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Piris A, Garcia-Linacero LM, Ortega-Perez R, Rivas-Garcia S, Martinez-Moya R, Sanmartin M, Zamorano JL. Safety of an Early Discharge Strategy (≤48 h) after ST-Elevation Myocardial Infarction. J Clin Med 2024; 13:3827. [PMID: 38999393 PMCID: PMC11242729 DOI: 10.3390/jcm13133827] [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: 05/23/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Early discharge following ST-segment-elevation myocardial infarction (STEMI) confers notable advantages for both patients and healthcare systems. However, the adoption of a very early discharge strategy for selected patients remains limited due to safety considerations. We aimed to provide some insight into the safety of a discharge program with a hospital stay lasting <48 h after a primary percutaneous coronary intervention (PCI). Methods: Using a registry of 1105 patients undergoing primary PCI for STEMI in our hospital between January 2015 and October 2023, we enrolled all the patients who had a hospital stay ≤48 h, according to a prespecified institutional protocol. The primary objective was a combined rate of non-fatal stroke, non-fatal acute myocardial infarction, or cardiovascular death within 30 days of discharge. Emergency department visits or hospitalizations due to cardiovascular causes, along with the all-cause mortality, were measured during the same period. Results: A total of 453 (41%) patients were discharged ≤48 h after admission for a STEMI. The mean age was 62.4 (±12.5 years), 24.3% were women, and 17.9% were people with diabetes. Up to 96% of the procedures had been performed through radial artery access, and there were no major vascular complications. Regarding the primary endpoint, there was one event (0.2%; one patient suffered a non-fatal myocardial infarction). There were no cardiovascular deaths or deaths from other causes. Only five patients (1.1%) were re-hospitalized or visited the emergency department due to cardiovascular causes. Conclusions: An early discharge strategy for patients within 48 h of experiencing STEMI and undergoing primary PCI appears feasible and safe.
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Affiliation(s)
- Antonio Piris
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Luis Manuel Garcia-Linacero
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Rodrigo Ortega-Perez
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Sonia Rivas-Garcia
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Rafael Martinez-Moya
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Unidad Críticos Cardiovasculares, Hospital Universitario Ramon y Cajal, Carretera de Colmenar Viejo 9100, 28034 Madrid, Spain
| | - Marcelo Sanmartin
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Unidad Críticos Cardiovasculares, Hospital Universitario Ramon y Cajal, Carretera de Colmenar Viejo 9100, 28034 Madrid, Spain
- Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
- Centro de Investigación en Red en Enfermedades Cardiovasculares, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (UAH), 28034 Madrid, Spain
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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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Bawamia B, Brown A, Spyridopoulos I, Bagnall A, Edwards R, Purcell I, Egred M, Zaman A, Alkhalil M. Very Early Discharge After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: Mortality Outcomes at Six Months. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:12-18. [PMID: 36058828 DOI: 10.1016/j.carrev.2022.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Current guidelines recommend that low risk patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing uncomplicated primary percutaneous coronary intervention (PPCI) can be discharged home in 48-72 h. We report the safety of early discharge in STEMI patients undergoing uncomplicated PPCI after 24-h stay in-hospital. METHODS We performed a retrospective analysis of prospectively collected data of consecutive patients presenting with STEMI between January 2014 and December 2020. One- and 6-month mortality rates were compared between patients who underwent next day (early discharge group) and two days in-hospital stay (standard discharge group). RESULTS Of 6119 STEMI patients, 4033 were included in the analysis, of whom 1674 (42 %) underwent early discharge. Patients in the early discharge group were younger, more likely to be male, and had a lower peak troponin. Both groups had similar ischemia- and door-to-balloon time, but anterior STEMI were less frequent in the early discharge group. The 1- and 6-month mortality rate for the whole cohort was 0.6 % and 1.3 %, respectively. After adjustment, there were no significant differences in the 1-month [HR 0.54; 95 % CI (0.20 to 1.47), P = 0.23] and 6-month mortality [HR 0.73; 95 % CI (0.38 to 1.41), P = 0.35] between early and standard discharge groups. Age, admission heart rate and chronic obstructive lung disease were identified as independent predictors of 6-month mortality in patients who underwent early discharge strategy. CONCLUSION Our data confirms safety of next day discharge of patients presenting with STEMI after successful PPCI and uncomplicated post-procedural course.
