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Sugiharto F, Trisyani Y, Nuraeni A, Songwathana P. Safety of Early Discharge Among Low-Risk Patients After Primary Percutaneous Coronary Intervention: An Updated Systematic Review and Meta-Analysis. Ther Clin Risk Manag 2024; 20:169-183. [PMID: 38463615 PMCID: PMC10924750 DOI: 10.2147/tcrm.s451598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/28/2024] [Indexed: 03/12/2024] Open
Abstract
Background Guidelines for early discharge (ED) strategies after primary percutaneous coronary intervention (PPCI) in low-risk patients still need to be informed. Previous meta-analysis evidence is considered to have limitations, from the level of heterogeneity, which is still relatively high, and the sample size still needed to be more significant. Purpose This study aims to identify the safety of early discharge after PPCI in low-risk patients. Methods The literature search used five primary databases: CINAHL, PubMed, ScienceDirect, Scopus, Taylor and Francis, and one search engine: Google Scholar. Two reviewers independently screened and critically appraised studies using JBI's and Cochrane's Risk of Bias tool. Fixed and random effects model were applied to collect standardized mean differences and risk differences. Statistical analysis was performed using Review Manager 5.3 and JAMOVI version 2.4.8.0. Results Seven RCTs consisting of 1.780 patients and seven cohort studies consisting of 46.710 patients were included in the quantitative analysis. The results of the RCT analysis showed no significant differences in all-cause readmission (RD -0.01; 95% CI: -0.04 to 0.01; Z=1.20; p=0.23; I2=0%) and mortality (RD 0.00; 95% CI: -0.01 to 0.01; Z=0.01; p=0.99; I2=0%) and also significant in reducing LOS in hour (SMD -2.32; 95% CI: -3.13 to -1.51; Z=5.64; p<0.001; I2=93%) and day (SMD -0.58; 95% CI: - 1.00 to -0.17; Z=2.76; p=0.006; I2=84%). In addition, analysis of cohort studies showed that ED strategy was associated with all-cause readmission (RD -0.00; 95% CI: -0.01 to -0.00; Z =2.18; p=0.03; I2=0%) and mortality (RD -0.01; 95% CI: -0.02 to -0.00; Z=2.04; p=0.04; I2=94%). Conclusion ED strategies in low-risk patients after PPCI can be completely safe. This is proven by the absence of significant differences in readmission and mortality rates as well as reduce the length of stay.
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Affiliation(s)
- Firman Sugiharto
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Yanny Trisyani
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Aan Nuraeni
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
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Sahin AT, Aydin N, Alsancak Y, Gurbuz AS. The Impact of Hospitalization Time on Major Cardiovascular Event Frequency in Patients with ST-Elevation Myocardial Infarction Over a 6-Month Follow-up. HASEKI TIP BÜLTENI 2023. [DOI: 10.4274/haseki.galenos.2023.8368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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Shi W, Ghisi GLM, Zhang L, Hyun K, Pakosh M, Gallagher R. Systematic review, meta‐analysis and meta‐regression to determine the effects of patient education on health behaviour change in adults diagnosed with coronary heart disease. J Clin Nurs 2022. [DOI: 10.1111/jocn.16519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/03/2022] [Accepted: 08/17/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Wendan Shi
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Gabriela L. M. Ghisi
- Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute University Health Network Toronto Ontario Canada
| | - Ling Zhang
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
| | - Maureen Pakosh
- Library & Information Services, Toronto Rehabilitation Institute University Health Network Toronto Ontario Canada
| | - Robyn Gallagher
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
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Yndigegn T, Gilje P, Dankiewicz J, Mokhtari A, Isma N, Holmqvist J, Schiopu A, Ravn-Fischer A, Hofmann R, Szummer K, Jernberg T, James SK, Gale CP, Fröbert O, Mohammad MA. Safety of early hospital discharge following admission with ST-elevation myocardial infarction treated with percutaneous coronary intervention: a nationwide cohort study. EUROINTERVENTION 2022; 17:1091-1099. [PMID: 34338642 PMCID: PMC9725020 DOI: 10.4244/eij-d-21-00501] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. AIMS We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). METHODS Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. RESULTS A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. CONCLUSIONS Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.
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Affiliation(s)
- Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Patrik Gilje
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Nazim Isma
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Jasminka Holmqvist
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Alexandru Schiopu
- Department of Internal Medicine, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Annika Ravn-Fischer
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Stefan K. James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Medicine, University of Leeds, Leeds, United Kingdom,Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Moman A. Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221 85 Lund, Sweden
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Zhang T, Qi X. Greater Nursing Role for Enhanced Post-Percutaneous Coronary Intervention Management. Int J Gen Med 2021; 14:7115-7120. [PMID: 34720599 PMCID: PMC8550204 DOI: 10.2147/ijgm.s337385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Percutaneous coronary intervention (PCI) has increasingly been used in management of coronary artery diseases (CAD). Coupled that with an increasing incidence rate of CAD has augmented the hospital burden with consequential post-PCI patient management problems and dissatisfaction. Nursing care has a key role to play in upgrading the healthcare services and raising patients’ satisfaction through enhanced patient education and engagement. In this regard, nursing-led intervention has shown some success in three main domains: risk reduction; psychological improvement; and quality of life. Urgent efforts are needed to formulize a structured follow-up with enhanced nursing role in post-PCI management to raise quality of healthcare.
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Affiliation(s)
- Tian Zhang
- The First Internal Medicine Comprehensive Ward of Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Xiangxiu Qi
- Nursing Department of Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
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Lv J, Zhao Q, Yang J, Gao X, Zhang X, Ye Y, Dong Q, Fu R, Sun H, Yan X, Li W, Yang Y, Xu H. Length of Stay and Short-Term Outcomes in Patients with ST-Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention: Insights from the China Acute Myocardial Infarction Registry. Int J Gen Med 2021; 14:5981-5991. [PMID: 34588802 PMCID: PMC8473847 DOI: 10.2147/ijgm.s330379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Length of stay (LOS) in patients with ST-segment elevation myocardial infarction (STEMI) is directly associated with financial pressure and medical efficiency. This study aimed to determine impact of LOS on short-term outcomes and associated factors of LOS in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI). METHODS A total of 3615 patients with STEMI after PPCI in the China Acute Myocardial Infarction registry were included in the analysis. Predictors of prolonged LOS were analyzed by multivariate logistic regression model with generalized estimating equation. The impact of LOS on 30-day clinical outcomes was assessed. RESULTS The median LOS was 9 (7, 12) days. Patients with a longer LOS (>7 days) were older, more often in lower-level hospitals, had more periprocedural complications and hospitalization expense. Fourteen variables, such as weekend admission and lower-level hospitals, were identified as independent associated factors of prolonged LOS. There were no significant difference in 30-day major adverse cardiac and cerebrovascular events (MACCE), readmission, and functional status between patients with LOS≤7d and LOS>7d after multivariate adjustment and propensity score matching. However, patients who discharged over one week had better medication adherence (adjusted odds ratio: 0.817, 95% confidence interval: 0.687-0.971, P=0.022). Significant interaction was observed in medication use between gender and LOS (Pinteraction=0.038). CONCLUSION Patients with STEMI undergoing PPCI experienced a relatively long LOS in China, which resulted in more medical expenses but no improvement on 30-day MACCE, readmission, and functional recovery. Poor 30-day medication adherence with short LOS reflects unsatisfying transition of management from hospital to community. More efforts are needed to reduce LOS safely and improve the efficiency of medical care.
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Affiliation(s)
- Junxing Lv
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Qinghao Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Jingang Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Xiaojin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Xuan Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Yunqing Ye
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Qiuting Dong
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Rui Fu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Hui Sun
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Xinxin Yan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Wei Li
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Yuejin Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - On behalf of the China Acute Myocardial Infarction Registry Study Group
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People’s Republic of China
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Safety and Feasibility of Same Day Discharge Strategy for Primary Percutaneous Coronary Intervention. Glob Heart 2021; 16:46. [PMID: 34381668 PMCID: PMC8252969 DOI: 10.5334/gh.1035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Tomer O, Leibowitz D, Einhorn-Cohen M, Shlomo N, Dobrecky-Mery I, Blatt A, Meisel S, Alcalai R. The impact of short hospital stay on prognosis after acute myocardial infarction: An analysis from the ACSIS database. Clin Cardiol 2021; 44:748-753. [PMID: 34041766 PMCID: PMC8207980 DOI: 10.1002/clc.23652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Current evidence regarding the optimal length of hospital stay (LOS) following myocardial infarction (MI) is limited. This study aimed to examine LOS policy for MI patients and to assess the safety of early discharge. METHODS A prospective observational study that included patients with STEMI and NSTEMI enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) during the years 2000-2016. Patients were divided into three subgroups according to their LOS: <3 days (short-LOS), 3-6 days (intermediate-LOS) and >6 days (long-LOS). We compared baseline characteristics, management strategies and clinical outcomes at 30 days and 1 year in these groups. RESULTS Ten thousand four hundred and fifty eight patients were enrolled in the study. The LOS of MI patients gradually decreased over time. Short-LOS and intermediate-LOS patients had similar clinical characteristics while patients in the long-LOS group were older with more co-morbidity. There was no difference in the clinical outcomes, including re-MI, arrhythmias, 30 days MACE, and 30 days mortality between the short-LOS and intermediate-LOS groups. However, the rate of re-hospitalizations was higher in the short-LOS group (20.9% vs. 17.8%, p = .004) without evidence of increased cardiovascular events. In multivariate analysis, the LOS did not predict either 30 days mortality (HR: 1.3; CI:0.45-5.48), nor MACE at 30 days (HR: 1.1; CI:0.79-1.56). CONCLUSION Our study suggests that an early discharge strategy of up to 3 days from admission is safe for low and intermediate-risk patients after both STEMI and NSTEMI. Nevertheless, this strategy is associated with an increased risk of potential avoidable readmission and there might be psychological and social factors that may warrant a longer stay.
