Assessment of clinical outcomes related to early discharge after elective percutaneous coronary intervention

Same-day discharge after percutaneous coronary procedures-Structured review and comprehensive meta-analysis

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; I2 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.

Same day discharge following non-elective PCI for non-ST elevation acute coronary syndromes

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 collected as were in-hospital outcomes and post-PCI length of stay (LOS) 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 to 2014, 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 = 1,085) PCI. Thirty-day and one-year mortality and major bleeding rates were similar between the 2 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.

Outpatient Versus Inpatient Percutaneous Coronary Intervention in Patients With Left Main Disease (from the EXCEL Trial)

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.

Adoption of same day discharge following elective left main stem percutaneous coronary intervention

BACKGROUND

This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI.

METHODS

We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality.

RESULTS

SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34).

CONCLUSIONS

We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

Same-day discharge after elective percutaneous coronary intervention: A single center experience

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.

Same-Day Discharge After Outpatient PCI in a VA Hospital: Shared Decision Making and the VA MISSION Act

INTRODUCTION

The VA Mission Act of 2018 sought to increase access to local care facilities for Veterans meeting certain eligibility criteria including a drive time of >60 min from a VA facility. As part of an ongoing review of our VA program's same day discharge (SDD) program following elective percutaneous coronary intervention (PCI), we investigated whether the distance criteria of the VA Mission Act had any impact on overall safety outcomes.

METHODS

We performed a single center, retrospective study in patients who underwent outpatient PCI between 2013 and 2019. We stratified patients into an overnight observation (ON) and SDD group. We used Google Maps in order to calculate patient home distance to the Jesse Brown Veterans Affairs Hospital (JBVA). Primary endpoints included all-cause death andmajor adverse cardiac events (MACE; cardiovascular death, myocardial infarction, stroke, and/or target vessel revascularization). Secondary outcomes included total unplanned interactions with the healthcare system. Outcomes were analyzed at 30 days after PCI.

RESULTS

There were 76 patients in the SDD group. The SDD group had a median drive time of 80 min from the JBVA. Regarding primary outcomes, there were no cases of MACE in either group and there was no statistically significant difference in terms of all-cause mortality (ON: 1.3%, SDD: 0%, p = .5) 30 days following PCI. All secondary outcomes at 30 days did not demonstrate a statistically significant difference between either group.

CONCLUSION

Same day discharge following successful PCI procedures appears safe. In response to the VA Mission Act, drive time and distance travelled did not appear to impact outcomes.

SUMMARY

Same day discharge in select patients at our VA hospital was both safe and feasible. Neither drive time nor distance travelled affected overall outcomes in response to the 2018 VA MISSION Act. As such, shared decision making between patients and physicians remains essential to ensure Veterans continue to receive high quality care that is in their best medical interest.

[Safety and clinical-cost effectiveness of percutaneous coronary interventions with overnight hospitalization]

New methods and treatment plans for patients with chronic coronary artery disease after endovascular interventions are currently introduced into clinical practice. It allows reducing hospital stay down to 24 hour, with discharge the next morning. This approach is called overnight stay. Using a similar strategy increases the availability of various types of endovascular interventions, shorter waiting lists, and cut the cost of treatment due to a reduced hospital stay.

Prevalence, Outcomes and Cost Implications of Patients Undergoing Same Day Discharge After Elective Percutaneous Coronary Intervention in Australia

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.

The Feasibility and Safety of Same-Day Discharge for All Comers after Elective Percutaneous Coronary Interventions

BACKGROUND

The safety of same day discharge (SDD) after percutaneous coronary interventions (PCI) has been demonstrated in several studies. However, SDD was only allowed in patients meeting strict criteria. We aimed to evaluate the feasibility and safety of SDD following elective-PCI in all comers.

METHODS

In 2012, we implemented a strategy of SDD for all elective PCI (no exclusion) but admissions were allowed at the discretion of the treating physician. We assessed the feasibility and safety of this approach in consecutive patients who underwent elective PCI at WVU.

RESULTS

Out of 3355 patients who underwent PCI between 2012 and 2016, 691 (21%) presented electively. Radial access was utilized in 480 (69.5%). Same day discharge was achieved in 539/691 (78%), and there was no difference between patients who had SDD and those who were admitted with regards to the 30-day major adverse cardiovascular and cerebrovascular events (3.2% vs. 3.5% respectively, P = 0.195). Predictors of SDD failure were procedural complications (OR 12.08, 95%CI 2.20-57.8. P = 0.002), use of Glycoprotein IIB-IIIA inhibitors (OR 3.45, 95%CI 1.067-11.41, P = 0.039), femoral access (OR 2.067, 95%CI 1.25-3.419, p = 0.005), anemia (OR 1.80, 95%CI 1.06-3.04, P = 0.029), home distance ≥60 miles (OR 1.68, 95%CI 1.03-2.72, P = 0.037).