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Affiliation(s)
- Bilal Bawamia
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Andrew Brown
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Ioakim Spyridopoulos
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Alan Bagnall
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Ian Purcell
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Mohaned Egred
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.
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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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Abdelfattah OM, Abushouk AI, Saad AM, Gad MM, Isogai T, Saleh Y, Shekhar S, Iskander M, Omer M, Kaple R, Krishnaswamy A, Kapadia SR. Impact of post-procedural length of stay on short-term outcomes and readmissions after TAVR and MitraClip. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100130. [PMID: 38560061 PMCID: PMC10978317 DOI: 10.1016/j.ahjo.2022.100130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/10/2022] [Accepted: 03/22/2022] [Indexed: 04/04/2024]
Abstract
Background Post-procedural hospital length of stay (P-LOS) is an important determinant of cost-related outcomes. In the present study, we aimed to assess the impact of P-LOS on short-term outcomes after transcatheter aortic valve replacement (TAVR) and MitraClip. Methods We performed a retrospective cohort study, retrieving data from the National Readmissions Database (NRD) for patients who underwent transfemoral TAVR and MitraClip between January 2014 and December 2017. We employed multivariable logistic regression to evaluate the association between P-LOS and 30-day all-cause mortality and readmissions. Results A total of 65,726 and 7347 patients underwent TAVR and MitraClip, respectively within the study period. After 30 days of discharge, 13.7% and 15.1% of TAVR and MitraClip patients were readmitted for any reason, while 0.5% and 0.9% died within the readmission hospitalization. A longer P-LOS was associated with an increased risk of 30-day all-cause readmission in both TAVR (OR = 1.027, 95% CI [1.023-1.032]) and MitraClip (OR = 1.025, 95%CI [1.012-1.038]) patients. This finding remained true for patients who developed or did not develop complications after both procedures. In terms of 30-day inhospital mortality, a longer P-LOS was associated with a higher risk in TAVR patients (OR = 1.039, 95%CI [1.028-1.049]), but no increased risk in MitraClip patients (OR = 1.014, 95%CI [0.985-1.044]). Other predictors of 30-day readmission after both procedures included heart failure, post-procedural acute kidney injury, and discharge with disability. Conclusion The current study shows that shorter P-LOS was associated with reduced risk of short-term readmission after both TAVR and MitraClip and reduced short-term mortality after TAVR (mainly in patients who developed post-procedural complications). Shorter P-LOS is a predictor of readmission and sicker patient group. Patients requiring longer LOS should be followed closely to prevent readmission and enhance better outcomes. Future studies evaluating P-LOS impact on long-term and patient-oriented outcomes are needed.
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Affiliation(s)
- Omar M. Abdelfattah
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
- Internal Medicine Department, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
| | - Abdelrahman I. Abushouk
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anas M. Saad
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed M. Gad
- Internal Medicine Department, Cleveland Clinic, Cleveland, OH, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yehia Saleh
- Department of Cardiovascular Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mina Iskander
- Department of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Mohamed Omer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan Kaple
- Department of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Rathod KS, Comer K, Casey-Gillman O, Moore L, Mills G, Ferguson G, Antoniou S, Patel R, Fhadil S, Damani T, Wright P, Ozkor M, Das D, Guttmann OP, Baumbach A, Archbold RA, Wragg A, Jain AK, Choudry FA, Mathur A, Jones DA. Early Hospital Discharge Following PCI for Patients With STEMI. J Am Coll Cardiol 2021; 78:2550-2560. [PMID: 34915986 DOI: 10.1016/j.jacc.2021.09.1379] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care. OBJECTIVES This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients. METHODS Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in <48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months. RESULTS The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (>30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. CONCLUSIONS Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.
