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37% [95% CI, 0.16%-0.87%] vs overnight stay, 0.50% [95% CI, 0.46%-0.54%]; P = .51) or at 30 days (same-day discharge, 9.63% [95% CI, 8.17%-11.33%] vs overnight stay, 9.70% [95% CI, 9.52%-9.88%]; P = .94). Among patients with adverse outcomes, the median time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days [interquartile range, 7.0-21.0] vs overnight stay, 14 days [interquartile range, 7.0-21.0]; P = .96). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization (adjusted odds ratio, 0.95 [95% CI, 0.78-1.16]).
Among selected low-risk Medicare patients undergoing elective PCI, same-day discharge is rarely implemented but is not associated with death or rehospitalization compared with overnight observation.
The AmBulatory Closure Device Percutaneous Intervention (ABCD-PCI) study is a multicenter randomized prospective controlled trial evaluating the safety of and patient satisfaction with same-day discharge following ambulatory percutaneous intervention with a closure device. This article reviews the findings from a single center, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, from October 2008 through April 2010, with 23 patients in the same-day discharge group and 21 patients in the next-day discharge group. There were no differences between the groups in demographic or procedure characteristics. Outcomes were measured by a questionnaire and 7-day and 30-day follow-up phone calls. Results showed that same-day discharge after percutaneous intervention with a closure device is as safe as next-day discharge. However, there was a trend for a higher comfort level among patients in the next-day discharge group.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Same-day discharge transradial percutaneous coronary intervention (TRI) has been reported to be safe and feasible in Western countries. However, Asia has not produced any reports related to this matter. The present study explored the safety and feasibility of patients with indications for TR coronary angiography and ad hoc PCI with a same-day discharge protocol. Between October 1995 and December 2002, 660 adult patients were admitted to our hospital for ad hoc PCIs. Of these, 214 patients were discharged on the day of their PCI (group A), while the remaining 446 patients were referred for out-patient department (OPD) PCI with subsequent admission (group B). Periprocedural complications were not significantly different between the groups. There were no differences in 1-month major adverse cardiac events including death, myocardial infarction, and target vessel revascularization (1.4% versus 0.2% for groups A and B, respectively; P = 0.068). Three group A cases (1.4%) experienced peri- and post-PCI myocardial infarction and one group B case (0.2%) experienced a post-PCI myocardial infarction. No patient died or required emergency bypass surgery. In group A, 8 cases (3.7%) required cutting balloon angioplasty and 2 cases (0.9%) needed rotational atherectomy. TRI is safe and feasible on an outpatient basis. For select patients, even though PCI can carry the potential risk of subsequent cutting balloon angioplasty or rotational atherectomy, the procedure should still be considered.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Background:
The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs).
Methods:
The QUOROM group consisted of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items.
Findings:
The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It is organised into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with "trial flow", study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials.
Interpretation:
We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.
Objective: To study the utility of Transradial Coronary Angioplasty in Patients with Chronic stable Angina discharged on same day. Methodology: This was a single center observational study with prospective data collection of 228 patients underwent transradial coronary angioplasty from January to December 2010, at Post Graduate Medical Institute, Lady Reading Hospital, Peshawar. Patients of both genders and all ages who had transradial coronary angioplasty for chronic stable angina and were discharged on same day were included in the study, using purposive non-probability sampling technique. Patients with unstable angina and acute coronary syndrome who had to stay for more than one day, were excluded from the study. Patients were followed at one month of hospital discharge in out patients department and clinical outcome data was recorded. Results: A total of 228 patients were included in the study. Male were 64.9% and 35.1% were female with mean age of 56 ± 9years. All the patients had coronary intervention through right radial artery. Baseline characteristics of the patients were; diabetic 46.4%, hypertensive 45.6%, smokers 32.8%, dyslipidemic were 47.8% and mean values of serum creatinin and Hemoglobin were 1.2±0.5 and 12.8±2.4, respectively. The frequency of various complications were as follow; mild hematoma 1.7%, nausea and vomiting 1.3%, pain in hand 10.5%, readmission to hospital for chest pain 7.4%, need for revascularization 3%, hand ischemia 2.5%, minor bleeding 0.8%, and mortality was 1.3%.There was no access site major bleeding or hematoma. Conclusion: The radial artery approach for coronary angiopalsty is found to be very useful with low degree of access site vascular complications and an early patient mobilization.
