SCAI statement on ad hoc versus the separate performance of diagnostic cardiac catheterization and coronary intervention

Outcomes of patients discharged the same day following percutaneous coronary intervention

OBJECTIVES

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.

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation

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.

Survival benefit with concomitant clopidogrel and glycoprotein IIb/IIIa inhibitor therapy at ad hoc percutaneous coronary intervention

OBJECTIVE

To study clinical outcomes in patients given glycoprotein (GP) IIb/IIIa inhibitors with concomitant clopidogrel at the time of ad hoc percutaneous coronary interventions (PCI).

PATIENTS AND METHODS

We studied 30-day and long-term outcomes of patients undergoing elective or urgent PCI from March 1, 1998, to December 31, 2006, stratified by administration of GP IIb/IIIa inhibitors with concomitant clopidogrel treatment at the time of ad hoc PCI.

RESULTS

The mean+/-SD age was 66.3+/-11.9 years in 5196 patients receiving compared with 67.8+/-11.8 years in 4681 patients not receiving a GP IIb/IIIa inhibitor (P<.001). Overall, 30-day unadjusted mortality was lower in patients who received a GP IIb/IIIa inhibitor (1.0% vs 1.2%; P=.22). Long-term mortality was significantly lower (P<.001) in patients receiving GP IIb/IIIa inhibitors at the time of PCI. After propensity analysis to adjust for the likelihood of receiving GP IIb/IIIa inhibitors on the basis of clinical, angiographic, and procedural characteristics, a significant reduction in 30-day mortality with GP IIb/IIIa inhibitor use was identified (hazard ratio, 0.56; 95% confidence interval, 0.36-0.87; P=.01). Kaplan-Meier analysis (median follow-up, 48 months) revealed a significant improvement in long-term survival in patients receiving a GP IIb/IIIa inhibitor at the time of ad hoc PCI that persisted after propensity adjustments (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98; P=.021). Patients treated with drug-eluting stents showed a significant improvement in adjusted long-term mortality.

CONCLUSION

In patients undergoing elective or urgent ad hoc PCI, coadministration of a GP IIb/IIIa inhibitor and dual antiplatelet therapy is associated with reduced risk-adjusted 30-day and long-term mortality.

Outcomes following immediate (ad hoc) versus staged percutaneous coronary interventions (report from the 2000 to 2001 New York State Angioplasty Registry)

Health care providers are under increasing pressure to lower costs by combining diagnostic and "ad hoc" interventional coronary procedures. Despite increasing use of such a treatment strategy, its effect on periprocedural safety has not been rigorously assessed in the current stent era. Using the 2000/2001 New York State Angioplasty Registry, we compared in-hospital clinical outcomes in 47,020 patients who underwent ad hoc percutaneous coronary interventions (PCIs) versus staged procedures. Patients with previous PCIs, acute myocardial infarction within 24 hours, thrombolytic therapy within 7 days, or those presenting with hemodynamic instability or shock were excluded. Patients in the staged intervention group were more likely to have hypertension, diabetes mellitus, peripheral vascular disease, previous stroke, heart failure, renal failure, previous coronary artery bypass grafting, and a lower left ventricular ejection fraction. Mortality rate (0.4% vs 0.4%, p = 0.299), major adverse cardiac events (0.7% vs 0.8%, p = 0.199), and incidence of renal failure/dialysis (0.1% vs 0.1%, p = 0.520) during in-hospital stay did not differ significantly between the ad hoc PCI and staged groups. There was a higher rate of access site injury in the staged cohort (0.4% vs 0.3%, p = 0.011), and this trend persisted after multivariate logistic regression analysis (odds ratio 1.34, 95% confidence interval 0.99 to 1.81, p = 0.061). In addition, patients with "high-risk" features had similar in-hospital clinical outcomes after either treatment approach. In conclusion, as currently practiced in New York State, the strategy of ad hoc PCI in selected patient cohorts appears to be as safe as the strategy of staged procedures.

Ad Hoc percutaneous coronary interventions in patients with stable coronary artery disease—A study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®)

OBJECTIVE

To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) to monitor the performance and safety of ad hoc PCIs.

BACKGROUND

The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day.

METHODS

We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001-2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success.

RESULTS

Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2-60.3%), hospital PCI volume (67-50.2%), hospital owner (89.7-59.6%), and geographic area (75.5-47.4%). Ad hoc PCI per se was not independently related to PCI success or complications.

CONCLUSIONS

PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times.