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Affiliation(s)
- Krishnaraj S Rathod
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Katrina Comer
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Oliver Casey-Gillman
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Lizzie Moore
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Gordon Mills
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Gordon Ferguson
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Riyaz Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Tasleem Damani
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mick Ozkor
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Debashish Das
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Oliver P Guttmann
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - R Andrew Archbold
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Andrew Wragg
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ajay K Jain
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Fizzah A Choudry
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
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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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9
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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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10
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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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11
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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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12
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Jang S, Yeo I, Feldman DN, Cheung JW, Minutello RM, Singh HS, Bergman G, Wong SC, Kim LK. Associations Between Hospital Length of Stay, 30-Day Readmission, and Costs in ST-Segment-Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention: A Nationwide Readmissions Database Analysis. J Am Heart Assoc 2020; 9:e015503. [PMID: 32468933 PMCID: PMC7428974 DOI: 10.1161/jaha.119.015503] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Readmission after ST-segment-elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. There are limited data on the association between length of hospital stay (LOS), readmission rate, and overall costs in patients who underwent primary percutaneous coronary intervention for STEMI. Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent primary percutaneous coronary intervention, we examined the 30-day outcomes including readmission, mortality, reinfarction, repeat revascularization, and hospital charges/costs according to LOS (1-2, 3, 4, 5, and >5 days) stratified by infarct locations. The 30-day readmission rate after percutaneous coronary intervention for STEMI was 12.0% in the anterior wall (AW) STEMI group and 9.9% in the non-AW STEMI group. Patients with a very short LOS (1-2 days) were readmitted less frequently than those with a longer LOS regardless of infarct locations. However, patients with a very short LOS had significantly increased 30-day readmission mortality versus an LOS of 3 days (hazard ratio, 1.91; CI, 1.16-3.16 [P=0.01]) only in the AW STEMI group. Total costs (index admission+readmission) were the lowest in the very short LOS cohort in both the AW STEMI group (P<0.001) and the non-AW STEMI group (P<0.001). Conclusions For patients who underwent primary percutaneous coronary intervention for STEMI, a very short LOS was associated with significantly lower 30-day readmission and lower cumulative cost. However, a very short LOS was associated with higher 30-day mortality compared with at least a 3-day stay in the AW STEMI cohort.
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Affiliation(s)
- Sun‐Joo Jang
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
- Dalio Institute of Cardiovascular ImagingDepartment of RadiologyWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Ilhwan Yeo
- Division of CardiologyNew York Presbyterian Queens HospitalNew YorkNY
- Icahn School of Medicine at Mount SinaiNew YorkNY
| | - Dmitriy N. Feldman
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Jim W. Cheung
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Robert M. Minutello
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Harsimran S. Singh
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Geoffrey Bergman
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - S. Chiu Wong
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Luke K. Kim
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Division of CardiologyDepartment of MedicineWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
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13
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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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14
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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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15
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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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Alvarez Alvarez B, Cid Alvarez AB, Redondo Dieguez A, Sanmartin Pena X, Lopez Otero D, Avila Carrillo A, Gomez Peña F, Trillo Nouche R, Martinez Selles M, Gonzalez-Juanatey J. Short-term and long-term validation of the fastest score in patients with ST-elevation myocardial infarction after primary angioplasty. Int J Cardiol 2018; 269:19-22. [PMID: 30064924 DOI: 10.1016/j.ijcard.2018.07.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Belen Alvarez Alvarez