Introduction: Traditionally, Percutaneous Coronary Intervention (PCI) has been performed as an inpatient procedure followed by a hospital stay up to several days. With the advent of newer therapies, PCI is routinely requiring less hospital stay following the procedure. With the everincreasing cost of healthcare and advancement in PCI, same-day discharge for low-risk patients could become the mainstay of therapy. Methods: A retrospective chart review was conducted of patients who underwent PCI between 2008 and 2009 and had same day discharge at Providence Hospital. The parameters studied included patient's comorbidities, access site, vessels involved, anti-coagulation used, and any complications following discharge. Results: Seventeen patients met the criteria. Mean age of patients was 62±11 years. 90% of patients had stable angina and underwent elective procedures. Access site was obtained via femoral route in all of the patients with sixteen having a closure device. 80% of patients had a stent placement while the rest underwent angioplasty without stent placement. All patients had intervention involving only a single vessel. No cardiac events including sub-acute stent thrombosis, recurrent angina, and clinically significant arrhythmia were reported within 24 hours of the procedure. One patient developed a hematoma one week following PCI, which did not necessitate hospital admission. Conclusion: Newer advances in PCI have played a vital role in decreasing the incidence of acute complications following PCI. These advances especially when utilized with proper risk stratification through validated criteria can help identify low risk PCI patients that can be discharged safely on the same day of the procedure.
We studied both the time course and risk factors for adverse clinical events after percutaneous coronary intervention (PCI). Such information is critical to clinical decision-making, but scant quantitative data exist to describe the time course of these adverse outcomes. Patients enrolled in the Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-ii (IMPACT-II) trial were analyzed. Patients undergoing elective, urgent, or emergency PCI (n = 4,010) were randomized to receive either placebo or 1 of 2 eptifibatide regimens during intervention. We evaluated the time to the primary end point of the trial, the 30-day composite of death, myocardial infarction, repeat nonelective PCI, nonelective bypass surgery, or stenting for abrupt closure. Adverse events occurred in 407 patients (10.1%). Because the risk of events declined substantially between 6 and 9 hours (66% occurred within b hours), events were classified as occurring before or after 6 hours. Independent predictors of "early" events included dissection, pre- and postprocedural coronary blood flow, side-branch occlusion, procedural thrombolytic use, previous bypass, presentation with unstable angina, absence of diabetes, and hyperlipidemia. The predictors of "late" events included lower weight, increased baseline heart rate, coronary dissection, and procedural thrombolytic use. The risk of ischemic events were greatest immediately after PCI and rapidly declined, so that by 9 hours the hazard function plot was flat; 66% of events occurred within 6 hours of PCI. Knowledge of the risk factors for early and late events help risk-stratify patients before and after intervention for myocardial ischemic events. (C) 2000 by Excerpta Medico, Inc.
Ongoing development in percutaneous coronary intervention (PCI) techniques and closing devices facilitates same-day-discharge in patients undergoing uncomplicated PCI procedures. We examined the safety and outcome in low-risk patients discharged the same day as PCI with femoral access was performed.
From January 1, 2010, through December 31, 2010, the outcomes of same-day discharge in 355 (19.6%) of in total 1,809 patients undergoing PCI were analyzed. Composite end point included major adverse cardiac or cerebral events and/or bleeding/vascular complications within 24 hours and 30 days. Major adverse cardiac and cerebral events were defined as cardiac death, myocardial infarction, stroke, coronary artery bypass grafting, or repeat PCI.
The mean age of the study population was 64.5 years (40.0-93.0 years), 17.3% of the patients were ≥75 years old. The indication for PCI was: stable angina pectoris (n = 277, 78.0%) and unstable angina pectoris/non-ST-segment elevation myocardial infarction (n = 78, 22.0%). In all patients femoral access was used, and the puncture site was closed with the closing-device AngioSeal. No major adverse cardiac and cerebral events were seen within 24 hours or 30 days except in 1 patient who had target lesion revascularization done as PCI 4 days post-procedure. Three patients had bleeding/vascular complications; 2 patients were re-admitted within 24 hours due to access-site hematomas, which were treated with manual compression and bed-rest regimes. One patient developed a pseudoaneurysm within 12 hours post-procedure.