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Affiliation(s)
- Orr Tomer
- The Heart Institute, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Leibowitz
- The Heart Institute, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Nir Shlomo
- Neufeld Cardiac Research Institute, Sheba Medical Center, Ramat Gan, Israel
| | | | - Alex Blatt
- Department of Cardiology, Kaplan Medical Center and Hebrew University, Rehovot, Israel
| | - Simcha Meisel
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ronny Alcalai
- The Heart Institute, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Yousif N, Chachar TS, Subbramaniyam S, Vadgaonkar V, Noor HA. Safety and Feasibility of 48 h Discharge After Successful Primary Percutaneous Coronary Intervention. J Saudi Heart Assoc 2021; 33:77-84. [PMID: 33936941 PMCID: PMC8084303 DOI: 10.37616/2212-5043.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 11/20/2022] Open
Abstract
Background The aim of the current study is to determine the safety of early discharge (ED) within 48 hours (h) for ST-elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (PPCI) and to define the criteria of low-risk patients that can be considered for ED. Methods This is a single-center retrospective study that took place at Mohammed bin Khalifa Cardiac Centre in the Kingdom of Bahrain. 301 patients who underwent PPCI between January 2018 and March 2019 were included. Endpoints at 30 days follow-up comprised cardiac re-admission, cardiovascular death, non-fatal myocardial infarction, stroke, and major adverse cardiovascular and cerebrovascular events. Results Of the 301 patients included in our study, 74 (24.5%) were discharged within 48 h (group 1) compared with 227 (75.5%) hospitalized for more than 48 h after PPCI (group 2) (<0.0001). In terms of baseline characteristics, group 2 had higher proportions of chronic kidney disease (P = 0.051), mean HbA1c (P = 0.016) and mean CPK (P < 0.0001) compared to their group 1 counterparts. The prevalence of anterior STEMI was twice as high among group 2 (P < 0.0001), with a significantly higher prevalence of left main stenting (P = 0.025). Additionally, larger proportion of group 2 required inotropic therapy (P = 0.031), oral anticoagulation (P = 0.005) and had a significantly lower ejection fraction (LVEF) (P < 0.0001) with more procedural complications (P = 0.005). LVEF exerts a large effect on ED, as reflected by a high deviance R2 = 20.4%, and was able to correctly classify the subjects into their pertaining discharge group with an accuracy of 80.4%, a specificity of 82.7%, and a sensitivity of 71.2%. According to the fitted LVEF values using the logistic equation, each 1% increase in LVEF is associated with a 3.5% increase in the chance of ED. The two groups recorded fairly similar clinical outcomes at 30-day. Conclusion Preserved LV systolic function is a good predictor of early and safe discharge after successful PPCI. The presented data support the practice of ED, with length of stay even shorter than current guidelines recommendation in selected low-risk patients.
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Affiliation(s)
- Nooraldaem Yousif
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | - Tarique S Chachar
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | | | - Vinayak Vadgaonkar
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | - Husam A Noor
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
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Lim TW, Karim TS, Fernando M, Haydar J, Lightowler R, Yip B, Sriamareswaran R, Tong DC, Layland J. Utility of Zwolle Risk Score in Guiding Low-Risk STEMI Discharge. Heart Lung Circ 2020; 30:489-495. [PMID: 33277179 DOI: 10.1016/j.hlc.2020.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 10/10/2019] [Accepted: 08/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite emerging evidence suggesting that selected patients presenting with ST-segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention (PPCI) may be considered for early discharge, STEMI patients are typically hospitalised longer to monitor for serious complications. METHODS We assessed the feasibility of identifying low-risk STEMI patients in our institution for early discharge using the Zwolle risk score (ZRS). We evaluated consecutive STEMI patients who underwent successful PPCI within the period 1 January 2016 to 31 December 2017. Low-risk was defined as ZRS≤3. Demographic, angiographic characteristics, length of stay (LOS), and 30-day major adverse cardiovascular events (MACE) defined as cardiac death, stroke, congestive cardiac failure, and non-fatal myocardial infarction, were recorded. RESULTS There were 183 STEMI patients in our study cohort (mean age 62.0±12.2 years, 77.0% male). The median ZRS was 2 (interquartile range 1-4) with 132 (72.1%) patients classified as low-risk. The overall 30-day MACE and mortality rates were 10.4% and 3.3% respectively. None of the 35 (26.5%) low-risk patients who were discharged within 72 hours experienced MACE at 30 days. Low-risk STEMI patients had significantly shorter median LOS (86.3 vs. 93.2 hours, p=0.002), lower 30-day MACE (4.5% vs. 25.5%, p<0.0001) and mortality (0% vs. 11.8%, p<0.0001) compared to high-risk group (ZRS>3). Receiver operating characteristic (ROC) curve analyses for ZRS in predicting 30-day MACE and mortality yielded C-statistics of 0.79 (95%CI 0.68-0.90, p<0.0001) and 0.98 (95%CI 0.95-1.00, p<0.0001) respectively. CONCLUSION Low-risk STEMI patients stratified by Zwolle risk score, who were treated successfully with PPCI, experienced low 30-day MACE and mortality rates, indicating that early discharge may be safe in these patients. Larger studies are warranted to evaluate the safety of ZRS-guided early discharge of STEMI patients, as well as the economic and psychological impacts.
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Affiliation(s)
- Teik Wen Lim
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | | | - Melinda Fernando
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Joaud Haydar
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Rachel Lightowler
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Bryan Yip
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | | | - David C Tong
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia.
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Corones-Watkins K, Cooke M, Theobald K, White K, Thompson DR, Ski CF, King-Shier K, Conway A, Ramis MA. Effectiveness of nurse-led clinics in the early discharge period after percutaneous coronary intervention: A systematic review. Aust Crit Care 2020; 34:510-517. [PMID: 33272768 DOI: 10.1016/j.aucc.2020.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Readmission after percutaneous coronary intervention is common in the early postdischarge period, often linked to limited opportunity for education and preparation for self-care. Attending a nurse-led clinic within 30 d after discharge has the potential to enhance health outcomes. OBJECTIVE The aim of the study was to synthesise the available literature on the effectiveness of nurse-led clinics, during early discharge (up to 30 d), for patients who have undergone percutaneous coronary intervention. REVIEW METHOD USED A systematic review of randomised and quasi-randomised controlled trials was undertaken. DATA SOURCES The databases included PubMed, OVID, CINAHL, EMBASE, the Cochrane Library, SCOPUS, and ProQuest. REVIEW METHODS Databases were searched up to November 2018. Two independent reviewers assessed studies using the Cochrane risk-of-bias tool. RESULTS Of 2970 articles screened, only four studies, representing 244 participants, met the review inclusion criteria. Three of these studies had low to moderate risk of bias, with the other study unclear. Interventions comprised physical assessments and individualised education. Reported outcomes included quality of life, medication adherence, cardiac rehabilitation attendance, and psychological symptoms. Statistical pooling was not feasible owing to heterogeneity across interventions, outcome measures, and study reporting. Small improvements in quality of life and some self-management behaviours were reported, but these changes were not sustained over time. CONCLUSIONS This review has identified an important gap in the research examining the effectiveness of early postdischarge nurse-led support after percutaneous coronary intervention on outcomes for patients and health services. More robust research with sufficiently powered sample sizes and clearly defined interventions, comparison groups, and outcomes is recommended to determine effectiveness of nurse-led clinics in the early discharge period.
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Affiliation(s)
| | - Marie Cooke
- School of Nursing and Midwifery, Griffith University, Brisbane, Australia
| | - Karen Theobald
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Katherine White
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Chantal F Ski
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK; Integrated Care Academy, University of Suffolk, Ipswich, UK.
| | | | - Aaron Conway
- Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Mary-Anne Ramis
- School of Nursing, Queensland University of Technology, Brisbane, Australia
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12
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Khaled S, Jaha N, Shalaby G, Niazi AK, Alhazmi F, Alqasimi H, Ruzaizah RA, Haddad M, Alsabri M, Kufiah H. Early discharge (within 24-72 h) in low-risk AMI patients treated with PCI: feasibility and safety-Hajj study. Egypt Heart J 2020; 72:55. [PMID: 32894368 PMCID: PMC7477056 DOI: 10.1186/s43044-020-00095-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 08/27/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Shortening of the hospital stay in patients admitted with the diagnosis of acute myocardial infarction (AMI) has been observed within the last decades. Our center is the only cardiac center in the region providing tertiary care facility and hence receives all AMI patients deemed suitable for invasive assessment and management and this leads to huge required demand. Our aim is to assess feasibility and safety of the early discharge of selected proportion of AMI patients. RESULT Out of 557 of patients presented with AMI and treated with percutaneous coronary intervention (PCI), 310 (56%) were discharged early. Men patients and pilgrims were more prevalent among the early discharge group. Early discharged patients had significantly less comorbidities compared to the other group of patients. Moreover, they presented mainly with ST-elevation myocardial infarction (P = 0.04) and treated more with primary percutaneous coronary intervention (PPCI) (P = 0.04). They had favorable coronary anatomy (P = 0.01 and 0.02 for left main and multi-vessel coronary artery disease, respectively), better hospital course, and higher left ventricular ejection fraction compared to non-early discharged patients (P = 0.006 and < 0.001 for pulmonary edema and left ventricular ejection fraction post myocardial infarction). Follow-up of those early discharged patients were promising as majority of them were asymptomatic (95%) and did well post-discharge. CONCLUSION Our study demonstrated data that support safety of early discharge in a carefully selected group of AMI patients. Early but safe discharge may have a huge impact on increasing bed availability, reducing hospital costs, and improving patient's satisfaction.