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Ana Belen Cid Alvarez
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alfredo Redondo Dieguez
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Xoan Sanmartin Pena
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Diego Lopez Otero
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alejandro Avila Carrillo
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Fernando Gomez Peña
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Ramiro Trillo Nouche
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Jose Gonzalez-Juanatey
- Cardiology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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17
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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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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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Domínguez-Pérez L, Martín-Asenjo R, Bueno H. Early to bed and early to rise makes a patient healthy, a hospital wealthy, and a doctor wise, or not? Eur J Prev Cardiol 2018; 25:804-806. [PMID: 29658299 DOI: 10.1177/2047487318771775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Laura Domínguez-Pérez
- 1 Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- 1 Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Héctor Bueno
- 1 Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,2 Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,3 Facultad de Medicina, Universidad Complutense de Madrid, Spain
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Gong W, Li A, Ai H, Shi H, Wang X, Nie S. Safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials. Eur J Prev Cardiol 2018. [PMID: 29537296 DOI: 10.1177/2047487318763823] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early discharge after successful primary angioplasty is common, but the evidence supporting the practice is still lacking. We therefore performed a meta-analysis assessing the safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction (STEMI). Methods Randomised controlled trials were identified and extracted from PubMed, Embase, Cochrane Library databases and reference lists of relevant papers. Heterogeneity was analysed using the I2 test. If there was a lack of heterogeneity, fixed effects models would be used for the meta-analysis, otherwise random effects models were used. Statistical analyses were performed using Review Manager 5.3. Results Five randomised controlled trials involving 1575 STEMI patients met the criteria. Meta-analysis showed that the early discharge strategy group had a significantly shortened length of hospital stay compared to the conventional discharge strategy group (standardised mean difference -1.46, 95% confidence interval (CI) -2.04 to -0.88; P < 0.0001), and there was no difference in mortality and readmission rates between the two groups (risk ratio 0.78, 95% CI 0.50 to 1.22; P = 0.41). Conclusions The findings of this meta-analysis suggested that the early discharge strategy after successful primary angioplasty is safe among selected low-risk STEMI patients. A shorter hospital stay could benefit both the patients and the healthcare systems.
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Affiliation(s)
- Wei Gong
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Aobo Li
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Hui Ai
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Han Shi
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Xiao Wang
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Shaoping Nie
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
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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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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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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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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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Peckham E, Brabyn S, Cook L, Devlin T, Dumville J, Torgerson DJ. The use of unequal randomisation in clinical trials — An update. Contemp Clin Trials 2015; 45:113-22. [DOI: 10.1016/j.cct.2015.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/21/2015] [Accepted: 05/25/2015] [Indexed: 01/17/2023]
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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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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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Melberg T, Jørgensen M, Ørn S, Solli T, Edland U, Dickstein K. Safety and health status following early discharge in patients with acute myocardial infarction treated with primary PCI: a randomized trial. Eur J Prev Cardiol 2014; 22:1427-34. [DOI: 10.1177/2047487314559276] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Tor Melberg
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Marianne Jørgensen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Stein Ørn
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Torhild Solli
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Unni Edland