Same-day-discharge after uncomplicated PCI using femoral access is safe when patients are properly selected. The strategy may improve and benefit health costs in the future.
OBJECTIVES: This study sought to evaluate outcomes of same-day discharge (SDD) following percutaneous coronary intervention (PCI) versus overnight hospitalization (ON). BACKGROUND: Although there are data on the safety and feasibility of SDD after PCI, ON continues to be prevalent. METHODS: The Cochrane search strategy was used to search the PubMed database, EMBASE, and the Cochrane Library for relevant literature. Thirteen studies (5 randomized and 8 observational) of SDD after uncomplicated PCI versus ON met inclusion criteria. Data were pooled using a random effects model, and reported as odds ratios (OR) with their 95% confidence intervals (CI). The primary outcomes were incidence of total complications, major adverse cardiovascular events (MACE), and rehospitalization within 30 days after PCI. RESULTS: A total of 13 studies, involving 111,830 patients were pooled. There was significant variation in the definition of outcomes across studies. For total complications, the strategy of SDD compared with ON after PCI had an estimated OR of 1.20 (95% CI: 0.82 to 1.74) in randomized and 0.67 (95% CI: 0.27 to 1.66) in observational studies. Similar results were found for MACE (randomized, OR: 0.99, 95% CI: 0.45 to 2.18; observational, OR: 0.59, 95% CI: 0.06 to 5.57) and rehospitalizations (randomized, OR: 1.10, 95% CI: 0.70 to 1.74; observational, OR: 0.62, 95% CI: 0.10 to 3.98) at 30 days post PCI. CONCLUSIONS: There is considerable heterogeneity across published studies comparing SDD with ON. This, coupled with the low event rate and wide corresponding CIs, suggest that an adequately powered multicenter randomized trial comparing SDD with ON would require a very large sample size (>17,000). Until such a trial is completed, SDD after uncomplicated PCI seems a reasonable approach in selected patients.
Objective:
To assess clinical outcomes of same-day discharge (SDD) patients after elective percutaneous coronary intervention (PCI).
Background:
An overnight stay after PCI has been the standard approach in the majority of institutions. Data supporting SDD while maintaining patient safety, based on contemporary United States practice, have not been well established.
Methods:
Using institutional pre-, peri-, and post-procedural guidelines, short-term clinical outcomes of 200 consecutive patients discharged on the same day after elective PCI were prospectively studied. Major adverse cardiac events (MACE), access site and vascular complications, readmissions, and emergency room (ER) visits were assessed within 24 hrs and at 7-day post-SDD. MACE included cerebral vascular accidents, death, myocardial infarction, target vessel revascularization, pulmonary embolism, and emergent coronary artery bypass grafting.
Results:
The mean age of the population was 63.2 years; 75% were males. Of 200 patients, 75.5% were accessed femorally and 24.5% had radial access. Intra-procedural anticoagulation included bivalirudin alone (47%), bivalirudin with glycoprotein (GP) IIb/IIIa inhibitors (3.5%), heparin alone (37%), and heparin with GP IIb/IIIa inhibitors (12.5%). No major bleeding or MACE was reported within 24 hrs or at 7 days. Within 7 days, 8 (4%) patients experienced minor bleeding, 4 (2%) were readmitted, and 3 (1.5%) had ER visits only. Pseudoaneurysm occurred in 1 (0.5%) patient.
Conclusions:
Our institution-specific guidelines identify low-risk PCI patients who can be safely considered candidates for SDD with virtually no short-term adverse consequences.
Objectives:
The aim of this prospective, multicenter study was to assess the safety, feasibility, acceptance, and cost of ambulatory transradial percutaneous coronary intervention (PCI) under the conditions of everyday practice.
Background:
Major advances in PCI techniques have considerably reduced the incidence of post-procedure complications. However, overnight admission still constitutes the standard of care in most interventional cardiology centers.