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Affiliation(s)
- Sheeren Khaled
- Benha University, Benha, Egypt
- King Abdullah Medical City, Muzdallfa Road, Makkah, Saudi Arabia
| | - Najeeb Jaha
- King Abdullah Medical City, Muzdallfa Road, Makkah, Saudi Arabia
| | - Ghada Shalaby
- King Abdullah Medical City, Muzdallfa Road, Makkah, Saudi Arabia
- Zagazig University, Zagazig, Egypt
| | | | - Faisal Alhazmi
- King Faisal Specialist hospital and research center, King Abdullah Medical City, Muzdallfa Road, Makkah, Saudi Arabia
| | - Hadeel Alqasimi
- College of Medicine, Umm Al Qura University, Makkah City, Makkah 24353 Saudi Arabia
| | - Rahaf Abu Ruzaizah
- College of Medicine, Umm Al Qura University, Makkah City, Makkah 24353 Saudi Arabia
| | - Mryam Haddad
- College of Medicine, Umm Al Qura University, Makkah City, Makkah 24353 Saudi Arabia
| | - Mroj Alsabri
- College of Medicine, Umm Al Qura University, Makkah City, Makkah 24353 Saudi Arabia
| | - Heba Kufiah
- College of Medicine, Umm Al Qura University, Makkah City, Makkah 24353 Saudi Arabia
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13
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Satyamurthy A, Prabhu N, Padmakumar R, Babu AS. Feasibility of an exercise-based cardiac rehabilitation algorithm in patients following percutaneous coronary intervention for acute coronary syndrome. Indian Heart J 2020; 72:289-292. [PMID: 32861385 PMCID: PMC7474114 DOI: 10.1016/j.ihj.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 12/19/2022] Open
Abstract
Cardiac rehabilitation (CR) is underutilised across the world and India. The use of simple algorithms is one way to facilitate CR, however, these algorithms need to be feasible to use across low resource settings. The objectives were to assess the feasibility of a CR algorithm following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). A single group, pre-post study on 50 participants undergoing PCI for ACS found significant improvement in various feasibility metrics at discharge and 30-days, with no major adverse events. The proposed CR algorithm was safe and feasible for low and moderate risk patients with ACS undergoing PCI.
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Affiliation(s)
- Akhila Satyamurthy
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Nivedita Prabhu
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Ramachandran Padmakumar
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Abraham Samuel Babu
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
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14
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Santos VB, Dos Anjos LD, de Mattos Paixão C, Silva TOF, Begot I, Barbosa CB, Guizilinni S, Moreira RSL. Myocardial oxygen consumption in the bed bath and shower bath in patients with acute coronary syndrome. Intensive Crit Care Nurs 2020; 60:102895. [PMID: 32536515 DOI: 10.1016/j.iccn.2020.102895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/16/2020] [Accepted: 05/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Bed and shower hygiene measures are performed by the nursing staff in patients admitted with Acute Coronary Syndrome (ACS). Few studies have evaluated the difference in energy consumption between the two types of bath. OBJECTIVES To analyse and compare the variation in Heart Rate (HR), Systolic Blood Pressure (SBP) and rate-pressure-product (RPP) between bed and shower bath in ACS patients. DESIGN Quantitative, analytical, prospective study. SETTINGS This study was conducted in a Coronary Intensive Care Unit, including patients over 18 years admitted for ACS in Killip classes I and II. MAIN OUTCOME MEASURES The level of myocardial oxygen consumption was assessed by calculating the RPP before, immediately after and 5 minutes after the first bed bath and the first shower bath. Differences in mean RPP before, during and 5 minutes after each body hygiene were compared using the paired-samples Student's t-test. RESULTS Seventy patients were included. No important clinical variation was found in HR, SBP and RPP during bed bath and during shower bath. The comparison of HR, SBP and RPP between bed bath and shower showed no statistically significant difference. CONCLUSION Bed bath and shower bath did not significantly increase energy expenditure in patients with acute coronary syndrome and there was no difference in energy expenditure between the two types of body hygiene.
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Affiliation(s)
| | | | | | | | - Isis Begot
- Hospital São Paulo, Federal University of São Paulo, São Paulo, Brazil.
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15
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Hammad TA, Parikh M, Tashtish N, Lowry CM, Gorbey D, Forouzandeh F, Filby SJ, Wolf WM, Costa MA, Simon DI, Shishehbor MH. Impact of COVID-19 pandemic on ST-elevation myocardial infarction in a non-COVID-19 epicenter. Catheter Cardiovasc Interv 2020; 97:208-214. [PMID: 32478961 PMCID: PMC7300525 DOI: 10.1002/ccd.28997] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023]
Abstract
Objectives We sought to study the impact of COVID‐19 pandemic on the presentation delay, severity, patterns of care, and reasons for delay among patients with ST‐elevation myocardial infarction (STEMI) in a non‐hot‐spot region. Background COVID‐19 pandemic has significantly reduced the activations for STEMI in epicenters like Spain. Methods From January 1, 2020, to April 15, 2020, 143 STEMIs were identified across our integrated 18‐hospital system. Pre‐ and post‐COVID‐19 cohorts were based on March 23rd, 2020, whenstay‐at‐home orders were initiated in Ohio. We used presenting heart rate, blood pressure, troponin, new Q‐wave, and left ventricle ejection fraction (LVEF) to assess severity. Duration of intensive care unit stay, total length of stay, door‐to‐balloon (D2B) time, and radial versus femoral access were used to assess patterns of care. Results Post‐COVID‐19 presentation was associated with a lower admission LVEF (45 vs. 50%, p = .015), new Q‐wave, and higher initial troponin; however, these did not reach statistical significance. Among post‐COVID‐19 patients, those with >12‐hr delay in presentation 31(%) had a longer average D2B time (88 vs. 53 min, p = .033) and higher peak troponin (58 vs. 8.5 ng/ml, p = .03). Of these, 27% avoided the hospital due to fear of COVID‐19, 18% believed symptoms were COVID‐19 related, and 9% did not want to burden the hospital during the pandemic. Conclusions COVID‐19 has remarkably affected STEMI presentation and care. Patients' fear and confusion about symptoms are integral parts of this emerging public health crisis.
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Affiliation(s)
- Tarek A Hammad
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Melanie Parikh
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nour Tashtish
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Cynthia M Lowry
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Diane Gorbey
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Farshad Forouzandeh
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Steven J Filby
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William M Wolf
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Marco A Costa
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel I Simon
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mehdi H Shishehbor
- Cardiovascular Interventional Center, Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Syst Rev 2020; 5:CD012419. [PMID: 32383493 PMCID: PMC7207012 DOI: 10.1002/14651858.cd012419.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications. OBJECTIVES To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications. SEARCH METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality. MAIN RESULTS We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes. AUTHORS' CONCLUSIONS Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Austin Health, Heidelberg, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Lisha Kuruvilla
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Barwon Health, North Geelong, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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17
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Asad ZUA, Khan SU, Amritphale A, Shroff A, Lata K, Seto AH, Khan MS, Rao SV, Abu-Fadel M. Early vs Late Discharge in Low-Risk ST-Elevation Myocardial Infarction Patients Treated With Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1360-1368. [PMID: 32473910 DOI: 10.1016/j.carrev.2020.04.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND For low-risk patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) the recommended optimal discharge timing is inconsistent in guidelines. The European Society of Cardiology guidelines recommend early discharge within 48-72 h, while the American College of Cardiology guidelines do not recommend a specific discharge strategy. In this systematic review and meta-analysis we compared outcomes with early discharge (≤3 days) versus late discharge (>3 days). METHODS Randomized controlled trials (RCTs) and observational studies were selected after searching MEDLINE and EMBASE database. Meta-analysis was stratified according to study design. Outcomes were reported as random effects risk ratios (RR) with 95% confidence intervals. RESULTS Seven RCTs comprising 1780 patients and 4 observational studies comprising 39,288 patients were selected. The RCT-restricted analysis did not demonstrate significant differences in terms of all-cause mortality (RR, 0.97 [0.23-4.05]) and major adverse cardiac events (MACE) (RR, 0.84 [0.56-1.26]). Conversely, observational study restricted analysis showed that early vs late discharge strategy was associated with a reduction in all-cause mortality (RR, 0.40 [0.23-0.71]) and MACE (RR, 0.45 [0.26-0.78]). There were no significant differences in hospital readmissions between early vs late discharge in both RCT or observational study analyses. CONCLUSIONS Early discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and it has the potential to improve cost of care.
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Affiliation(s)
- Zain Ul Abideen Asad
- Department of Medicine, Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, United States of America.
| | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, WV, United States of America
| | - Amod Amritphale
- Department of Medicine, Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, United States of America
| | - Adhir Shroff
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Kusum Lata
- Sutter Tracy Community Hospital, Sutter Medical Network, Tracy, CA, United States of America
| | - Arnold H Seto
- Department of Medicine, Long Beach Veterans Affairs Healthcare System, Long Beach, CA, United States of America
| | - Muhammad Shahzeb Khan
- Department of Internal Medicine, John H Stroger, Jr Hospital of Cook County, Chicago, United States of America
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, United States of America
| | - Mazen Abu-Fadel
- Department of Medicine, Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, United States of America
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18
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Banga S, Gumm DC, Kizhakekuttu TJ, Emani VK, Singh S, Singh S, Kaur H, Wang Y, Mungee S. Left Ventricular Ejection Fraction along with Zwolle Risk Score for Risk Stratification to Enhance Safe and Early Discharge in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: A Retrospective Observational Study. Cureus 2019; 11:e5272. [PMID: 31583196 PMCID: PMC6768833 DOI: 10.7759/cureus.5272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Zwolle risk score (ZRS) is a validated scoring system to determine the time of discharge in ST-segment elevation myocardial infarction (STEMI) patients. Left ventricular ejection fraction (LVEF) also provides prognostic information after ST-elevation myocardial infarction (STEMI). We studied that the addition of LVEF to ZRS variable can improve decision making in safe and early discharge in STEMI patients post-primary coronary intervention. Methods Overall, 249 STEMI patients were studied retrospectively. LVEF was considered as an independent variable. The patients having LVEF <50% were under Group A and LVEF ≥50% were under Group B. Groups were analyzed by model comparison for overall hospital length of stay (LOS) and Intensive care unit (ICU) LOS post-primary percutaneous coronary intervention (PCI). Results There were 123 patients in Group A and 126 patients in Group B. Comparison for primary outcomes showed significant difference with hospital length of stay (LOS) being 3.1 ± 2.3 days in Group A versus 2.1 ± 0.8 days in Group B (p < 0.001). Similarly, ICU stay was also significantly higher in Group A with 36.5 ± 31.4 hours versus 24.0 ± 11.8 hours for Group B, which led to prolonged hospitalization for patients with LVEF <50%. Model 1 that considers ZRS individually is nested within Model 2 where ZRS and LVEF are considered together. The profile log-likelihood ratio test favors model 2 over model 1 (p < 0.0001). Similarly for ICU LOS, R2 = 0.12 (Model 1) < R2 = 0.20 (Model 2). The F test favors model 2 over model 1 (p < 0.0001). Conclusion We concluded that adding LVEF to Zwolle risk score gives a better model for risk stratification in STEMI patients to decide early and safe discharge post-primary PCI.
