Short-term (4 hours) observation after elective coronary angioplasty

Same Day Discharge versus Overnight Stay in the Hospital following Percutaneous Coronary Intervention in Patients with Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

New research in interventional cardiology has shown the demand for percutaneous coronary interventions (PCI) to have increased tremendously. Effective treatment with a lower hospital cost has been the aim of several PCI capable centers. This study aimed to compare the adverse clinical outcomes associated with same day discharge versus overnight stay in the hospital following PCI in a population of randomized patients with stable coronary artery disease (CAD).

Methods

The National Library of Medicine (MEDLINE/PubMed), the Cochrane Registry of Randomized Controlled Trials and EMBASE databases were searched (from March to June 2016) for randomized trials comparing same-day discharge versus overnight stay in the hospital following PCI. Main endpoints in this analysis included adverse cardiovascular outcomes observed during a 30-day period. Statistical analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) and 95% confidence intervals (CIs) were calculated with respect to a fixed or a random effects model.

Results

Eight randomized trials with a total number of 3081 patients (1598 patients who were discharged on the same day and 1483 patients who stayed overnight in the hospital) were included. Results of this analysis showed that mortality, myocardial infarction (MI) and major adverse cardiac events (MACEs) were not significantly different between same day discharge versus overnight stay following PCI with OR: 0.22, 95% CI: 0.04–1.35; P = 0.10, OR: 0.68, 95% CI: 0.33–1.41; P = 0.30 and OR: 0.45, 95% CI: 0.20–1.02; P = 0.06 respectively. Blood transfusion and re-hospitalization were also not significantly different between these two groups with OR: 0.64, 95% CI: 0.13–3.21; P = 0.59 and OR: 1.53, 95% CI: 0.88–2.65; P = 0.13 respectively. Similarly, any adverse event, major bleeding and repeated revascularization were also not significantly different between these two groups of patients with stable CAD, with OR: 0.42, 95% CI: 0.05–3.97; P = 0.45, OR: 0.73, 95% CI: 0.15–3.54; P = 0.69 and OR: 0.67, 95% CI: 0.14–3.15; P = 0.61 respectively.

Conclusion

In terms of adverse cardiovascular outcomes, same day discharge was neither superior nor inferior to overnight hospital stay following PCI in those patients with stable CAD. However, future research will have to emphasize on the long-term consequences.

Outcome and safety of same-day-discharge percutaneous coronary interventions with femoral access: a single-center experience

BACKGROUND

Ongoing development in percutaneous coronary intervention (PCI) techniques and closing devices facilitates same-day-discharge in patients undergoing uncomplicated PCI procedures. We examined the safety and outcome in low-risk patients discharged the same day as PCI with femoral access was performed.

METHODS

From January 1, 2010, through December 31, 2010, the outcomes of same-day discharge in 355 (19.6%) of in total 1,809 patients undergoing PCI were analyzed. Composite end point included major adverse cardiac or cerebral events and/or bleeding/vascular complications within 24 hours and 30 days. Major adverse cardiac and cerebral events were defined as cardiac death, myocardial infarction, stroke, coronary artery bypass grafting, or repeat PCI.

RESULTS

The mean age of the study population was 64.5 years (40.0-93.0 years), 17.3% of the patients were ≥75 years old. The indication for PCI was: stable angina pectoris (n = 277, 78.0%) and unstable angina pectoris/non-ST-segment elevation myocardial infarction (n = 78, 22.0%). In all patients femoral access was used, and the puncture site was closed with the closing-device AngioSeal. No major adverse cardiac and cerebral events were seen within 24 hours or 30 days except in 1 patient who had target lesion revascularization done as PCI 4 days post-procedure. Three patients had bleeding/vascular complications; 2 patients were re-admitted within 24 hours due to access-site hematomas, which were treated with manual compression and bed-rest regimes. One patient developed a pseudoaneurysm within 12 hours post-procedure.