Methods:
Eligibility for ambulatory management was assessed in 370 patients with stable angina referred to three high-volume angioplasty centers. On the basis of pre-specified clinical and PCI-linked criteria, 220 patients were selected for ambulatory PCI.
Results:
The study population included a substantial proportion of patients with complex procedures: 115 (52.3%) patients with multivessel coronary artery disease, 50 (22.7%) patients with multilesion procedures, and 60 (21.5%) bifurcation lesions. After 4-6 hr observation period, 213 of the 220 patients (96.8%) were cleared for discharge. The remaining seven (3.2%) patients were kept overnight for unstable angina (n = 1), atypical chest discomfort (n = 2), puncture site hematoma (n = 1), or non-cardiovascular reasons (n = 3). Within 24 hr after discharge, no patients experienced readmission, stent occlusion, recurrent ischemia, or local complications. Furthermore, 99% of patients were satisfied with ambulatory management and 85% reported no anxiety. The average non-procedural cost was lower for ambulatory PCI than conventional PCI (1,230 ± 98 Euros vs. 2,304 ± 1814 Euros, P < 10(-6)).
Conclusions:
Ambulatory PCI in patients with stable coronary artery disease is safe, effective, and well accepted by the patients. It may both significantly reduce costs and optimize hospital resource utilization.
To the Editor: Dr Rao and colleagues¹ found that in patients enrolled in Medicare and at low risk for undergoing elective percutaneous coronary intervention (PCI), same day discharge was rarely implemented but was not associated with increased risk of death or readmission compared with overnight observation. They concluded that “ . . . overnight observation is driven less by patient risk and more by either local practice patterns or other nonclinical reasons.” Unfortunately, the authors offered no practice pattern explanations and only one nonclinical reason, reimbursement, which they dismissed.
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2010 alone, the various Statistical Updates were cited 1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year's edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing various disorders of heart rhythm. Also, the 2012 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update.
The practice of same-day discharge after uncomplicated percutaneous coronary intervention in the USA has been analyzed using a large database including >700,000 patients and, overall, is safe when compared with patients who stay in hospital overnight, but is still rarely used.
The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.
In recent medical history, a number of therapies that were widely adopted based on observational data or pathophysiological constructs turned out to be useless or even harmful when tested in randomized comparative effectiveness trials. These therapies not only harmed patients but also did a disservice to the practical education of medical students, residents, and fellows. These trainees effectively learned that it is acceptable to implement practices even in the absence of high-quality evidence, and so they may not have learned how to analyze the quality of evidence. In this issue of Academic Medicine, seven groups address critical aspects of the intersection between comparative effectiveness research (CER) and academic medicine. Their topics include the need at academic health centers for cultural shifts, for addressing conflicts of interest, for exploiting academic talent and electronic information resources, for interacting well with policy makers, for incorporating economic evaluations, for incorporating tests of educational methods, for developing multidisciplinary models, and for integrating CER into "predictive health." This commentary argues that academia must embrace CER by insisting on the highest levels of evidence, by viewing all clinical interactions as opportunities for scientific advancement, by setting an example for policy makers and colleagues working in nonacademic settings, and by engaging all physicians in the clinical research enterprise.
Our goal was to compare recently published Consensus Statement from the SCAI/ACC on appropriateness for same-day PCI with patient characteristics from a real-world same-day PCI experience in the United States.
Recent practice statement published by the SCAI /ACC in 2009 describes patients suitable for outpatient PCI procedures. Whether this practice statement reflects actual real-world practice in the setting of advances in transradial catheterization needs further exploration.
Pre-existing, deidentified, quality assurance data from 100 sequential patients undergoing transradial PCI, and same-day discharge were compared with criteria in SCAI/ACC statement on outpatient PCI. Each had been identified post-PCI as uncomplicated and therefore eligible for same day discharged. Specific attention was placed on whether the patients carried any exclusion to same-day discharge.
One hundred six procedures were recorded in 100 patients including 11 women and 89 men, median age 62 (55,71) years all with stable ischemia. Early follow up was done for medication compliance. None were readmitted nor had post-PCI complications. Only 15% met appropriateness criteria for same-day discharge. Older age, distance from the hospital, greater than simple PCI, and the need for specific antiplatelet therapy represented the dominant contraindications to discharge.
