Low-risk patients were discharged safely less than 48 hours after successful primary percutaneous coronary intervention (PCI) using an investigational pathway designed and implemented during the Covid-19 pandemic, a single-center observational study showed.
Rates of mortality and major adverse cardiovascular events (MACE) for low-risk post-ST-segment elevation myocardial infarction (STEMI) intervention patients discharged at <48 hours were similar to a historical cohort who met criteria for earlier discharge but who were discharged at >48 hours, reported Daniel Jones, PhD, of St. Bartholomew’s Hospital in London, England, and co-authors.
Over a median 271-day follow-up after discharge, early versus later discharge pathway rates of mortality were 0.33% and 0.70% (P=0.349), respectively, and rates of MACE were 1.2% and 1.9% (P=0.674), the researchers wrote in the Journal of the American College of Cardiology.
Median hospital stay was 24.6 hours in the early discharge group versus a median of 56.1 hours for patients discharged >48 hours. There were two deaths on follow-up, both caused by Covid-19 infection.
“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,” Jones and co-authors wrote.
“Although the implementation of this pathway was driven by the necessity to adapt to the Covid-19 pandemic to shorten hospital admission times, optimize resource use, and decrease the risk of nosocomial infection, it has the potential to change standard practice in this patient group,” they added.
To assess the safety and feasibility of an early post-STEMI hospital discharge pathway, researchers identified 600 patients between March 2020 and June 2021. Eligibility for early discharge and low-risk for MACE were determined by:
- Left ventricular ejection fraction 40% or more.
- Successful primary PCI, with Thrombolysis in Myocardial Infarction (TIMI) flow grade 3.
- Absence of bystander disease requiring inpatient revascularization.
- No recurrence of ischemic symptoms.
- Absence of heart failure or hemodynamic instability.
- No significant arrhythmias (ventricular fibrillation, ventricular tachycardia, or atrial fibrillation or flutter requiring prolongation of stay for ventricular rate control) after the procedure.
- Mobility, with suitable social circumstances for discharge.
Selected patients were discharged in < 48 hours and outcomes on follow-up (48 hours after discharge by telephone, with tele-follow-up at 2, 6, and 8 weeks, and at 3 months) were compared with a historical group of 700 patients who met pathway criteria but were discharged per pre-pathway practice at >48 hours.
“This is the first prospective observational study to demonstrate the safety and feasibility of an early hospital discharge pathway (<48 hours) for patients who are at low risk of complications after STEMI that was treated successfully by primary PCI,” Jones and colleagues noted.
“Furthermore, all-cause mortality, cardiovascular mortality, and MACE rates were significantly lower in patients discharged on the early hospital discharge pathway compared with a standard discharge group,” they wrote. “This finding highlights that low-risk patients were selected for early hospital discharge and confirms the suitability of pathway inclusion criteria.”
The adverse event rate was low in the early discharge group and suggested that of the two deaths, both caused by Covid-19 and occurring >30 days after hospital discharge, neither could have been predicted or prevented by following standard discharge protocol, the researchers noted.
“With the advent of radial access for PCI and performance of outpatient elective PCI, it was only a matter of time before length of stay was further shortened after primary PCI,” wrote Cindy Grines, MD, and J. Jeffrey Marshall, MD, both of Northside Hospital Cardiovascular Institute in Atlanta, in an accompanying editorial.
The researchers have demonstrated the ability to safely discharge very low-risk patients 24 hours after primary PCI for STEMI, the editorialists noted. “Although we believe the discharge criteria should include other factors associated with poor outcomes, their study should cause cardiologists to rethink the ultra low risk STEMI pathway,” they wrote.
“However, it is unlikely that the American College of Cardiology and American Heart Association or European Society of Cardiology guidelines will shorten the length of stay to less than or equal to 24 hours on the basis of an observational report from a single center,” they added. “Future randomized trials of very early discharge versus standard discharge will be necessary.”
Physician judgment may overrule an early discharge protocol in cases of very late reperfusion (the maximum duration of myocardial infarction to reperfusion was only 4 hours in the current study), advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic COVID-19 infection, Grines and Marshall suggested.
A 2018 meta-analysis of five randomized trials that included 1,575 STEMI patients found no difference in mortality and readmission rates in those on early discharge pathways compared to the conventional discharge group.
In a 2015 U.S. study, 26.8% of patients age 65 or older with STEMI were discharged after short length of stay, defined as 3 days or less, with the authors noting that “patients discharged as early as 48 hours after primary percutaneous coronary intervention have outcomes similar to patients who stay in the hospital for 4 to 5 days.”
Generalizability of results may depend on institutional characteristics, Grines and Marshall suggested. “Importantly, these excellent clinical outcomes were achieved by a highly sophisticated and coordinated team approach with high-volume operators using PCI protocols,” they observed.
“It should also be pointed out that early discharge was applied to patients treated very early (median symptom onset to reperfusion of only 80 minutes, door-to-balloon time of 50 minutes), thus suggesting there may have been minimal myocardial damage from the STEMI.”
-
Low-risk patients were discharged safely less than 48 hours after successful primary percutaneous coronary intervention (PCI) using an investigational pathway implemented during the Covid-19 pandemic, a single-center observational study showed.
-
Rates of mortality and major adverse cardiovascular events (MACE) for low-risk post-ST-segment elevation myocardial infarction (STEMI) intervention patients discharged at <48 hours were similar to a historical cohort who met criteria for earlier discharge but who were discharged at >48 hours.
Paul Smyth, MD, Contributing Writer, BreakingMED™
Jones has received funding from the Barts Charity and has received financial support for blood pressure machines from the Barts Guild.
Grines and Marshall had no disclosures.
Cat ID: 306
Topic ID: 74,306,730,306,358,192,925
