JACC: Same-day discharge safe for uncomplicated PCIs
Proper patient selection and adherence to set protocols allow same-day discharge after uncomplicated cases of elective PCI, despite using femoral access, according to a study published in the August edition of the Journal of the American College of Cardiology: Cardiovascular Interventions.

“Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients,” the authors wrote. “Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge.”

To study this theory on a larger patient cohort, Mehul Patel, MD, of the Mount Sinai Hospital in New York City, and colleagues analyzed the outcomes of same-day discharge in 2,400 patients who underwent elective PCI procedures at Mount Sinai between April 2003 and March 2008.

Same-day discharge criteria consisted of:
  • Scheduled or ad hoc elective PCI for stable angina or crescendo angina or asymptomatic but positive stress test or perfusion imaging or stenosis on coronary CT;
  • Successful PCI with or without the use of a bolus dose of intravenous GP IIb/IIIa inhibitors;
  • Less than 30 percent residual stenosis without type C or higher intimal dissection of the National Heart, Lung and Blood Institute classification;
  • A left ventricular ejection junction of greater than 30 percent;
  • Absence of post-procedural chest pain and vascular complications;
  • PCI performed prior to 3 p.m. to allow for an eight-hour observation period;
  • Unsuccessful but uncomplicated PCI; and
  • A successful completion of a 200-meter walk.

Additionally, the researchers followed institutional triage criteria for in-hospital admission. This included:
  • Acute coronary syndrome presenting as rest angina or MI;
  • Use of the full-recommended bolus and infusion of GP IIb/IIIa inhibitors;
  • Complex PCI or assisted PCI;
  • Significant procedural complications;
  • Periprocedural hemodynamic instability;
  • Serum creatinine over 1.5 mg/dl, not on hemodialysis;
  • Sustained ventricular or atrial arrhythmia;
  • LV ejection fraction of less than 30 percent or decompensated systolic heart failure;
  • Uncontrolled diabetes mellitus;
  • Patients requiring optimization of medications;
  • Patients who experienced difficulties in ambulation; and
  • Socio-economic issues regarding placement and post-PCI care.

Primary endpoints evaluated were major adverse cardiac events (MACE) including repeat revascularization, cerebral events and major bleeding complications/access site bleeding. Patients had a mean age of 57 years--12 percent were 65 and above--75.5 percent were men and 43.3 percent had diabetes and 87.3 percent had hypertension.

PCI was performed using the femoral approach in 99.5 percent of patients using 5 to 8 F guiding catheters. All patients were treated with 81 to 162 mg of aspirin and 300 to 600 mg of clopidogrel (Plavix, Sanofi-Aventis/Bristol-Myers Squibb) pre-procedure.

The transradial approach was used during intervention in 11 patients and closure devices were used in 90.5 percent of the transfemoral procedures.

All patients received a 12-lead electrocardiogram post-PCI and before discharge. Patients were ambulated after two to three hours of bed rest if closure devices were used and four to six hours if a sheath was removed. Transradial patients were ambulated two to three hours post-procedure.

Patients who were discharged the same day as PCI were free from symptoms, serum creatinine elevation, saw no drop in hematocrit, and had an absence of puncture site abnormalities and a successful ambulation.

Multilesion interventions occurred in 375 patient cases, 1,617 patients had complex lesion anatomy (B2 and C lesions), 350 patients had bifurcation interventions and 98 patients had total occlusions.

PCI procedures were successful in 97 percent of same-day discharge patients (2,329 of 2,400). And of the 1,990 coronary stents placed, 76.5 percent were drug-eluting.

The researchers found no closure device-related complications at 30 days and no major complications during patients’ six- to eight-hour triage period. Additionally, no death, MIs or cerebrovascular accidents were reported at 30 days; however, 28 patients were readmitted within 30 days of discharge—19 cardiac related and nine, noncardiac related.

“The length of stay following PCI is one of the major determinants of hospital cost and quality-of-care assessment,” the authors wrote. Reimbursement policies governing the length of stay for elective PCI may possibly contribute to unwarranted hospitalizations causing logistic constraints on healthcare resources.

“The present study demonstrates that this can be achieved without compromising the quality-of-care or safety in the patient population with a higher-risk profile,” the authors concluded. “Also, once the protocol for ambulatory PCI is set in place, it does not incur extra costs on the hospital system to follow these patients and it does not add any costs to the physicians.”