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Affiliation(s)
- Sandeep Banga
- Cardiology, West Virginia University School of Medicine, Morgantown, USA
| | - Darrel C Gumm
- Cardiology, University of Illinois College of Medicine at Peoria, Order of St. Francis Medical Centre, Peoria, USA
| | - Tinoy J Kizhakekuttu
- Cardiology, University of Illinois College of Medicine at Peoria, Order of St. Francis Medical Centre, Peoria, USA
| | - Vamsi K Emani
- Internal Medicine, University of Illinois College of Medicine at Peoria, Order of St. Francis Medical Centre, Peoria, USA
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Shivank Singh
- Internal Medicine, Southern Medical University, Guangzhou, CHN
| | - Harleen Kaur
- Neurology, Univeristy of Missouri, Columbia, USA
| | - Yanzhi Wang
- Epidemiology and Public Health, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Sudhir Mungee
- Cardiology, University of Illinois College of Medicine, Order of St. Francis Medical Centre, Peoria, USA
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19
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Ebinger JE, Strauss CE, Garberich RR, Bradley SM, Rush P, Chavez IJ, Poulose AK, Porten BR, Henry TD. Value-Based ST-Segment-Elevation Myocardial Infarction Care Using Risk-Guided Triage and Early Discharge. Circ Cardiovasc Qual Outcomes 2019; 11:e004553. [PMID: 29654000 DOI: 10.1161/circoutcomes.118.004553] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 03/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention can be considered for early discharge. We describe the implementation of an STEMI risk score to decrease cost while maintaining optimal patient outcomes. METHODS AND RESULTS We determined the impact of risk-guided STEMI care on healthcare value through the retrospective application of the Zwolle Risk Score to 967 patients receiving primary percutaneous coronary intervention between 2009 and 2011. Of these patients, 540 (56%) were categorized as low risk, indicating they may be safely triaged directly to a telemetry unit rather than the intensive care unit and targeted for early discharge. We subsequently developed and implemented a modified Zwolle Risk Calculator into the electronic medical record to support application of the fast-track protocol for low-risk STEMI patients. Among 549 prospective patients with STEMI, 62% were low risk, and the fast-track protocol was followed in 75% of cases. Prospective results confirmed lower rates of complications (low risk 8.3% versus high risk 38.7%; P<0.001) and in-hospital mortality (low risk 0.4% versus High risk 12.5%; P<0.001) in the low-risk cohort. Low-risk patients had a shorter median length of stay (median and [25th, 75th percentiles]: low risk 2 [2, 3] versus high risk: 3 [2, 6]; P<0.001) and lower overall costs (low risk $6720 [$5280-$9030] versus high risk $11 783 [$7953-$25 359]; P<0.001). Low-risk patients treated on-protocol had shorter median length of stay (on-protocol 2 [1, 2] versus off-protocol 2 [2, 3]; P<0.001) and hospital costs (on-protocol $6090 [$4730, $7356] versus off-protocol $11 783 [$7953, $25 359]; P<0.001) than those treated off-protocol. On-protocol low-risk patients in the prospective cohort also had lower costs and shorter length of stay than low-risk patients in the retrospective cohort (P<0.001 for both). CONCLUSIONS In our study, risk-guided triage and discharge after primary percutaneous coronary intervention for STEMI improved healthcare value by reducing costs of care without compromising quality of care or patient outcomes.
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Affiliation(s)
- Joseph E Ebinger
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Craig E Strauss
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Ross R Garberich
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Steven M Bradley
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Pam Rush
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Ivan J Chavez
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Anil K Poulose
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Brandon R Porten
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.)
| | - Timothy D Henry
- Cedars-Sinai Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (J.E.E., T.D.H.). Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (C.E.S., S.M.B., P.R., I.J.C., A.K.P., T.D.H.). Minneapolis Heart Institute Foundation, MN (R.R.G., S.M.B., B.R.P.).
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Sharkawi MA, McMahon S, Al Jabri D, Thompson PD. Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 8:562-570. [PMID: 31264471 DOI: 10.1177/2048872619860217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE There is marked variability in location of care and hospital length of stay after primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI). OBSERVATIONS We performed a literature review on non-critical care monitoring and early discharge following primary percutaneous coronary intervention and describe a framework for implementation in the real world. The medical literature was searched from 1 January 1988 to 31 April 2019 using PubMed and Cochrane Central Register of Controlled Trials. Randomized clinical trials, observational studies and guideline statements were included. Available data suggest that carefully selected low-risk STEMI patients identified using Zwolle or CADILLAC risk stratification scores after primary percutaneous coronary intervention may be considered for discharge after 48 hours of hospital care. There was no increase in major adverse cardiac events, medication non-compliance or hospital readmission with this treatment strategy. There are limited data on non-critical monitoring of uncomplicated STEMI patients; however, given the low adverse events rate, this strategy is likely to be safe in selected patients and may facilitate reduced length of stay and reduce resource utilization. CONCLUSIONS AND RELEVANCE Available evidence supports the safety of early discharge after 48 hours of care and omission of critical care monitoring in carefully selected patients following primary percutaneous coronary intervention. Early risk stratification and structured discharge planning are imperative. Adoption of this treatment strategy could reduce hospital costs, resource utilization and enhance patient satisfaction without affecting outcomes.
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Affiliation(s)
- Musa A Sharkawi
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
| | - Sean McMahon
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
| | | | - Paul D Thompson
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
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Buccheri S, D’Arrigo P, Franchina G, Capodanno D. Risk Stratification in Patients with Coronary Artery Disease: A Practical Walkthrough in the Landscape of Prognostic Risk Models. Interv Cardiol 2018; 13:112-120. [PMID: 30443266 PMCID: PMC6234492 DOI: 10.15420/icr.2018.16.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/15/2018] [Indexed: 02/06/2023] Open
Abstract
Although a combination of multiple strategies to prevent and treat coronary artery disease (CAD) has led to a relative reduction in cardiovascular mortality over recent decades, CAD remains the greatest cause of morbidity and mortality worldwide. A variety of individual factors and circumstances other than clinical presentation and treatment type contribute to determining the outcome of CAD. It is increasingly understood that personalised medicine, by taking these factors into account, achieves better results than "one-size-fitsall" approaches. In recent years, the multiplication of risk scoring systems for CAD has generated some degree of uncertainty regarding whether, when and how predictive models should be adopted when making clinical decisions. Against this background, this article reviews the most accepted risk models for patients with evidence of CAD to provide practical guidance within the current landscape of tools developed for prognostic risk stratification.
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Affiliation(s)
- Sergio Buccheri
- CAST, AOU. Policlinico-Vittorio Emanuele, University of CataniaCatania, Italy
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala UniversityUppsala, Sweden
| | - Paolo D’Arrigo
- CAST, AOU. Policlinico-Vittorio Emanuele, University of CataniaCatania, Italy
| | - Gabriele Franchina
- CAST, AOU. Policlinico-Vittorio Emanuele, University of CataniaCatania, Italy
| | - Davide Capodanno
- CAST, AOU. Policlinico-Vittorio Emanuele, University of CataniaCatania, Italy
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22
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Novobilsky K, Stipal R, Cerny P, Horak I, Kaucak V, Mrozek J, Vaclavik J, Kryza R. Safety of early discharge in low risk patients after acute ST-segment elevation myocardial infarction, treated with primary percutaneous coronary intervention. Open label, randomized trial. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 163:61-66. [PMID: 30181666 DOI: 10.5507/bp.2018.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/12/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The length of hospital stay in patients with acute myocardial infarction and ST-segment elevation (STEMI) has been shortened in recent years with corresponding savings in costs, but there is limited available data on its implementation in clinical practice. The aim of this trial was to determine whether early discharge in selected patients after STEMI is feasible and safe. METHODS 151 patients with STEMI successfully treated with primary percutaneous coronary intervention (PCI) who fulfilled the inclusion criteria of low risk were randomly assigned to two groups on a 1:1 ratio: early (within 48-72 h of admission) and standard (after 72 h) discharge. The primary end point was the composite of death, myocardial infarction (MI), unstable angina, stroke, unplanned rehospitalization, repeated target vessel revascularization and stent thrombosis at 90 days after discharge. The study is registered with ClinicalTrials.gov (identifier NCT02023983). RESULTS The primary end point occurred in 5 patients in the early group and 6 in the standard group (6.6% vs. 8.0%, P=0.765). There were no significant differences in the incidence of individual components of the primary end point at 90 days. The length of hospital stay was significantly shorter in the intervention group (60.8 ± 8.5 vs. 92.1 ± 12.1 h, P<0.0001). CONCLUSION This study confirms that early discharge within 48-72 h in selected low risk patients after STEMI treated with successful primary PCI is feasible and safe, with outcomes comparable to the later discharge. This strategy applies to more than a quarter of all STEMI patients.