CONCLUSIONS

Same-day-discharge after uncomplicated PCI using femoral access is safe when patients are properly selected. The strategy may improve and benefit health costs in the future.

Outpatient percutaneous coronary intervention: Ready for prime time?

Outpatient practice after percutaneous coronary intervention (PCI) is gaining momentum due to constantly optimizing results. Furthermore, the availability of limited beds to handle the large volume of coronary interventions also promotes outpatient practice. The present report relates the current experience with same-day discharge and defines persisting challenges in promoting accelerated in-hospital turnover. Since the mid-1990s, there have been several reports on same-day discharge following uncomplicated procedures. Overall, the success of outpatient PCI practice is based on a few technological and pharmacological advances. First, the systematic use of stents and potent antiplatelet agents have revolutionized the acute success rates of PCI by virtually eliminating the risks of acute vessel closure within the first 24 h following a successful procedure. Second, the miniaturization of catheter sizes has also simplified access site management, accelerated ambulation time and limited the risks of puncture site bleeding. In this regard, the transradial approach initially described in Canada and later popularized in Europe has transformed the acute care of patients after PCI. Today, however, the practice of transradial PCI still varies largely from country to country. From the literature review, it appears that after a short period of observation (4 h to 6 h), the majority of eligible patients who have undergone uncomplicated coronary stenting can be discharged on the same day. Whereas implementation of same-day discharge to referring centres is simple, home discharge requires the development of structured outpatient programs with dedicated resources to assist the patient and family with short-term logistics, to provide reassurance, to serve as a 'safety net' and, lastly, to promote medication compliance and cardiovascular risk factor management. Further studies are required to better define the cost-minimization effects of outpatient PCI practice, as well as patient perception of fast-track PCI. It is proposed that outpatient PCI will likely continue to expand over the next decade.

Randomized Trial Comparing Same-Day Discharge With Overnight Hospital Stay After Percutaneous Coronary Intervention

Background— Percutaneous coronary intervention (PCI) in a day-case setting might reduce logistic constraints on hospital resources, but data on safety are limited. We evaluated the safety and feasibility of same-day discharge after PCI.

Methods and Results— Eight hundred consecutive patients scheduled for elective PCI by femoral approach were randomized to same-day discharge or overnight hospital stay. Four hours after PCI, patients were triaged as suitable for early discharge or not. Suitable patients were discharged immediately or kept overnight, according to randomization. Patients with an indication for extended hospital stay were not discharged regardless of randomization. Primary end points were death, myocardial infarction, coronary artery bypass graft surgery, repeat PCI, or puncture-related complications occurring within 24 hours after PCI. A total of 403 patients were assigned to same-day discharge, of whom 77 (19%) were identified for extended observation; 397 patients were assigned to overnight stay, of whom 85 (21%) were identified for extended observation. Among all patients, the composite primary end point occurred in 9 (2.2%) same-day discharge patients and in 17 (4.2%) overnight stay patients (risk difference, −0.020; 95% CI, −0.045 to −0.004; P for noninferiority <0.0001). Among patients deemed suitable for early discharge, the composite end point occurred in 1 of 326 (0.3%) same-day discharge patients and 2 of 312 (0.6%) overnight-stay patients (risk difference, −0.003; 95% CI, −0.014 to 0.007; P for noninferiority <0.0001). The last 3 events were related to puncture site.

Conclusions— Same-day discharge after elective PCI is feasible and safe in the majority (80%) of patients selected for day-case PCI. Same-day discharge does not lead to additional complications compared with overnight stay.

