The feasibility and safety of early discharge for low risk patients with acute myocardial infarction after successful direct percutaneous coronary intervention

Safety of Early Discharge Among Low-Risk Patients After Primary Percutaneous Coronary Intervention: An Updated Systematic Review and Meta-Analysis

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.

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

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.

Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction

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.

Predictors of Prolonged In-Hospital Stay After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Health care costs increase with prolonged in-hospital stays. Many factors influence the length of stay for patients with ST-elevation myocardial infarction (STEMI). In this study, we aimed to determine the differences between long-stay and early discharged patients with STEMI. For this retrospective study, a total of 2486 consecutive patients with STEMI (mean age: 56.2 ± 11.7 years, 16.5% female) who had undergone primary percutaneous coronary intervention (pPCI) were enrolled. Patients were divided into 2 groups based on mean in-hospital stay: <6 days and ≥6 days. Anterior STEMI (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.02-2.54; P = 0.03), angiographic failure (OR: 2.89, 95% CI: 1.19-7.01; P = .01), and peripheral vascular complications (PVCs; OR: 4.18, 95% CI: 1.16-15.03; P = .02) were found to be independent predictors of ≥6-day in-hospital stay. The incidence of long-term total mortality and composite end point for death, reinfarction, and target vessel revascularization were significantly higher in ≥6-day in-hospital stay patients. Anterior STEMI, angiographic failure, and PVCs were found to be independently associated with prolonged in-hospital stay for patients with STEMI following pPCI.

National trends in hospital length of stay for acute myocardial infarction in China

BACKGROUND

China is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization.

METHODS

We used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported.

RESULTS

The weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n = 1,901), 11 and 12.6 days in 2006 (n = 3,553), and 11 and 11.9 days in 2011 (n = 7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p = 0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS.

CONCLUSIONS

Despite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.

Early discharge after primary percutaneous coronary intervention for ST-elevation myocardial infarction

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.

Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction--a prospective and randomized trial in low-risk primary percutaneous coronary intervention patients (the Safe-Depart Trial)

BACKGROUND

Patients with ST-segment elevation myocardial infarction (STEMI) have traditionally been hospitalized for 5 to 7 days to monitor for serious complications such as heart failure, arrhythmias, reinfarction, and death. The Zwolle Primary Percutaneous Coronary Intervention (PCI) Index is an externally validated risk score that has been used to identify low-risk STEMI patients who have undergone primary PCI and can safely be discharged from hospital within 72 hours. Previous studies have shown that many low-risk patients remain in hospital significantly longer.

METHODS

We randomly assigned 54 low-risk STEMI patients treated with primary or rescue PCI to 1 of 2 groups. Patients in the intervention group (n = 27) were actively targeted for early hospital discharge (48-72 hours) and received outpatient follow-up with an advanced practice nurse (APN). In the control group (n = 27), discharge planning and follow-up were left to the treating physician, and there was no added nursing intervention. The 2 primary outcomes of this pilot study were to demonstrate feasibility and safety. Secondary outcomes included compliance with medications, smoking cessation, attendance at cardiac rehabilitation, and quality of life, measured in both groups at 6 weeks time.

RESULTS

In the intervention group, 74% of patients were discharged within 72 hours, 100% had follow-up with the APN within 3 days (74% in person, 26% by phone), and 100% had >/= 3 APN follow-ups in total, meeting our prespecified criteria for feasibility. The median length of stay was 55 hours in both groups. There were no deaths in either group, and there was no difference in rehospitalization between patients in the intervention and control groups (8% vs 4%, P = .56). There was no difference in rates of medication compliance, smoking cessation, attendance at cardiac rehabilitation, or quality of life between the 2 groups, although our small pilot study was not powered to detect a difference in these outcomes.

CONCLUSION

In low-risk STEMI patients treated with primary or rescue PCI, a strategy of early hospital discharge facilitated by close nursing follow-up is feasible. Although our study did not identify differences in compliance or quality of life between the 2 groups, it did provide a functional study design for a larger trial powered to detect these important clinical end points.

Next day discharge after successful primary angioplasty for acute ST elevation myocardial infarction. An open randomized study "Prague-5"

This study tested the feasibility and safety of next day hospital discharge after successful primary PCI for uncomplicated STEMI. Twenty-three p-PCI patients (out of 271 consecutive patients) who fulfilled the study inclusion criteria were enrolled in the pilot nonrandomized phase (transfer of patients from the coronary unit to a standard ward within 24 hours after their admission) of the study. The randomized phase of the study screened a total of 1946 consecutive STEMI patients undergoing p-PCI in the two participating centers. Only 56 (ie, 2.9% from all p-PCI) very low risk patients residing less than 20 km from the PCI center were selected. They were randomized 1:2 to either a standard hospital stay (group A, n = 19, age, 58 +/- 8) or first day discharge (group B, n = 37, age, 56 +/- 10; NS). There were no serious complications among 79 study patients within 30 days. The duration of hospital stay was 105 +/- 45 hours (group A) and 29 +/- 3 hours (P < 0.0001) in group B. Ejection fraction after 30 days was 56.8 +/- 6.5% in group A versus 57.3 +/- 7% in group B (NS). A patient comfort questionnaire showed a clear preference of first day discharge in all patients randomized into group B. The results indicate that next day discharge after successful p-PCI is feasible and safe in selected uncomplicated STEMI patients.

Mobilization and early hospital discharge for patients with acute myocardial infarction: literature review

OBJECTIVE: This study was a literature review with the purpose of analyzing articles comparing early and late mobilization and those comparing early and late discharge for patients with acute myocardial infarction. METHODS: The literature review was performed using the Lilacs and Medline databases (1966-2007), and the length of the resting period, the hospitalization and possible complications were analyzed. RESULTS: We selected 18 articles; 11 of them compared early and late mobilization and 7 compared early and late discharge. The length of the resting period in the early mobilization group varied from 2 to 10 days and 5 to 28 days for the longest resting period. The early discharge group stayed in the hospital from 3 to 14 days and the late discharge group stayed in the hospital from 5 to 21 days. CONCLUSION: The studies show that there is no evidence of complications related to short periods of bed rest and hospitalization.