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Affiliation(s)
- Kamil Novobilsky
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Roman Stipal
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Petr Cerny
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Ivo Horak
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Vladimir Kaucak
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Jan Mrozek
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
| | - Jan Vaclavik
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Radim Kryza
- Department of Cardiology, Municipal Hospital Ostrava, Nemocnicni 20, 728 80, Ostrava, Czech Republic
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23
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Meta-Analysis of Clinical Trials That Evaluate the Effectiveness of Hospital-Initiated Postdischarge Interventions on Hospital Readmission. J Healthc Qual 2018; 39:354-366. [PMID: 27631713 DOI: 10.1097/jhq.0000000000000057] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Under pressure to avoid readmissions, hospitals are increasingly employing hospital-initiated postdischarge interventions (HiPDI), such as home visits and follow-up phone calls, to help patients after discharge. This study was conducted to assess the effectiveness of HiPDI on reducing hospital readmissions using a systematic review of clinical trials published between 1990 and 2014. We analyzed twenty articles on HiPDI (from 503 reviewed abstracts) containing 7,952 index hospitalizations followed for a median 3 months (range 1-24) after discharge for readmission. The two most common HiPDI included follow-up phone calls (n = 14, 70%) or home visits (n = 11, 55%); eighty-five percent (n = 17) of studies had multiple HiPDI. In meta-analysis, exposure to HiPDI was associated with a lower likelihood of readmission (odds ratio [OR], 0.8 [95% CI, 0.7-0.9]). Patients receiving ≥2 postdischarge home visits or ≥2 follow-up phone calls had the lowest likelihood of readmission (OR, 0.5 [95% CI, 0.4-0.8]). Hospital-initiated postdischarge interventions seem to have an effect on reducing hospital readmissions. Together, multiple home visits and follow-up phone calls may be the most effective HiPDI to reduce hospital readmission.
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Rymer JA, Tempelhof MW, Clare RM, Pieper KS, Granger CB, Van de Werf F, Moliterno DJ, Harrington RA, White HD, Armstrong PW, Lopes RD, Mahaffey KW, Newby LK. Discharge timing and outcomes after uncomplicated non-ST-segment elevation acute myocardial infarction. Am Heart J 2018; 201:103-110. [PMID: 29910048 DOI: 10.1016/j.ahj.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/14/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Length of stay after non-ST-segment elevation myocardial infarction (NSTEMI) continues to decrease, but information to guide duration of hospitalization is limited. METHODS We used landmark analyses, in which the landmark defined potential days of discharge, to estimate complication rates on the first day the patient would have been out of the hospital, and estimated associations between timing of discharge and 30-day and 1-year event-free survival after discharge among NSTEMI patients. RESULTS Among 20,410 NSTEMI patients, median length of stay was 7 (4, 12) days; 3,209 (15.7%) experienced a cardiac complication on days 0 to 2 and 1,322 (6.5%) were discharged without complications during hospital days 0 to 2. At the start of day 3, 15,879 patients (77.8%) were still hospitalized without complications. Of these, 1,689 (10.6%) were discharged event-free on day 3. Adjusted event-free survival rates of death or myocardial infarction from day 4 to 30 days after among the 1,689 patients was 99.1% compared with 93.1% for the 14,190 who remained hospitalized at the end of day 3. For 1-year mortality, these rates were 98.1% and 96.4%, respectively. Among 13,334 patients hospitalized without complications at the start of day 4, 1,706 were discharged event-free that day. Adjusted survival rates among these patients, compared with those still hospitalized at the end of day 4, were 98.0% versus 93.7% for 30-day death or myocardial infarction and 97.8% versus 96.1% for 1-year mortality. CONCLUSIONS Patients with NSTEMI who had no serious complications during the first 2 hospital days were at low risk of subsequent short- and intermediate-term death or ischemic events.
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25
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Seto AH, Shroff A, Abu-Fadel M, Blankenship JC, Boudoulas KD, Cigarroa JE, Dehmer GJ, Feldman DN, Kolansky DM, Lata K, Swaminathan RV, Rao SV. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv 2018; 92:717-731. [DOI: 10.1002/ccd.27637] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Arnold H. Seto
- Department of Medicine; Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Adhir Shroff
- Department of Medicine; University of Illinois at Chicago, Chicago, Illinois
| | - Mazen Abu-Fadel
- Department of Internal Medicine, Section of Cardiovascular Medicine; University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - James C. Blankenship
- Department of Cardiology, Section of Interventional Cardiology; Geisinger Medical Center, Danville, Pennsylvania
| | | | - Joaquin E. Cigarroa
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Gregory J. Dehmer
- Department of Medicine (Cardiology Division) Texas A&M University College of Medicine; Scott & White Medical Center; Temple Texas
| | - Dmitriy N. Feldman
- New York-Presbyterian Hospital; Weill Cornell Medical College; New York New York
| | - Daniel M. Kolansky
- Cardiovascular Medicine Division; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kusum Lata
- Sutter Tracy Community Hospital, Sutter Medical Network, Tracy, California
| | | | - Sunil V. Rao
- Division of Cardiology; Duke Clinical Research Institute, Durham, North Carolina
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Tran HV, Lessard D, Tisminetzky MS, Yarzebski J, Granillo EA, Gore JM, Goldberg R. Trends in Length of Hospital Stay and the Impact on Prognosis of Early Discharge After a First Uncomplicated Acute Myocardial Infarction. Am J Cardiol 2018; 121:397-402. [PMID: 29254677 PMCID: PMC5783729 DOI: 10.1016/j.amjcard.2017.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/27/2017] [Accepted: 11/07/2017] [Indexed: 11/28/2022]
Abstract
Few studies have examined recent trends in the length of stay (LOS) among patients hospitalized with a first uncomplicated acute myocardial infarction (AMI) and the impact of early hospital discharge on various short-term outcomes in these low-risk patients. We used data from 1,501 residents hospitalized with a first uncomplicated AMI from all central Massachusetts medical centers on a biennial basis between 2001 and 2011. The association between hospital LOS and subsequent hospital readmission or death was examined using logistic regression modeling. The average age of the study population was 63.7 years, 63.0% were men, and 91.4% were non-Hispanic whites. The average hospital LOS declined from 4.1 days in 2001 to 2.9 days in 2011. During the years under study, the average 30-day hospital readmission rate was 11.9%, whereas the 30- and 90-day death rates were 1.5% and 2.9%, respectively. The multivariable adjusted odds ratio of a 30-day hospital readmission (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.52 to 1.41), or 30-day (OR = 0.93, 95% CI = 0.29 to 2.98) and 90-day (OR = 0.89, 95% CI = 0.36 to 2.20) death rates were not significantly different between patients who were discharged from central Massachusetts medical centers during the first 2 days as compared with those discharged thereafter. In conclusion, the average LOS in patients with a first uncomplicated AMI declined during the years under study, and early discharge from the hospital at day 2 or sooner of these low-risk patients does not appear to be associated with an increased risk of adverse events post discharge compared with those discharged at a later time.
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Affiliation(s)
- Hoang V Tran
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mayra S Tisminetzky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edgard A Granillo
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joel M Gore
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.
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Salamanca-Balen N, Seymour J, Caswell G, Whynes D, Tod A. The costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs: A systematic review of international evidence. Palliat Med 2018; 32:447-465. [PMID: 28655289 PMCID: PMC5788084 DOI: 10.1177/0269216317711570] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with palliative care needs do not access specialist palliative care services according to their needs. Clinical Nurse Specialists working across a variety of fields are playing an increasingly important role in the care of such patients, but there is limited knowledge of the extent to which their interventions are cost-effective. OBJECTIVES To present results from a systematic review of the international evidence on the costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs, defined as seriously ill patients and those with advanced disease or frailty who are unlikely to be cured, recover or stabilize. DESIGN Systematic review following PRISMA methodology. DATA SOURCES Medline, Embase, CINAHL and Cochrane Library up to 2015. Studies focusing on the outcomes of Clinical Nurse Specialist interventions for patients with palliative care needs, and including at least one economic outcome, were considered. The quality of studies was assessed using tools from the Joanna Briggs Institute. RESULTS A total of 79 papers were included: 37 randomized controlled trials, 22 quasi-experimental studies, 7 service evaluations and other studies, and 13 economic analyses. The studies included a wide variety of interventions including clinical, support and education, as well as care coordination activities. The quality of the studies varied greatly. CONCLUSION Clinical Nurse Specialist interventions may be effective in reducing specific resource use such as hospitalizations/re-hospitalizations/admissions, length of stay and health care costs. There is mixed evidence regarding their cost-effectiveness. Future studies should ensure that Clinical Nurse Specialists' roles and activities are clearly described and evaluated.
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Affiliation(s)
| | - Jane Seymour
- 2 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Glenys Caswell
- 1 School of Health Sciences, The University of Nottingham, Nottingham, UK
| | - David Whynes
- 3 School of Economics, The University of Nottingham, Nottingham, UK
| | - Angela Tod
- 2 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
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International practice settings, interventions and outcomes of nurse practitioners in geriatric care: A scoping review. Int J Nurs Stud 2018; 78:61-75. [DOI: 10.1016/j.ijnurstu.2017.09.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 07/28/2017] [Accepted: 09/13/2017] [Indexed: 01/15/2023]
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Kähkönen O, Saaranen T, Kankkunen P, Lamidi ML, Kyngäs H, Miettinen H. Predictors of adherence to treatment by patients with coronary heart disease after percutaneous coronary intervention. J Clin Nurs 2018; 27:989-1003. [PMID: 29098747 DOI: 10.1111/jocn.14153] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 12/19/2022]
Abstract
AIMS AND OBJECTIVES To identify the predictors of adherence in patients with coronary heart disease after a percutaneous coronary intervention. BACKGROUND Adherence is a key factor in preventing the progression of coronary heart disease. DESIGN An analytical multihospital survey study. METHODS A survey of 416 postpercutaneous coronary intervention patients was conducted in 2013, using the Adherence of People with Chronic Disease Instrument. The instrument consists of 37 items measuring adherence and 18 items comprising sociodemographic, health behavioural and disease-specific factors. Adherence consisted of two mean sum variables: adherence to medication and a healthy lifestyle. Based on earlier studies, nine mean sum variables known to explain adherence were responsibility, cooperation, support from next of kin, sense of normality, motivation, results of care, support from nurses and physicians, and fear of complications. Frequencies and percentages were used to describe the data, cross-tabulation to find statistically significant background variables and multivariate logistic regression to confirm standardised predictors of adherence. RESULTS Patients reported good adherence. However, there was inconsistency between adherence to a healthy lifestyle and health behaviours. Gender, close personal relationship, length of education, physical activity, vegetable and alcohol consumption, LDL cholesterol and duration of coronary heart disease without previous percutaneous coronary intervention were predictors of adherence. CONCLUSIONS The predictive factors known to explain adherence to treatment were male gender, close personal relationship, longer education, lower LDL cholesterol and longer duration of coronary heart disease without previous percutaneous coronary intervention. RELEVANCE TO CLINICAL PRACTICE Because a healthy lifestyle predicted factors known to explain adherence, these issues should be emphasised particularly for female patients not in a close personal relationship, with low education and a shorter coronary heart disease duration with previous coronary intervention.