CONCLUSION

SDD is feasible in the majority of all-comers after elective PCI, and is not associated with increase in adverse events at 30-days. Certain procedural and patient's characteristics predict SDD failure. If validated in prospective studies, these factors can possibly be integrated in a predictive tool to aid in triaging patients, post-elective PCI.

Early versus late clinical outcomes following same day discharge after elective percutaneous coronary intervention: A systematic review and meta-analysis

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.

Safety of Same-Day Discharge after Percutaneous Coronary Intervention with Orbital Atherectomy

BACKGROUND

Severely calcified lesions present many challenges to percutaneous coronary intervention (PCI). Orbital atherectomy (OA) aids vessel preparation and treatment of severely calcified coronary lesions. Same-day discharge (SDD) after PCI has numerous advantages including cost savings and improved patient satisfaction. The aim of this study is to evaluate the safety of SDD among patients treated with OA in a real-world setting.

METHODS

This was a single-center retrospective analysis of patients undergoing OA. In-hospital and 30-day outcomes were assessed for major adverse cardiac events (MACE), device-related events and hospital readmissions.

RESULTS

There were 309 patients treated with OA of whom 94 had SDD (30.4%). Among SDD patients, there were no acute procedural complications and all patients were safely discharged on the day of the procedure. MACE at 30 days occurred in 1 patient (1.06%) due to major bleeding in the setting of a gastric arteriovenous malformation. There were 8 patients with unplanned 30-day readmissions (8.5%).

CONCLUSION

SDD after OA in patients with heavily calcified lesions appears to be safe, with low rates of adverse events and readmissions in select patients. In patients with SDD treated with OA, unplanned readmission occurred at a similar rate to the statewide average 30-day PCI readmission rate. Larger studies are needed to confirm the safety of this treatment paradigm and the potential cost savings.

Implementing Same Day Discharge Following Percutaneous Coronary Intervention: A Process Evaluation

BACKGROUND

The safety and effectiveness of same day discharge (SDD) following percutaneous coronary intervention are well demonstrated; however, the uptake of this model of care is low.

PURPOSE

The aim was to examine the effectiveness of implementing SDD using a process evaluation methodology.

METHODS

This study was undertaken in a cardiac services department of a tertiary teaching hospital in southeast Queensland, Australia. It was anticipated before the implementation that 120 patients could be discharged the same day in a 6 months' time period. Patient selection process and guideline adherence were assessed along with patients' and relatives' satisfaction.

RESULTS

During implementation, 22 patients were discharged home the same day. It was found that staff did not follow the guideline consistently, with an overall adherence of 77.3%.

CONCLUSION

The uptake of SDD was low in this implementation. The study is important as it provides direction for future improvement both in the criteria and the implementation process.

Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention

Background

Same‐day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low‐risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a “patient‐centered” protocol based on risk of complications at Barnes‐Jewish Hospital.

Methods and Results

Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient‐centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient‐centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes‐Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score–adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient‐centered approach markedly increased SDD eligibility.

Conclusions

With a patient‐centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient‐centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.

Phenotype of Same-Day-Discharge Patients After Percutaneous Coronary Intervention

BACKGROUND

Overnight observation is the standard of care for uncomplicated elective percutaneous coronary intervention (PCI). However, same-day discharge (SDD) is reportedly safe using predetermined criteria and patient risk categories. Characteristics of patients with SDD have not yet been described.

OBJECTIVE

The purpose of this study was to describe the phenotype of patients appropriate for SDD after PCI without predetermined criteria and patient risk categories.

METHODS

Analysis of PCI registry data was conducted on patients (n = 2174) who underwent elective and nonelective PCI between January 2012 and June 2014. Preliminary analysis included descriptive statistics, t tests, and χ tests. All variables were analyzed using random forest plot to determine importance of predictors of SDD followed by confirmatory logistic regression.

RESULTS

Random forest plot indicated 6 predictors of SDD. Confirmatory logistic regression using a model with all 6 predictors indicated that the model was able to distinguish between patients with SDD and overnight observation after PCI and was statistically significant (χ(7.12, N = 2174) = 511.12, P < .005). Strongest predictors of SDD were stable angina (odds ratio, 5.93 [95% confidence interval, 1.316-26.712]; P = .020) followed by non-ST elevation myocardial infarction/high-risk unstable angina (odds ratio, 1.66 [95% confidence interval, 1.239-2.225]; P = .001). Readmission within 24 hours of SDD after PCI was low at 0.91%.

CONCLUSIONS

Age, access site, complexity, and number of lesions stented did not preclude SDD. A broader range of patients, particularly patients in higher risk categories (non-ST elevation myocardial infarction and unstable angina), are candidates for SDD.