Adjunctive pharmacotherapy for coronary interventions-time to read the writing on the wall

None of the authors has any financial interests to disclose. With the new era of coronary stenting supported by triple anti-platelet therapy, in-hospital life threatening ischemic complications are rare, and minimally affected by the intensity and duration of the anti-coagulation protocol. Bleeding complications, however, became the most commonly observed adversity of percutaneous coronary intervention. Hemorrhagic complications are clearly related to the intensity and duration of anti-coagulation and platelet inhibition protocols, and result in excessive mortality, morbidity, and medical costs. Demographic and clinical predictors of bleeding complications are reviewed. Accumulating data on the safety of PCI with low-dose unfractionated heparin is pointed out. In view of the contemporary data, the authors question the recently published European and American guideline, which suggest uniform dosing and therapeutic targets for both anticoagulants and glycoprotein IIb/IIIa blockers. Instead, we suggest that these agents will be used judiciously and cautiously tailored, bearing in mind their benefits against the potential to harm. After over three decades of PCI, it is time to engage in dose and duration optimizing studies for these agents.

Periprocedural routines of coronary angioplasty--extreme diversity with unrevealed consequences

Our objective was to evaluate the current trends of coronary angioplasty periprocedural care in the state of Israel. PTCA technology has undergone through some major developments and refinements, which have yielded new algorithms and routines. With this shift of paradigms, some of the periprocedural routines (these include medications and dosing before, during and after the procedure, as well as the handling of anti-coagulation, femoral sheath removal and the extent of patient monitoring post-PTCA) have been partially re-established. In order to assess trends in periprocedural care, we elected to analyze the current state of practice in the state of Israel. A questionnaire was sent to every cardiac catheterization laboratory in Israel that performs PTCA. An authorized senior cardiologist representing the laboratory submitted the information required for our survey. A nurse-to-nurse telephone questionnaire was conducted simultaneously to cross-examine the validity of the data. All centers submitted results. The average heparin dose for PTCA varied between 5000 and 15 000 units, ACT was monitored routinely by some and not at all by others, post-PTCA heparin administration was routinely administered by some institutions and not by others, and the mean femoral sheath dwell time ranged from 4 to 18 h. Post-PTCA cardiac monitoring varied from 6 to more than 24 h. Some institutions prescribed to all patients nitrates, calcium channel blockers and low-molecular-weight heparin, while others did not. We conclude that there is profound variability in the periprocedural routines that may translate into a significant cost increase, patient discomfort, a prolonged monitoring and hospital stay, and potential patient morbidity. We suggest that these routines should be critically evaluated, and that if they do not contribute to the procedural success and patient well-being they should be abandoned.

Minimal heparinization in coronary angioplasty--how much heparin is really warranted?

The purpose of the study was to assess the results of percutaneous transluminal coronary angioplasty (PTCA), performed with a single intravenous bolus of 2,500 U of heparin, in a nonemergency PTCA cohort. Three hundred of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the study. They received heparin, 2,500-U intravenous bolus, before PTCA, with intention of no additional heparin administration. Patient and lesion characteristics as well as PTCA results were evaluated independently by 2 physicians. Patients were followed up by structured telephone questionnaires at 1 and 6 months after PTCA. Mean activated clotting time obtained 5 minutes after heparin administration was 185+/-19 seconds (range 157 to 238). There were 3 (1%) in-hospital major adverse cardiovascular events: 2 deaths (0.66%), 1 (0.33%) Q-wave myocardial infarction. Emergency coronary surgery and stroke were not reported. Six patients (2%) experienced abrupt coronary occlusion within 14 days after PTCA, warranting repeat target vessel revascularization. Angiographic and clinical success were achieved in 96% and 93.3%, respectively. No bleeding or vascular complications were recorded. Six-month follow-up (184 patients) revealed 3 cardiac deaths (1 arrhythmic, 2 after cardiac surgery), 1 Q-wave myocardial infarction, and 9.7% repeat target vessel revascularization. This study suggests that very low doses of heparin and reduced activated clotting time target values are safe in non-emergency PTCA, and can reduce bleeding complications, hospital stay, and costs. Larger, randomized, double-blind heparin dose optimization studies need to confirm this notion.