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Affiliation(s)
- Outi Kähkönen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Terhi Saaranen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Päivi Kankkunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Marja-Leena Lamidi
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Helvi Kyngäs
- Department of Health Science, University of Oulu, Oulu, Finland
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Crawshaw J, Auyeung V, Ashworth L, Norton S, Weinman J. Healthcare provider-led interventions to support medication adherence following ACS: a meta-analysis. Open Heart 2017; 4:e000685. [PMID: 29344366 PMCID: PMC5761293 DOI: 10.1136/openhrt-2017-000685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 11/07/2017] [Indexed: 01/01/2023] Open
Abstract
We conducted a systematic review and meta-analysis to determine the effectiveness of healthcare provider-led (HCPs) interventions to support medication adherence in patients with acute coronary syndrome (ACS). A systematic search of Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, IPA, CINAHL, ASSIA, OpenGrey, EthOS, WorldCat and PQDT was undertaken. Interventions were deemed eligible if they included adult ACS patients, were HCP-led, measured medication adherence and randomised participants to parallel groups. Intervention content was coded using the Behaviour Change Technique (BCT) Taxonomy and data were pooled for analysis using random-effects models. Our search identified 8870 records, of which 27 were eligible (23 primary studies). A meta-analysis (n=9735) revealed HCP-led interventions increased the odds of medication adherence by 54% compared to control interventions (k=23, OR 1.54, 95% CI 1.26 to 1.88, I2=57.5%). After removing outliers, there was a 41% increase in the odds of medication adherence with moderate heterogeneity (k=21, OR 1.41, 95% CI 1.21 to 1.65, I2=35.3%). Interventions that included phone contact yielded (k=12, OR 1.63, 95% CI 1.25 to 2.12, I2=32.0%) a larger effect compared to those delivered exclusively in person. A total of 32/93 BCTs were identified across interventions (mean=4.7, SD=2.2) with 'information about health consequences' (BCT 5.1) (19/23) the most common. HCP-led interventions for ACS patients appear to have a small positive impact on medication adherence. While we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on study effectiveness. PROSPERO registration number CRD42016037706.
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Affiliation(s)
- Jacob Crawshaw
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Vivian Auyeung
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Lucy Ashworth
- School of Health Sciences, City University of London, London, UK
| | - Sam Norton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - John Weinman
- Institute of Pharmaceutical Science, King's College London, London, UK
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31
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Lopatina E, Donald F, DiCenso A, Martin-Misener R, Kilpatrick K, Bryant-Lukosius D, Carter N, Reid K, Marshall DA. Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review. Int J Nurs Stud 2017; 72:71-82. [PMID: 28500955 DOI: 10.1016/j.ijnurstu.2017.04.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/21/2017] [Accepted: 04/28/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. OBJECTIVE To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. METHODS Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. RESULTS The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. CONCLUSION Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.
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Affiliation(s)
- Elena Lopatina
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3C60, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, B3H 4R2, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montréal, Research Centre Hôpital Maisonneuve-Rosemont, CSA - RC - Aile bleue - Room F121, 5415 boul. l'Assomption, Montréal, QC, H1T 2M4, Canada.
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, L8S 4L8, Canada.
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28H, Hamilton, ON, L8S 4L8, Canada.
| | - Kim Reid
- KJResearch, Rosemere, QC, Canada.
| | - Deborah A Marshall
- Department of Community Health Sciences and Faculty of Medicine, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C58, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Abdelnoor M, Andersen JG, Arnesen H, Johansen O. Early discharge compared with ordinary discharge after percutaneous coronary intervention - a systematic review and meta-analysis of safety and cost. Vasc Health Risk Manag 2017; 13:101-109. [PMID: 28356750 PMCID: PMC5367460 DOI: 10.2147/vhrm.s122951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies. Methods The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days. Results For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52–0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88–1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge. Conclusion The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue.
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Affiliation(s)
- Michael Abdelnoor
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway; Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Jack Gunnar Andersen
- Clinic of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway; Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo Norway
| | - Odd Johansen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
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Abstract
Background The Zwolle Risk Score (ZRS) identifies primary percutaneous coronary intervention (PPCI) patients at low mortality risk, eligible for early discharge. Recently, this score was improved by adding baseline NT-proBNP. However, the optimal timepoint for NT-proBNP measurement is unknown. Methods PPCI patients in the On-Time 2 study were candidates. The ZRS and NT-proBNP levels on admission, at 18–24 h, at 72–96 h, and the change in NT-proBNP from baseline to 18–24 h (delta NT-proBNP) were determined. We investigated whether addition of the different NT-proBNP measurements to the ZRS improves the prediction of 30-day mortality. Based on cut-off values reflecting zero mortality at 30 d, patients who potentially could be discharged early were identified and occurrence of major adverse cardiac events (MACE) and major bleeding until 10 d was registered. Results 845 patients were included. On multivariate analyses, NT-proBNP at baseline (HR 2.09, 95% CI 1.59–2.74, p < 0.001), at 18–24 h (HR 6.83, 95% CI 2.94–15.84), and at 72–96 h (HR 3.32, 95% CI 1.22–9.06) independently predicted death at 30 d. Addition of NT-proBNP to the ZRS improved prediction of mortality, particularly at 18–24 h (net reclassification index 29%, p < 0.0001, integrated discrimination improvement 17%, p < 0.0001). Based on ZRS (<2) or NT-proBNP at 18–24 h (<2500 pg/ml) 75% of patients could be targeted for early discharge at 48 h, with expected re-admission rates of 1.2% due to MACE and/or major bleeding. Conclusions NT-proBNP at different timepoints improves prognostication of the ZRS. Particularly at 18–24 h post PPCI, the largest group of patients that potentially could be discharged early was identified. Electronic supplementary material The online version of this article (doi: 10.1007/s12471-016-0935-2) contains supplementary material, which is available to authorized users.
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Sharkawi MA, Filippaios A, Dani SS, Shah SP, Riskalla N, Venesy DM, Labib SB, Resnic FS. Identifying patients for safe early hospital discharge following st elevation myocardial infarction. Catheter Cardiovasc Interv 2016; 89:1141-1146. [DOI: 10.1002/ccd.26873] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/06/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Musa A. Sharkawi
- Department of Cardiovascular Medicine; Hartford Hospital; Hartford Connecticut
- University of Connecticut School of Medicine; Farmington Connecticut
| | - Andreas Filippaios
- Department of Internal Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
| | - Saurabh S. Dani
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
| | - Sachin P. Shah
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
- Tufts University School of Medicine; Boston Massachusetts
| | - Nabila Riskalla
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
| | - David M. Venesy
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
- Tufts University School of Medicine; Boston Massachusetts
| | - Sherif B. Labib
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
- Tufts University School of Medicine; Boston Massachusetts
| | - Frederic S. Resnic
- Department of Cardiovascular Medicine; Lahey Hospital & Medical Center; Burlington Massachusetts
- Tufts University School of Medicine; Boston Massachusetts
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Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified. Int J Cardiol 2016; 228:615-620. [PMID: 27880927 DOI: 10.1016/j.ijcard.2016.11.276] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Early discharge protocols have been proposed for ST-segment elevation myocardial infarction (STEMI) low risk patients despite the existence of few but significant cardiovascular events during mid-term follow-up. We aimed to identify a subgroup of patients among those considered low-risk in which prognosis would be particularly good. METHODS We analyzed 30-day outcomes and long-term follow-up among 1.111 STEMI patients treated with reperfusion therapy. RESULTS Multivariate analysis identified seven variables as predictors of 30-day outcomes: Femoral approach; age>65; systolic dysfunction; postprocedural TIMI flow<3; elevated creatinine level>1.5mg/dL; stenosis of left-main coronary artery; and two or higher Killip class (FASTEST). A total of 228 patients (20.5%), defined as very low-risk (VLR), had none of these variables on admission. VLR group of patients compared to non-VLR patients had lower in-hospital (0% vs. 5.9%; p<0.001) and 30-day mortality (0% vs. 6.25%: p<0.001). They also presented fewer in-hospital complications (6.6% vs. 39.7%; p<0.001) and 30-day major adverse events (0.9% vs. 4.5%; p=0.01). Significant mortality differences during a mean follow-up of 23.8±19.4months were also observed (2.2% vs. 15.2%; p<0.001). The first VLR subject died 11months after hospital discharge. No cardiovascular deaths were identified in this subgroup of patients during follow-up. CONCLUSIONS About a fifth of STEMI patients have VLR and can be easily identified. They have an excellent prognosis suggesting that 24-48h in-hospital stay could be a feasible alternative in these patients.
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Buccheri S, Capranzano P, Condorelli A, Scalia M, Tamburino C, Capodanno D. Risk stratification after ST-segment elevation myocardial infarction. Expert Rev Cardiovasc Ther 2016; 14:1349-1360. [PMID: 27817218 DOI: 10.1080/14779072.2017.1256201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Risk stratification according to the timing of assessment, treatment modality and outcome of interest is highly advisable in patients with ST-elevation myocardial infarction (STEMI) to identify optimal treatment strategies, proper length of hospital stay and correct timing of follow-up. Areas covered: This review is an overview summarizing the characteristics and performance of available risk-scoring systems for STEMI. In particular, we sought to highlight the characteristics of STEMI cohorts used for derivation and validation of the available algorithms and appraise their discrimination ability, calibration and global accuracy. Expert commentary: Applying the appropriate score, customized on patients' profile and clinical characteristics at presentation or during the hospitalization, might prove useful to improve the overall quality of care provided to STEMI patients.