Using transradial approaches and structured early follow up by advance practice nurses, same-day discharge can be accomplished successfully in a broad range of patients outside of those suggested by the SCAI/ACC 2009 Consensus Document. Confirmation of these results could result in shorter hospitalizations for US patients and align advances in catheterization technology to optimize heath care delivery.
Background:
Randomised trials use the play of chance to assign participants to comparison groups. The unpredictability of the process, if not subverted, should prevent systematic differences between comparison groups (selection bias). Differences due to chance will still occur and these are minimised by randomising a sufficiently large number of people.
Objectives:
To assess the effects of randomisation and concealment of allocation on the results of healthcare studies.
Search strategy:
We searched the Cochrane Methodology Register, MEDLINE, SciSearch and reference lists up to September 2009. In addition, we screened articles citing included studies (ISI Science Citation Index) and papers related to included studies (PubMed).
Selection criteria:
Eligible study designs were cohorts of studies, systematic reviews or meta-analyses of healthcare interventions that compared random allocation versus non-random allocation or adequate versus inadequate/unclear concealment of allocation in randomised trials. Outcomes of interest were the magnitude and direction of estimates of effect and imbalances in prognostic factors.
Data collection and analysis:
We retrieved and assessed studies that appeared to meet the inclusion criteria independently. At least two review authors independently appraised methodological quality and extracted information. We prepared tabular summaries of the results for each comparison and assessed the results across studies qualitatively to identify common trends or discrepancies.
Main results:
A total of 18 studies (systematic reviews or meta-analyses) met our inclusion criteria. Ten compared random allocation versus non-random allocation and nine compared adequate versus inadequate or unclear concealment of allocation within controlled trials. All studies were at high risk of bias.For the comparison of randomised versus non-randomised studies, four comparisons yielded inconclusive results (differed between outcomes or different modes of analysis); three comparisons showed similar results for random and non-random allocation; two comparisons had larger estimates of effect in non-randomised studies than in randomised trials; and two comparisons had larger estimates of effect in randomised than in non-randomised studies.Five studies found larger estimates of effect in trials with inadequate concealment of allocation than in trials with adequate concealment. The four other studies did not find statistically significant differences.
Authors' conclusions:
The results of randomised and non-randomised studies sometimes differed. In some instances non-randomised studies yielded larger estimates of effect and in other instances randomised trials yielded larger estimates of effect. The results of controlled trials with adequate and inadequate/unclear concealment of allocation sometimes differed. When differences occurred, most often trials with inadequate or unclear allocation concealment yielded larger estimates of effects relative to controlled trials with adequate allocation concealment. However, it is not generally possible to predict the magnitude, or even the direction, of possible selection biases and consequent distortions of treatment effects from studies with non-random allocation or controlled trials with inadequate or unclear allocation concealment.
There is a body of literature reporting the safety of discharging patients the same day as percutaneous coronary revascularisation. Nevertheless, overnight stay continues to be the general standard of care.
Over a single calendar year, 130 patients having elective, percutaneous coronary revascularisation were discharged home the day of the procedure with the majority of procedures using radial access. Patients were observed post procedure for six hours and if no problems occurred, discharge was undertaken. The purpose of the study was to assess complications in the 24 hours following discharge.
Within the following 24 hours post discharge, there were no complications reported including bleeding, recurrent ischaemia, or hospitalisation.
Same day discharge following elective percutaneous revascularisation appears both efficacious and safe with a low risk of post discharge complications.
Tremendous improvements in interventional cardiology make percutaneous coronary intervention (PCI) a rather routine procedure, at least in the U.S. and other wealthy countries around the world. Approximately 1 million PCIs are performed annually in the U.S., with health care costs approaching $10
This study sought to estimate the economic impact of same-day home discharge compared with overnight hospitalization after transradial percutaneous coronary intervention (PCI).
Same-day home discharge after transradial PCI and a bolus-only abciximab regimen was found to be clinically noninferior to the abciximab standard therapy and overnight hospitalization in patients with various forms of acute coronary syndromes.