Barriers to Early Discharge after Elective Percutaneous Coronary Intervention (BED PCI): A Single-Center Study

Objective

To identify patient characteristics and procedural factors that may play a role in hindering same-day discharge (SDD) practices.

Background

Multiple studies have shown the safety and cost effectiveness of SDD following elective percutaneous coronary intervention (PCI), but factors that hinder SDD practices have not been thoroughly studied.

Material and Methods

A retrospective comparative analysis of elective PCI patients who had an overnight stay (OS) (n = 345) vs. SDD patients (n = 222) was conducted to identify significant differences between the two groups in baseline patient characteristics, procedural, and postprocedural factors.

Results

Comparing OS to SDD patients, OS patients had a lower prevalence of radial access (20.29% vs. 39.64%, P < 0.0001); a higher incidence of suboptimal angiographic results (14.49% vs. 1.80%, P = 0.0027); CRCL values lower than 60 mL/min (26.38% vs. 15.32%, P = 0.0019); and greater femoral vascular site hemostasis with manual compression (69.09% vs. 36.57%, P = 0.0027). OS patients received larger sheath sizes (P = 0.0209), more bivalirudin (45.80% vs. 36.70%) and glycoprotein IIb/IIIa inhibitors (5.51% vs. 2.25%), but less heparin (51.30% vs. 53.21%). Chest pain (8.12% vs. 0.92%, P = 0.0042) and vascular access site concerns (20.58% vs. 0%, P = 0.0027) were more common among OS patients.

Conclusions

Pre-, peri-, and post-procedural factors play a role in SDD eligibility. Understanding factors that limit as well as those that facilitate SDD may enable institutions to establish or enhance a SDD program.

Implementation Strategies for Same Day Discharge Post Percutaneous Coronary Intervention: An Integrative Review

BACKGROUND

Same day discharge following percutaneous coronary intervention has emerged worldwide to enhance discharge efficiency and decrease length of stay. However, uptake of this practice is variable and strategies to support its implementation have not been examined.

RESEARCH QUESTION

Among patients who undergo nonurgent percutaneous coronary intervention, what components are included in and which strategies are used to facilitate the implementation of same day discharge in clinical practice?

METHODS

An integrative review was conducted. Keywords including same day discharge, outpatient, percutaneous coronary intervention, outpatient coronary stenting were used to search databases including Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica dataBase, Cochrane, and Medline between 1990 and 2014. Data were extracted and summarized specific to: (a) components of same day discharge, (b) patient selection, and (c) strategies used to implement same day discharge.

RESULTS

Nineteen articles were included that provided information about implementation strategies for same day discharge. Variability was identified in how same day discharge was operationalized, how patients were selected, and the strategies that were used to implement same day discharge. Culture, patient preference, and acceptance of same day discharge were important for its implementation. Guideline or protocol, physical environment, champion, education, audit or feedback, and team building were all found to be important strategies in implementing same day discharge.

LINKING EVIDENCE TO ACTION

The results of this integrative review inform our understanding of how same day discharge is operationalized and what strategies can be used to implement same day discharge. The findings of the review highlight that there is a need for more research examining implementation strategies in a detailed manner that can assist others to introduce and sustain same day discharge in routine practice.

Thirty-day readmission rates after PCI in a metropolitan center in Europe: incidence and impact on prognosis

INTRODUCTION

Thirty-day readmission rates after percutaneous coronary intervention (PCI) have been related to adverse prognosis, and represent one of the most investigated indicators of quality of care. These data, however, derive from non-European centers evaluating all-cause readmissions, without stratification for diagnosis.

METHODS

All consecutive patients undergoing PCI at our center from January 2009 to December 2011 were enrolled. Thirty-day readmissions related to postinfarction angina, myocardial infarction, unstable angina or heart failure were defined as acute coronary syndrome (ACS) or heart failure rehospitalizations. Major cardiac adverse event (MACE) was the primary outcome, and its single components (death, myocardial infarction and repeated revascularization) the secondary ones.

RESULTS

A total of 1192 patients were included; among them, 53 (4.7%) were readmitted within 30 days, and 25 (2.1%) were classified as ACS/heart failure related. During hospitalization, patients with ACS/heart failure readmissions were more likely to suffer a periprocedural myocardial infarction (22 vs. 4%; P = 0.012), and to undergo PCI at 30 days (52 vs. 0.5%; P < 0.001). Logistic regression analysis indicated that periprocedural myocardial infarction represented the only independent predictor of an ACS/heart failure readmission [odds ratio (OR) 4.5; 1.1-16.8; P = 0.047]. After a median follow-up of 787 days (434-1027; first and third quartiles), patients with a 30-day ACS/heart failure readmission experienced higher rates of MACE, all-cause death and myocardial infarction (64 vs. 21%, P < 0.001; 28 vs. 6%, P = 0.017; and 20 vs. 2.7%, P < 0.001, respectively). Cox multivariate analysis indicated that ACS/heart failure 30-day readmissions were independently related to an increased risk of all-cause death (OR 3.3; 1.1-8.8; P = 0.02), differently from 30-day non-ACS/heart failure readmissions (OR 3.1; 0.7-12.9; P = 0.12).