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Affiliation(s)
- Sergio Buccheri
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Piera Capranzano
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Antonio Condorelli
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Matteo Scalia
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Davide Capodanno
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
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Laurencet ME, Girardin F, Rigamonti F, Bevand A, Meyer P, Carballo D, Roffi M, Noble S, Mach F, Gencer B. Early Discharge in Low-Risk Patients Hospitalized for Acute Coronary Syndromes: Feasibility, Safety and Reasons for Prolonged Length of Stay. PLoS One 2016; 11:e0161493. [PMID: 27551861 PMCID: PMC4994963 DOI: 10.1371/journal.pone.0161493] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 08/05/2016] [Indexed: 12/19/2022] Open
Abstract
Introduction Length of hospital stay (LHS) is an indicator of clinical effectiveness. Early hospital discharge (≤72 hours) is recommended in patients with acute coronary syndromes (ACS) at low risk of complications, but reasons for prolonged LHS poorly reported. Methods We collected data of ACS patients hospitalized at the Geneva University Hospitals from 1st July 2013 to 30th June 2015 and used the Zwolle index score to identify patients at low risk (≤ 3 points). We assessed the proportion of eligible patients who were successfully discharged within 72 hours and the reasons for prolonged LHS. Outcomes were defined as adherence to recommended therapies, major adverse events at 30 days and patients' satisfaction using a Likert-scale patient-reported questionnaire. Results Among 370 patients with ACS, 255 (68.9%) were at low-risk of complications but only 128 (50.2%)were eligible for early discharge, because of other clinical reasons for prolonged LHS (e.g. staged coronary revascularization, cardiac monitoring) in 127 patients (49.8%). Of the latter, only 45 (35.2%) benefitted from an early discharge. Reasons for delay in discharge in the remaining 83 patients (51.2%) were mainly due to delays in additional investigations, titration of medical therapy, admission or discharge during weekends. In the early discharge group, at 30 days, only one patient (2.2%) had an adverse event (minor bleeding), 97% of patients were satisfied by the medical care. Conclusion Early discharge was successfully achieved in one third of eligible ACS patients at low risk of complications and appeared sufficiently safe while being overall appreciated by the patients.
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Affiliation(s)
- Marie-Eva Laurencet
- Internal Medicine Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - François Girardin
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Clinical Pharmacology and Toxicology Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Medical Direction, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Fabio Rigamonti
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Anne Bevand
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Philippe Meyer
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David Carballo
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Stéphane Noble
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - François Mach
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Baris Gencer
- Cardiology Division, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
- * E-mail:
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Chase JAD, Bogener JL, Ruppar TM, Conn VS. The Effectiveness of Medication Adherence Interventions Among Patients With Coronary Artery Disease: A Meta-analysis. J Cardiovasc Nurs 2016; 31:357-66. [PMID: 27057598 PMCID: PMC4826853 DOI: 10.1097/jcn.0000000000000259] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite the known benefits of medication therapy for secondary prevention of coronary artery disease (CAD), many patients do not adhere to prescribed medication regimens. Medication nonadherence is associated with poor health outcomes and higher healthcare cost. OBJECTIVE The purpose of this meta-analysis was to determine the overall effectiveness of interventions designed to improve medication adherence (MA) among adults with CAD. In addition, sample, study design, and intervention characteristics were explored as potential moderators to intervention effectiveness. METHODS Comprehensive search strategies helped in facilitating the identification of 2-group, treatment-versus-control-design studies testing MA interventions among patients with CAD. Data were independently extracted by 2 trained research specialists. Standardized mean difference effect sizes were calculated for eligible primary studies, adjusted for bias, and then synthesized under a random-effects model. Homogeneity of variance was explored using a conventional heterogeneity statistic. Exploratory moderator analyses were conducted using meta-analytic analogs for analysis of variance and regression for dichotomous and continuous moderators, respectively. RESULTS Twenty-four primary studies were included in this meta-analysis. The overall effect size of MA interventions, calculated from 18,839 participants, was 0.229 (P < .001). The most effective interventions used nurses as interventionists, initiated interventions in the inpatient setting, and informed providers of patients' MA behaviors. Medication adherence interventions tested among older patients were more effective than those among younger patients. The interventions were equally effective regardless of number of intervention sessions, targeting MA behavior alone or with other behaviors, and the use of written instructions only. CONCLUSIONS Interventions to increase MA among patients with CAD were modestly effective. Nurses can be instrumental in improving MA among these patients. Future research is needed to investigate nurse-delivered MA interventions across varied clinical settings. In addition, more research testing MA interventions among younger populations and more racially diverse groups is needed.
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Affiliation(s)
- Jo-Ana D. Chase
- S343 School of Nursing, University of Missouri, Columbia, MO 65211
| | - Jennifer L. Bogener
- University of Missouri, School of Nursing, School of Health Professions, 100 E. Green Meadows Rd. Ste. 10, Columbia, MO 65203
| | - Todd M. Ruppar
- S423 School of Nursing, University of Missouri, Columbia, MO 65211
| | - Vicki S. Conn
- S317 School of Nursing, University of Missouri, Columbia, MO 65211
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Safety of Early Discharge After Primary Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:1911-6. [PMID: 27156829 DOI: 10.1016/j.amjcard.2016.03.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/20/2022]
Abstract
In contrast to ST-elevation myocardial infarction treatment, there is no clear definition for when and which patient to discharge. Our study's main goal was to test the hypothesis that an early discharge strategy (within 48 to 56 hours) in patients with successful primary percutaneous coronary intervention (PPCI) is as safe as in patients who stay longer. The Early Discharge after Primary Percutaneous Coronary Intervention trial was designed in a prospective, randomized, multicenter fashion and registered with http://clinicaltrials.gov (NCT01860079). Of 900 patients with ST-elevation myocardial infarction, the study randomized 769 eligible patients to the early or the standard discharge group. The study's primary outcomes were all-cause mortality and readmission at 30 days. We considered assessment of functional status and health-related quality of life to be secondary outcomes. The early discharge group had significantly shorter length of hospital stay compared with the standard discharge group (45.99 ± 9.12 vs 114.87 ± 63.53 hours; p <0.0001). Neither all-cause mortality nor readmissions were different between the 2 study groups (p = 0.684 and p = 0.061, respectively). Quality-of-life measures were not statistically different between the 2 study groups. Our study reveals that discharge within 48 to 56 hours after successful PPCI is feasible, safe, and does not increase the 30-day readmission rate. Moreover, the patients perceived health status at 30 days did not differ with early discharge.
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Ganovska E, Arrigo M, Helanova K, Littnerova S, Sadoune M, Kubena P, Pavlusova M, Jarkovsky J, Gottwaldova J, Kala P, Dastych M, Ishihara S, Van Aelst LNL, Cohen-Solal A, Gayat E, Spinar J, Parenica J, Mebazaa A. Natriuretic peptides in addition to Zwolle score to enhance safe and early discharge after acute myocardial infarction: A prospective observational cohort study. Int J Cardiol 2016; 215:527-31. [PMID: 27155548 DOI: 10.1016/j.ijcard.2016.04.148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 04/12/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Zwolle score is recommended to identify low-risk patients eligible for early hospital discharge after ST-elevation myocardial infarction (STEMI), but since only one third of STEMI has low Zwolle score, hospital discharge is frequently delayed. B-type natriuretic peptide (BNP) also provides prognostic information after STEMI. The aim of the study was to test the hypothesis that patients with high Zwolle score associated with low BNP share similar outcomes than those with low Zwolle score. METHODS AND RESULTS The study population consisted of 1032 consecutive STEMI patients in whom BNP was measured 24h after chest pain onset. The area under the curve of Zwolle score and plasma BNP for 30-day mortality were 0.82 and 0.87, p=0.39. A BNP threshold of 200pg/ml had sensitivity of 100% and specificity of 34% for predicting 30-day mortality. Patients with high Zwolle score and BNP≤200pg/ml (n=183) had similar mortality and hospital stay to those with low Zwolle score (0% vs. 0.5% and 5 vs. 5days, both p=1.0). By contrast, patients with high Zwolle score and BNP>200pg/ml had the highest mortality (6.7%) and the longest hospital stay (6days), both p<0.01. CONCLUSION STEMI patients with high Zwolle score but low BNP share similar outcomes with those with low Zwolle score and should be eligible for early discharge. Hence, using the rule of "low-Zwolle or low-BNP" might increase the number of STEMI patients that might be eligible for early discharge.
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Affiliation(s)
- Eva Ganovska
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Mattia Arrigo
- INSERM UMR-S 942, Paris, France; Department of Anesthesiology and Critical Care Medicine, APHP, Saint Louis Lariboisière University Hospitals, Paris, France; Department of Cardiology, APHP, Lariboisière University Hospital, Paris, France; Division of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.
| | - Katerina Helanova
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Simona Littnerova
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic.
| | - Malha Sadoune
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic.
| | - Petr Kubena
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Marie Pavlusova
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic.
| | - Jana Gottwaldova
- Department of Biochemistry, University Hospital Brno, Brno, Czech Republic; Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Petr Kala
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Milan Dastych
- Department of Biochemistry, University Hospital Brno, Brno, Czech Republic; Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Shiro Ishihara
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic.
| | - Lucas N L Van Aelst
- INSERM UMR-S 942, Paris, France; Department of Cardiology, APHP, Lariboisière University Hospital, Paris, France; KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium.
| | - Alain Cohen-Solal
- INSERM UMR-S 942, Paris, France; Department of Cardiology, APHP, Lariboisière University Hospital, Paris, France; Université Paris Diderot, PRES Sorbonne Paris Cité, France.
| | - Etienne Gayat
- INSERM UMR-S 942, Paris, France; Department of Anesthesiology and Critical Care Medicine, APHP, Saint Louis Lariboisière University Hospitals, Paris, France; Université Paris Diderot, PRES Sorbonne Paris Cité, France.
| | - Jindrich Spinar
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic; Medical Faculty, Masaryk University, Brno, Czech Republic.
| | - Alexandre Mebazaa
- INSERM UMR-S 942, Paris, France; Department of Anesthesiology and Critical Care Medicine, APHP, Saint Louis Lariboisière University Hospitals, Paris, France; Université Paris Diderot, PRES Sorbonne Paris Cité, France.