In the EASY (Early Discharge After Transradial Stenting of Coronary Arteries) trial, 1,005 patients were randomized after a bolus of abciximab and uncomplicated transradial coronary stenting, either to same-day home discharge and no infusion (outpatient group) or to overnight hospitalization and 12-h abciximab infusion (overnight-stay group). We estimated post-PCI health care cost (in Canadian dollars) of trial subjects and short-term economic impact of same-day home discharge. As randomization was done after the procedure, outcomes were similar, and PCI resource use showed minimal and nonsignificant differences, a post-PCI cost-minimization analysis was conducted. Detailed per-patient information of health care resources used immediately after PCI up to 30 days was collected.
Mean post-PCI hospital stay was 8.9 h for outpatients versus 26.5 h for overnight-stay patients (p < 0.001). At 30-day follow-up, the mean cumulative medical cost per outpatient was $1,117 ± $1,554 versus $2,258 ± $1,328 for overnight-stay patients. The mean difference of $1,141 (95% confidence interval: $962 to $1,320) was mainly due to the extra night for overnight hospital stay.
In a real-world setting, same-day home discharge after uncomplicated transradial PCI and a bolus-only abciximab regimen resulted in a 50% relative reduction in medical costs. Extension of this outpatient strategy would be welcomed by the hospitals and reimbursement systems in a context of increasing demand for health care cost reduction. (Early Discharge After Transradial Stenting of Coronary Arteries [EASY]; NCT00169819).
This study evaluated the outcomes of patients discharged the day of percutaneous coronary intervention (PCI) by analyzing the data from a single-center, large, multioperator registry of interventions.
Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients. Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge. Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population.
We analyzed the outcomes of consecutive same-day discharge in 2,400 of 16,585 patients who underwent elective PCI without any procedural or hospital complication. Composite end point included 30-day major adverse cardiac cerebral events and bleeding/vascular complications.
The mean age of the study population was 57.0 +/- 23.7 years with 12% aged over 65 years. Twenty-eight percent received glycoprotein IIb/IIIa inhibitor with closure devices in 90.5%. Clinical and angiographic success was noted in 97% of all PCIs. The average length-of-stay following PCI was 8.2 +/- 2.5 h. The composite end point was reached in 23 patients (0.96%). Major adverse cardiac cerebral events occurred in 8 patients (0.33%) and vascular/bleeding complications in the form of Thrombolysis In Myocardial Infarction minor bleeding in 14 patients (0.58%) and pseudoaneurysm in 1 patient (0.04%).
When appropriately selected, with strict adherence to the set protocol, same-day discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients.
Same-day discharge after elective percutaneous coronary intervention (PCI) is safe in the majority of patients. However, the elderly have more comorbidities and less favorable coronary and peripheral arterial anatomy, which may preclude safe same-day discharge after PCI. We assessed the feasibility and safety of same-day discharge in an elderly cohort of patients.
A total of 1,580 consecutive patients undergoing elective PCI in a single center between January 2001 and January 2009 were included in the study. We compared the outcomes of elderly patients aged 75 or older to control patients under the age of 75 years. Patients were examined 6 hours post procedure and discharged if there were no complications.
Of the 1,580 study patients 212 (13.4%) were elderly and 1,365 (86.6%) were younger controls. The elderly were more likely to be female, hypertensive and to have had previous coronary artery bypass graft (CABG) surgery and less likely to be smokers or to have hyperlipidemia (all p < 0.05). The number of lesions treated and their complexity were similar in both groups. Procedural success, in-hospital major adverse cardiac events (MACE) and the rates of same-day discharge were also similar in both groups. Same-day discharge was achieved in the majority (84%) of the elderly. There were no deaths within 24 hours of discharge. Readmission within 24 hours of discharge was rare (< 0.7%) in both groups. The 30-day MACE rate was low in both the elderly (3.3%) and control groups (3.6%; p = 1.0).
Same-day discharge is safe and feasible in the majority of elderly patients following elective PCI.
Received June 2, 2009; accepted November 16, 2009.