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Kenneth Dickstein
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
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Schellings DAAM, Adiyaman A, Giannitsis E, Hamm C, Suryapranata H, Ten Berg JM, Hoorntje JCA, Van't Hof AWJ. Early discharge after primary percutaneous coronary intervention: the added value of N-terminal pro-brain natriuretic peptide to the Zwolle Risk Score. J Am Heart Assoc 2014; 3:e001089. [PMID: 25389283 PMCID: PMC4338696 DOI: 10.1161/jaha.114.001089] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The Zwolle Risk Score (ZRS) identifies ST‐elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) eligible for early discharge. We aimed to investigate whether baseline N‐terminal pro–brain natriuretic peptide (NT‐proBNP) is also able to identify these patients and could improve future risk strategies. Methods and Results PPCI patients included in the Ongoing Tirofiban in Myocardial Infarction Evaluation (On‐TIME) II study were candidates (N=861). We analyzed whether ZRS and baseline NT‐proBNP predicted 30‐day mortality and assessed the occurrence of major adverse cardiac events (MACEs) and major bleeding. Receiver operating characteristic curve analysis was used to assess discriminative accuracy for ZRS, NT‐pro‐BNP, and their combination. After multiple imputation, 845 patients were included. Both ZRS >3 (hazard ratio [HR]=9.42; P<0.001) and log NT‐pro‐BNP (HR=2.61; P<0.001) values were associated with 30‐day mortality. On multivariate analysis, both the ZRS (HR=1.41; 95% confidence interval [CI]=1.27 to 1.56; P<0.001) and log NT‐proBNP (HR=2.09; 95% CI=1.59 to 2.74; P<0.001) independently predicted death at 30 days. The area under the curve for 30‐day mortality for combined ZRS/NT‐proBNP was 0.94 (95% CI=0.90 to 0.99), with optimal predictive values of a ZRS ≥2 and a NT‐proBNP value of ≥200 pg/mL. Using these cut‐off values, 64% of the study population could be identified as very low risk with zero mortality at 30 days follow‐up and low occurrence of MACEs and major bleeding between 48 hours and 10 days (1.3% and 0.6%, respectively). Conclusion Baseline NT‐proBNP identifies a large group of low‐risk patients who may be eligible for early (48‐ to 72‐hour) discharge, whereas optimal predictive accuracy is reached by the combination of both baseline NT‐proBNP and ZRS.
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Affiliation(s)
- Dirk A A M Schellings
- Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.)
| | - Ahmet Adiyaman
- Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.)
| | | | - Christian Hamm
- Department of Cardiology, Kerckhoff Klinik, Bad Nauheim, Germany (C.H.)
| | - Harry Suryapranata
- Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.) Department of Cardiology, Radboud University, Nijmegen, The Netherlands (H.S.)
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands (J.M.B.)
| | - Jan C A Hoorntje
- Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.)
| | - Arnoud W J Van't Hof
- Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.)
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Noman A, Zaman AG, Schechter C, Balasubramaniam K, Das R. Early discharge after primary percutaneous coronary intervention for ST-elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 2:262-9. [PMID: 24222838 DOI: 10.1177/2048872612475231] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/31/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND To assess safety of early discharge following primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS Retrospective analysis of prospectively collected data of 2448 STEMI patients treated with PPCI surviving to hospital discharge. Post-discharge all-cause mortality was reported at 1, 7, and 30 days and long-term follow up. A total of 1542 patients (63.0%) were discharged within 2 days of admission (early discharge group) and 906 patients (37.0%) after 2 days (late discharge group). In both groups, no deaths were recorded 1 day post discharge. The early and late discharge group mortality figures for 7 days were 0 and 4 patients (0.04%) and between 7 and 30 days were 11 (0.7%) and 11 patients (1.2%), respectively. During a mean follow up of 584 days, 178 patients (7.3%) died: 67 in the early discharge group (4.3%) and 111 in the late discharge group (12.3%). CONCLUSIONS This exploratory, observational study demonstrates that discharging low-risk STEMI patients within 2 days following PPCI is safe. For providers of health care, early discharge can help to allay the cost of providing a 24-hour PPCI service and adds to the recognized benefits arising from PPCI.
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Gehani A, Al Suwaidi J, Arafa S, Tamimi O, Alqahtani A, Al-Nabti A, Arabi A, Aboughazala T, Bonow RO, Yacoub M. Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program. Glob Cardiol Sci Pract 2013; 2012:43-55. [PMID: 24688990 PMCID: PMC3963721 DOI: 10.5339/gcsp.2012.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/17/2012] [Indexed: 11/03/2022] Open
Abstract
In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as 'high volume', both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.
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Affiliation(s)
| | | | - Salah Arafa
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Omer Tamimi
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | | | | | - Magdi Yacoub
- Qatar Cardiovascular Research Center, Doha, Qatar
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