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Soo Hoo SY, Gallagher R, Elliott D. Field triage to primary percutaneous coronary intervention: Factors influencing health-related quality of life for patients aged ≥70 and <70 years with non-complicated ST-elevation myocardial infarction. Heart Lung 2015; 45:56-63. [PMID: 26651599 DOI: 10.1016/j.hrtlng.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 10/15/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine clinical and health-related quality of life (HRQOL) outcomes and predictors of HRQOL for uncomplicated field triage ST-elevation myocardial infarction (STEMI) patients aged ≥70 years and <70 years after primary percutaneous coronary intervention (PPCI). BACKGROUND Pre-hospital field triage for PPCI is associated with lower mortality but the impact of age and other factors on HRQOL remains unknown. METHODS 77 field triage STEMI patients were assessed for HRQOL using the Short Form-12 (SF-12) and the Seattle Angina Questionnaire (SAQ) at 4 weeks and 6 months after PPCI. RESULTS Regression analysis showed improvements in SF-12 domains and angina stability for older people. Age predicted lower physical function (p = 0.001) and better SAQ QOL at 6 months (p = 0.003). CONCLUSION Age, length of hospitalization, recurrent angina and hypertension were important predictors of HRQOL with PPCI. Assessment of HRQOL combined with increased support for physical and emotional recovery is needed to improve clinical care for field triage PPCI patients.
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Affiliation(s)
- Soon Yeng Soo Hoo
- Royal North Shore Hospital, Department of Cardiology, Sydney, Australia; University of Technology Sydney, Faculty of Health, Sydney, Australia.
| | - Robyn Gallagher
- University of Sydney, Charles Perkins Centre, Sydney Nursing School, Sydney, Australia
| | - Doug Elliott
- University of Technology Sydney, Faculty of Health, Sydney, Australia
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Applicability of the Zwolle risk score for safe early discharge after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tralhão A, Ferreira AM, Madeira S, Borges Santos M, Castro M, Rosário I, Trabulo M, Aguiar C, Ferreira J, Almeida MS, Mendes M. Applicability of the Zwolle risk score for safe early discharge after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Rev Port Cardiol 2015; 34:535-41. [PMID: 26297630 DOI: 10.1016/j.repc.2015.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 03/28/2015] [Accepted: 04/08/2015] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND AIM The optimal length of stay for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) is still undetermined. The Zwolle risk score (ZRS) is a simple tool designed to identify patients who can be safely discharged within 72 hours. The purpose of this study was to assess the applicability and performance of the ZRS in our population. METHODS We studied 276 consecutive patients (mean age 62 ± 14 years, 75% male, 20% Killip class >1) admitted over a two-year period for STEMI and treated with PPCI. ZRS, length of stay, 30-day mortality and readmission were obtained for all patients. Low risk was defined as ZRS ≤ 3. RESULTS The median ZRS was 3 (interquartile range [IQR] 1-4), with 171 patients (62%) being classified as low risk. Thirty-day mortality was 4.7% (13 patients). Compared to other patients, low-risk patients had shorter length of stay (median 5.0 [IQR 4-7] vs. 7.0 [5-13] days, p<0.001), and lower 30-day mortality (0 vs. 12.4%, p<0.001), yielding a negative predictive value of 100% (95% CI 97.0-100%) for the proposed cutoff. The ZRS showed excellent discriminative power (C-statistic: 0.937, 95% CI 0.906-0.968, p<0.001), and good calibration against the original cohort. CONCLUSIONS The ZRS appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 hours of admission. Using the ZRS in our population could result in a more rational use of in-patient resources.
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Affiliation(s)
- António Tralhão
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal.
| | - António Miguel Ferreira
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Sérgio Madeira
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Miguel Borges Santos
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Mariana Castro
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Ingrid Rosário
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Marisa Trabulo
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Carlos Aguiar
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Jorge Ferreira
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Manuel Sousa Almeida
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
| | - Miguel Mendes
- Hospital de Santa Cruz, Western Lisbon Hospital Centre, Department of Cardiology, Carnaxide, Portugal
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Barth J, Jacob T, Daha I, Critchley JA. Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database Syst Rev 2015; 2015:CD006886. [PMID: 26148115 PMCID: PMC11064764 DOI: 10.1002/14651858.cd006886.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required. OBJECTIVES This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification. SEARCH METHODS The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI). MAIN RESULTS We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status). AUTHORS' CONCLUSIONS Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.
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Affiliation(s)
- Jürgen Barth
- University of BernInstitute of Social and Preventive MedicineNiesenweg 6BernSwitzerlandCH‐3012
| | - Tiffany Jacob
- University of BernInstitute of Social and Preventive MedicineNiesenweg 6BernSwitzerlandCH‐3012
| | - Ioana Daha
- Carol Davila University of Medicine and Pharmacy, Colentina Clinical HospitalDepartment of Cardiology19‐21, Stefan cel MareBucharestRomania020142
| | - Julia A Critchley
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
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Resnic FS, Shah SP. Balloon-to-door time: emerging evidence for shortening hospital stay after primary PCI for STEMI. J Am Coll Cardiol 2015; 65:1172-1174. [PMID: 25814224 DOI: 10.1016/j.jacc.2015.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/15/2015] [Accepted: 01/19/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Frederic S Resnic
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - Sachin P Shah
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Hospital Length of Stay and Clinical Outcomes in Older STEMI Patients After Primary PCI. J Am Coll Cardiol 2015; 65:1161-1171. [DOI: 10.1016/j.jacc.2015.01.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/22/2014] [Accepted: 01/13/2015] [Indexed: 12/29/2022]
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Early discharge (within 72 h) in low risk patients after acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Single centre experience. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2014.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Azzalini L, Solé E, Sans J, Vila M, Durán A, Gil-Alonso D, Santaló M, Garcia-Moll X, Sionis A. Feasibility and Safety of an Early Discharge Strategy after Low-Risk Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: The EDAMI Pilot Trial. Cardiology 2015; 130:120-9. [DOI: 10.1159/000368890] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 10/02/2014] [Indexed: 11/19/2022]
Abstract
Objectives: This pilot trial evaluated the feasibility and safety of an early discharge strategy (EDS: ≤72 h, followed by outpatient lifestyle interventions), in comparison with a conventional discharge strategy (CDS) for low-risk (Zwolle risk score ≤3) ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty. Methods: One hundred patients were randomized to an EDS (n = 54) or a CDS (n = 46). The primary end point was the feasibility of the EDS: (1) ≥70% of EDS patients discharged ≤72 h, (2) ≥70% visited by a nurse ≤7 days after discharge, (3) ≥70% with ≥3 visits by the nurse and (4) ≥70% visited by a cardiologist ≤3 months. Results: The mean age was 59.2 ± 12.2 years and ejection fraction 54.0 ± 7.1%. Eighty-six percent were male (12% diabetics). Vascular access was radial in 91%. Ischemic time was ≤4 h in 75%. Length of stay was shorter in EDS as compared with CDS (70.1 ± 8.1 vs. 111.8 ± 28.3 h, p < 0.001). EDS feasibility was: (1) 72.2%; (2) 81.5%; (3) 76.9%; (4) 72.2%. There were no adverse events or differences in intervention goals and quality of life between groups. Conclusions: An EDS in low-risk STEMI patients is feasible and seems to be safe. A shorter hospital stay could benefit patients and health care systems.
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Li Q, Lin Z, Masoudi FA, Li J, Li X, Hernández-Díaz S, Nuti SV, Li L, Wang Q, Spertus JA, Hu FB, Krumholz HM, Jiang L. National trends in hospital length of stay for acute myocardial infarction in China. BMC Cardiovasc Disord 2015; 15:9. [PMID: 25603877 PMCID: PMC4360951 DOI: 10.1186/1471-2261-15-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 01/12/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND China is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization. METHODS We used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported. RESULTS The weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n = 1,901), 11 and 12.6 days in 2006 (n = 3,553), and 11 and 11.9 days in 2011 (n = 7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p = 0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS. CONCLUSIONS Despite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.
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Affiliation(s)
- Qian Li
- />Department of Epidemiology, Harvard School of Public Health, Boston, MA USA
- />Epidemiology, Worldwide Safety & Regulatory, Pfizer Inc., New York, NY USA
| | - Zhenqiu Lin
- />Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT USA
| | - Frederick A Masoudi
- />Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jing Li
- />National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037 China
| | - Xi Li
- />National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037 China
| | | | - Sudhakar V Nuti
- />Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT USA
| | - Lingling Li
- />Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA USA
| | - Qing Wang
- />National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037 China
| | - John A Spertus
- />Saint Luke’s Mid America Heart Institute, Kansas City, MO USA
| | - Frank B Hu
- />Department of Epidemiology, Harvard School of Public Health, Boston, MA USA
- />Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
- />Department of Nutrition, Harvard School of Public Health, Boston, MA USA
| | - Harlan M Krumholz
- />Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT USA
| | - Lixin Jiang
- />National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037 China
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Mercuri M, Welsford M, Schwalm JD, Mehta SR, Rao-Melacini P, Sheth T, Rokoss M, Jolly SS, Velianou JL, Natarajan MK. Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network. CMAJ Open 2015; 3:E1-7. [PMID: 25844361 PMCID: PMC4382034 DOI: 10.9778/cmajo.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI. METHODS This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI. RESULTS Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI. INTERPRETATION A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Cardiology, Columbia University, New York ; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Jon-David Schwalm
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Shamir R Mehta
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | | | - Tej Sheth
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Michael Rokoss
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - James L Velianou
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
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