Percutaneous coronary intervention (PCI) is the most commonly performed invasive therapeutic cardiac procedure and plays an important role in the treatment of ischemic heart disease. Since the first description of coronary angioplasty in a human by Gruntzig,1 the technique, equipment, and associated pharmacotherapy have undergone substantial evolution, leading to significant improvements in periprocedural complications.2 In particular, procedural anticoagulant therapy has been the focus of numerous clinical trials, and several options are now available and supported by practice guidelines; each agent has both advantages and disadvantages, and procedural pharmacotherapy continues to be a focus of drug development. The purpose of this review is to summarize the goals of anticoagulant therapy during PCI, the pharmacokinetics and pharmacodynamics of available agents, and the clinical data surrounding each agent and to identify new agents in development.
The goals of pharmacotherapy during PCI are 2-fold: (1) to mitigate the sequelae of iatrogenic plaque rupture from balloon angioplasty or stenting and (2) to reduce the risk of thrombus formation on intravascular PCI equipment. Central to these thrombotic events is thrombin (factor IIa). Iatrogenic damage to the endothelium during PCI leads to increased expression of tissue factor, activation of the coagulation cascade, and formation of activated factor Xa. This ultimately leads to the generation of thrombin, conversion of fibrinogen to fibrin, and thrombus formation.3 In addition to its effects on fibrin, thrombin also directly activates platelets, enhances platelet aggregation, and is proinflammatory.4 Because of its multiple actions in promoting thrombosis, the focus of most anticoagulant agents is thrombin inhibition. Available agents for use include unfractionated heparin (UFH), low-molecular-weight heparins (LMWH, of which enoxaparin has the largest body of clinical data), the synthetic pentasaccharides (of which fondaparinux has the largest body of clinical data), and the …
Bleeding in patients undergoing percutaneous coronary intervention (PCI) is associated with increased morbidity, mortality, length of hospitalization, and cost. We identified baseline clinical characteristics associated with bleeding complications after PCI and developed a simplified, clinically useful algorithm to predict patient risk.
Data were analyzed from 302 152 PCI procedures performed at 440 US centers participating in the National Cardiovascular Data Registry. As defined by the National Cardiovascular Data Registry, bleeding required transfusion, prolonged hospital stay, and/or a drop in hemoglobin >3.0 g/dL from any location, including percutaneous entry site, retroperitoneal, gastrointestinal, genitourinary, and other/unknown location. Bleeding complications occurred in 2.4% of patients. From the best-fitting model consisting of 15 clinical elements associated with post-PCI bleeding in a random 80% training cohort, we developed a parsimonious risk algorithm. Predictors of bleeding included age, gender, previous heart failure, glomerular filtration rate, peripheral vascular disease, no previous PCI, New York Heart Association/Canadian Cardiovascular Society Functional Classification class IV heart failure, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and cardiogenic shock. The parsimonious model was validated in the remaining 20% of the population (c-statistic, 0.72) and in clinically relevant subgroups of patients. This simplified model was used to derive a clinical risk algorithm, with larger numbers corresponding with greater risk. In 3 categories, bleeding rates were greater in patients with higher estimates (<or=7, 0.7%; 8 to 17, 1.8%; >or=18, 5.1%).
This report identifies baseline clinical factors associated with bleeding and proposes a clinically useful algorithm to estimate bleeding risk. This model is potentially actionable in altering therapeutic decision making and improving outcomes in patients undergoing PCI.
Progress in techniques and equipment facilitates same-day-discharge percutaneous coronary intervention (PCI).
To present initial experience of a same-day-discharge intention-to-treat ad hoc PCI strategy with a preferentially radial approach.
The first 102 same-day-discharge PCIs performed in our centre were analysed retrospectively. Subjects were stable or stabilised coronary patients, free of cardiac insufficiency, with a normal Allen test and residing within 60min of the centre. Discharge was authorized after six hours' event-free monitoring. The principal assessment criterion combined major adverse cardiovascular events, stroke, major haemorrhage and unscheduled medical consultation in the 30 days following PCI. Overall patient satisfaction and anxiety associated with same-day discharge were assessed by telephone questionnaire at some time after the intervention.
