SCAI: Radial approach challenges PCI discharge guidelines

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San Diego -- Recently published SCAI/ACC guidelines for appropriate same-day PCI may not accurately reflect what is possible in real-world U.S. practice using standard transradial approaches, according to a study presented Wednesday at the Society for Cardiovascular Angiography and Interventions (SCAI) 33rd annual scientific sessions.

“Whether these findings reflect regulatory or reimbursement constraints, the net effect will result in longer hospitalizations for U.S. patients than similar patients outside of the U.S.,” the authors wrote.

“The transradial techniques that have been introduced over the last decade have changed the PCI procedure dramatically,” said Ian Gilchrist, MD, a professor of medicine at Penn State College of Medicine in Hershey, Pa. “This study challenges conventional thinking that PCI patients must stay overnight.”

For the study, Gilchrist and colleagues set out to document the types of patients who safely underwent radial PCI and were discharged home the same day from a medical center with a decade’s experience in the procedure. Researchers analyzed data from 100 patients who had a total of 106 uncomplicated PCI procedures using radial techniques, focusing on clinical and procedural characteristics that traditionally would have excluded patients from having an outpatient procedure.

Specifically, they compared same-day discharge for their appropriateness under the latest 2009 SCAI/ACC statements on outpatient trandradial PCI. The researchers utilized pre-existing data that was prospectively collected for a quality assurance database and verified for submission under the National Cardiovascular Data Registry program.

Nurse practitioners conducted early follow-up over the telephone to confirm education and medication compliance.

No patients were readmitted nor had any post-procedural complication related to the PCI procedure. The population included 11 women and 89 men, median age 62 years, all presenting with stable angina.

Contrary to published practice suggestions, Gilchrist and colleagues found that 26 were older than 70 years, five were insulin-dependent diabetics, one had decreased estimated glomerular filtration rate, four had contrast allergies, eight had chronic obstructive pulmonary disease and were on medications, four had multivessel disease and six had peripheral vascular disease, congestive heart failure or prior heart transplant.

The researchers also discovered that 62 patients lived further than 20 miles from the hospital at a median 54 miles; and 23 underwent complex PCI with five left main coronary arteries, two grafts, 12 proximal left anterior descending and three multivessel disease.

If not preloaded with clopidogrel (52 patients) for at least two hours, IV GP IIb/IIIa agents were given as bolus or short infusions. Only 15 percent had no exclusion to same day PCI.

Based on their findings, the authors concluded that practice guidelines, regulatory/reimbursement policies and advances in catheterization technology need to be aligned to optimize healthcare delivery.

“A broad range of patients who have transradial PCI can be discharged the same day if they have had an uneventful procedure without complications,” Gilchrist said. “Decisions about same-day discharge should be based on procedural outcome, rather than pre-procedural characteristics.”

Gilchrist reported no conflicts of interest related to this study.