CONCLUSION

Thirty-day readmissions after PCI in an Italian center are infrequent, and only those patients with ACS/heart failure show a detrimental impact on prognosis who have periprocedural myocardial infarction as the only independent predictor.

Intravascular ultrasound observation of the mechanism of no-reflow phenomenon in acute myocardial infarction

Objective

To study the mechanism of the no-reflow phenomenon using coronary angiography (CAG) and intravascular ultrasound (IVUS).

Methods

A total of 120 patients with acute myocardial infarction (AMI) who successfully underwent indwelling intracoronary stent placement by percutaneous coronary intervention (PCI). All patients underwent pre- and post-PCI CAG and pre-IVUS. No-reflow was defined as post-PCI thrombolysis in myocardial infarction (TIMI) grade 0, 1, or 2 flow in the absence of mechanical obstruction. Normal reflow was defined as TIMI grade 3 flow. The pre-operation reference vascular area, minimal luminal cross-sectional area, plaque cross-sectional area, lesion length, plaque volume and plaque traits were measured by IVUS.

Results

The no-reflow group was observed in 14 cases (11.6%) and normal blood-flow group in 106 cases (89.4%) based on CAG results. There was no statistically significant difference in the patients’ medical history, reference vascular area (no-flow vs. normal-flow; 15.5 ± 3.2 vs. 16.2 ± 3.3, p> 0.05) and lesion length (21.9 ± 5.1 vs. 19.5 ± 4.8, p> 0.05) between the two groups. No-reflow patients had a longer symptom onset to reperfusion time compared to normal blood-flow group [(6.6 ± 3.1) h vs (4.3 ± 2.7) h; p< 0.05] and higher incidence of TIMI flow grade< 3 (71.4% vs 49.0%, p< 0.05). By IVUS examination, the no-reflow group had a significantly increased coronary plaque area and plaque volume compared to normal blood-flow group [(13.7 ± 3.0) mm² vs (10.2 ± 2.9) mm²; (285.4 ± 99.8) mm³ vs (189.7 ± 86.4) mm³; p< 0.01]. The presence of IVUS-detected soft plaque (57.1% vs. 24.0%, p< 0.01), eccentric plaque (64.2% vs. 33.7%, p< 0.05), plaque rupture (50.0% vs. 21.2%, p< 0.01), and thrombosis (42.8% vs. 15.3%) were significantly more common in no-reflow group.

Conclusion

There was no obvious relationship between the coronary risk factors and no-reflow phenomenon. The symptom onset to reperfusion time, TIMI flow grade before stent deployment, plaque area, soft plaques, eccentric plaques, plaque rupture and thrombosis may be risk factors for the no-reflow phenomenon after PCI.

Influence of Access, Anticoagulant, and Bleeding Definition on Outcomes of Primary Percutaneous Coronary Intervention: Early Experience of an US Academic Center

Background We aimed to carry out comparison of different bleeding avoidance strategies in doing primary percutaneous coronary intervention (PPCI) using either radial or femoral as access of choice and either bivalirudin or unfractionated heparin as anticoagulant of choice. In this analysis, we analyzed the influence of major bleeding definition on bleeding outcomes as well. Methods We did a retrospective analysis of 139 patients with ST-segment elevation myocardial infarction (STEMI) who had PPCI in our academic center from January 2010 till October 2013. The primary outcome at 30 days was a composite of death from any cause or stent thrombosis or non-coronary artery bypass grafting (CABG) related major bleeding (CathPCI Registry definition) and secondary outcomes were individual components of primary outcome and the hospital length of stay. Results There was no significant difference among different access/anticoagulant combinations with regards to primary outcome (22% in radial/bivalirudin vs. 5% in radial/heparin vs. 17% in femoral/bivalirudin vs. 28% in femoral/heparin group; p = 0.2) as well as its individual components except the hospital length of stay (2.56 vs. 3 vs. 3.97 vs. 4.4 days each; p < 0.0001). The overall rate of major bleeding was 11.5%. When we use HORIZON-AMI bleeding definition, it went up to 25 % due to one particular component (p < 0.004). Conclusions This single center observational study doing PPCI did not show any superiority of one bleeding avoidance strategy over others with regard to primary outcome and its individual components except the hospital length of stay. It also shows the importance of bleeding definition on bleeding outcomes.