Between January 2006 and March 2008, 95 day-hospital patients underwent 102 distinct PCIs (50 complex, 13 bifurcation lesions, nine intravascular ultrasound, 18 fractional flow reserve, two Rotablator procedures). Crossover to overnight admission was necessary for 5.9% (n=6) of interventions. Baseline clinical and angiographic characteristics were similar to those of an unselected Western population. At 30 days, four clinical events were observed (3.9% of interventions), which occurred within 6 hours (n=2) or after the 24th hour. Classical 24-hour admission would thus have provided no added benefit. On an analogue scale, overall satisfaction was high (8.9/10) and anxiety associated with same-day discharge was low (1.7/10).
A same-day-discharge ad hoc PCI strategy proved reliable and safe for most patients selected a priori on simple clinical criteria, entailing no unexpected complications due to shorter medical monitoring.
Previous investigation has suggested that early discharge after percutaneous coronary intervention (PCI) is feasible and safe, but these studies have utilized largely radial approaches or been conducted in non-U.S. cohorts. We sought to assess patient satisfaction, safety and cost of a strategy of selective early discharge in U.S. patients undergoing PCI via a femoral approach with contemporary adjunctive pharmacologic and hemostasis agents.
Patients with stable coronary artery disease undergoing elective PCI were prospectively recruited and randomized to either routine care, with an overnight hospital stay, versus early discharge 2 hours following successful PCI with adjunctive bivalirudin therapy and a femoral arterial closure device at the end of the procedure. The primary endpoints were safety and patient satisfaction as measured by a validated patient satisfaction survey during the index hospital stay and at 30 days. A total of 39 patients were randomized, with 20 to routine care and 19 to early discharge. There was no difference in major safety endpoints including death, non-fatal MI, urgent target lesion revascularization and thrombolysis in myocardial infarction (TIMI) major bleeding, with none in either group. Mean patient satisfaction scores were similar and high in both groups (89.6 for early discharge patients and 90.7 for routine care patients, p = 0.68). There was lower cost in the early discharge group, with a mean cost of 8,604 USD versus 10,565 USD in the routine care group (mean difference 1,961 USD, 95% confidence interval, -96 USD to 4,017 USD).
Patients undergoing elective PCI for stable coronary artery disease may have similar safety and satisfaction with early discharge when using a careful strategy that incorporates optimal stent and hemostasis results and contemporary adjunctive anticoagulation therapy, with lower cost. This strategy may serve as a basis for a larger-scale randomized trial.
Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.
Although the safety and cost-effectiveness of same-day discharge after uncomplicated transradial percutaneous coronary intervention (TR-PCI) is well established in Europe and Asia, such data are not available for US patients.
All patients who underwent TR-PCI at our high-volume US medical center between 2004 and 2007 were included in this study. The primary end point was in-hospital adverse clinical outcomes between 6 and 24 hours postprocedure.
A total of 450 patients were included in this study (aged 59 +/- 11 years). Of these, 13% were female, 27% were diabetic, 6% had peripheral vascular disease, and 5% had chronic kidney disease. Procedural indications included stable angina (49%), unstable angina (31%), non-ST elevation myocardial infarction (NSTEMI) (17%), and ST elevation myocardial infarction (STEMI) (3%). All patients received an intra-arterial cocktail of heparin, verapamil, and nitroglycerin, and 13% of patients received glycoprotein IIb/IIIa inhibitors. Seven percent of patients had 3-vessel disease, 3% had bypass grafts stenoses, and 20% had class B(2)/C lesions. Procedural success rate was 96%. A total of 24 (5.3%) postprocedural complications were observed; however, none occurred between hours 6 to 24, the time differential between same-day and next-day discharge. Thirteen patients (2.9%) experienced significant complications within the first 6 hours (MI, urgent repeat revascularization, and ventricular tachycardia). Eleven (2.4%) spontaneously resolved minor access complications developed. There were 12 same-day discharges according to the operators' discretion; none required readmission.
Although a low incidence of complications did occur, none would have been impacted by same-day discharge. Those observed before 6 hours would have prevented early discharge, and those occurring after 24 hours would have been unaffected by routine next-day discharge. This observational study demonstrated the safety and feasibility for a prospective evaluation of ambulatory TR-PCI in an American practice setting.