Discharge Safe as Early as a Day After Primary PCI for STEMI

A strategy to send select patients home within 48 hours after undergoing primary PCI for STEMI is safe and feasible if they’re considered low risk, according to results of a new study. In fact, the median time to discharge was just over 24 hours.

The findings are the latest attempt to safely shorten the window for length of stay in STEMI patients, which is of particular interest in the midst of the current global pandemic, said senior investigator Daniel A. Jones, PhD (St. Bartholomew’s Hospital, London, England), who called the strategy a “mentality change” for all involved.

“Although initially it did feel early, our pilot data previously suggested it was safe,” he told TCTMD. Rather than waiting in the hospital for postprocedural counseling and prescriptions, the pathway created by Jones and colleagues identifies low-risk patients who are likely to be ambulatory, with no rhythm disturbances, and ready to head home in 48 hours or less.

The median length of stay in the single-center study was reduced from the pre-COVID standard of 3 days to 2 days (P < 0.0001). Some patients went home as quickly as 17 hours after their procedure, and all who were eligible for early discharge left the hospital within 40 hours. Over median follow-up of 271 days, during which time patients were monitored frequently via a structured telehealth program, no CV deaths were reported.

In an editorial accompanying the study in the Journal of the American College of Cardiology, Cindy L. Grines, MD, and J. Jeffrey Marshall, MD (both Northside Hospital Cardiovascular Institute, Lawrenceville, GA), congratulate the authors for moving “the target discharge time even shorter than previously attempted.” Grines was the lead investigator of the Primary Angioplasty in Myocardial Infarction-2 (PAMI-2) study, the first RCT of early discharge in primary PCI, which found that sending patients home on day 3 was both safe and cost-effective. She and Marshall note that European Society of Cardiology guidelines state that early discharge can be considered in selected patients 72 hours after STEMI, while the US guidelines embrace early discharge but do not specify length of stay.

The results of the new study, according to Grines and Marshall, likely reflect the sophisticated team approach, with high-volume operators using optimal protocols to reduce bleeding, including radial access in nearly all patients. Additionally, they point out that early-discharge patients were “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.” They also say it is “somewhat concerning” that the pathway only requires 12 hours of cardiac rhythm monitoring, but acknowledge that it may be acceptable in patients with minimal myocardial damage.

To TCTMD, Jones said the investigators were comfortable with the 12-hour monitoring based on their pilot data in which no one had late rhythm disturbance beyond that time.

Remote Follow-up

For the study, the researchers, led by Krishnaraj S. Rathod, PhD (Queen Mary University of London), selected 600 patients treated between April 2020 and June 2021 who met criteria for early discharge based on the preexisting policy for 48- to 72-hour discharge and on recommendations for early discharge from the European Society of Cardiology. The criteria included: LVEF > 40%, absence of disease requiring in-patient revascularization, no recurrence of ischemic symptoms, absence of HF, nonsignificant arrhythmias, absence of hemodynamic instability, no significant comorbidities, and suitable mobility and social circumstances for home discharge.

Compared with 700 historical controls (October 2018-April 2020) discharged 48 hours or more after PCI for STEMI, patients in the early-discharge group were younger, had lower rates of renal disease, previous peripheral vascular disease, or stroke, and were less likely to present in cardiogenic shock, cardiac arrest, or with anterior MI. Although the early-discharge patients had lower rates of multivessel disease than the historic controls, 15% underwent multivessel intervention at the time of primary PCI. Overall, those discharged early were more likely to have single-vessel disease, non-left anterior descending artery culprit vessels, preserved LV systolic function, and lower incidences of severe LV impairment.

The median length of stay in the early-discharge group was 24.6 hours. In comparison, the historical control group had a median length of stay of 56.1 hours. Prior to discharge, the early-discharge group downloaded a health app onto their phones and were given BP monitors if they did not have them at home. Follow-up at 48 hours via structured video call was done by cardiac rehab nurses who assessed symptoms, heart rate and BP, medications, and compliance. Remote follow-up with an advanced clinical practitioner (ACP) occurred via a virtual clinic at 2 and 8 weeks postprocedure, while a specialist CV pharmacist was in contact with them at 6 weeks. At 12 weeks, patients had a video appointment with the interventional cardiologist.

The MACE rate was 1.2%, compared with 1.9% reported at the same institution in the pre-COVID period (P = 0.674). The only deaths in the early-discharge group were due to COVID-19, and both occurred in patients who contracted the virus outside of the hospital. A propensity-matched analysis of 580 patients in each group also showed no difference in mortality (P = 0.410) or MACE (P = 0.342) over the follow-up period.

A patient survey found that 85% were “satisfied” or “very satisfied” with the expedited care pathway, 75% reported cost savings, and 62.5% reported saved time off work due to virtual follow-up.

Selection Is Key

Rajesh Swaminathan, MD (Duke University Medical Center, Durham, NC), who was not involved in the study, said results are reassuring.

“This has implications for healthcare systems working to make care more efficient without compromising quality. I see this as practice changing, but the key is patient selection,” he said in an email. Swaminathan added that the “unique structure of the virtual telehealth visits utilizing a comprehensive health app is critical, but may not be accessible for all patients. I do think this study should prompt all centers to take a closer look at their own institution’s STEMI discharge practice patterns.”

He noted that other centers could emulate the pathway used in the study, and many already have, through modifications in clinical care decisions to facilitate the short STEMI stays.

“In this study, for example, 88% of patients had left ventriculograms to meet LV function assessment metric requirements since echo assessments prior to a short discharge time frame may be limited,” he noted. “In addition, 23% of patients were staged to come back for a separate elective outpatient procedure (staged PCI, FFR, CABG).”

While patients may like the faster discharge, Swaminathan added that it does raise concern that some might associate it with a less serious nature of the event, which he said “may have implications for their willingness to implement important lifestyle changes.” He noted that the faster discharge also leaves less time while in the hospital to discuss secondary prevention measures and titrate medications.

“I don't think getting people out of the hospital at 24 compared to 48 hours has a bearing on that as long as there's structured follow-up,” Jones countered. “The patients all had the contact number of the ACP's, so if anyone had questions they had an available point of contact even in that first week before the first outpatient appointment.” He added that the early discharge pathway likely “is generalizable to any health center in the UK, Europe, or really anywhere in the world, including the United States. But, we would need more data to be able to support that.”