Early Discharge Feasible, Safe for Selected Elderly STEMI Patients

Some elderly STEMI patients who do not develop in-hospital complications after undergoing primary PCI may be safely discharged home as early as 48 hours after the procedure, according to a registry study published in the March 31, 2015, issue of the Journal of the American College of Cardiology. The study also showed a trend toward earlier release of such patients over a 5-year period.

“This pattern may reflect the increasing safety of PCI in general, the use of bleeding avoidance strategies, and the financial pressures for hospitals to reduce inpatient [length of stay],” write Rajesh V. Swaminathan, MD, of Weill Cornell Medical College (New York, NY), and colleagues.

The researchers collected data from the National Cardiovascular Data Registry CathPCI Registry and the Centers for Medicare & Medicaid Services on 33,920 STEMI patients aged 65 years and older who underwent primary PCI at 1,028 US hospitals between 2004 and 2009. Patients were stratified into groups by length of stay as follows:

• Short (≤ 3 days): 26.9%                                                                 

• Medium (4-5 days): 46.3%                                                                                                      

• Long (> 5 days): 26.8%                                                             

Patients with longer stays were older and more frequently had prior MI, heart failure, diabetes, renal failure, cerebrovascular disease, peripheral vascular disease, chronic lung disease, hypertension, and shock. In addition, symptom onset-to-admission times were generally shorter in those with short or medium stays compared with long stays. Patients in the short-stay group were more likely to have preserved LV function, non-LAD culprit vessels, TIMI flow grade 1 to 3 before PCI, and successful procedures.

Shorter stays were more often seen at smaller hospitals with fewer beds and a lower number of annual PCI cases. Discharging patients early was also more commonly practiced in hospitals in the West and Midwest regions compared with the South and Northeast.

Earlier Discharge Proves Safe

Median length of stay for the 5-year study period was 4 days. However, the relative frequency of patients in each stay category changed, showing a trend toward earlier discharge over time.

At 30 days, mortality (primary endpoint) and MACE (mortality, readmission for MI, or unplanned revascularization) rates were similar between the groups with medium and short stays, but patients with long stays were more likely than those with short stays to report adverse events (table 1).

The incidence of readmission for MI at 30 days did not differ between those with short and medium stays but was higher for those with longer stays. There was no difference in readmission for unplanned revascularizations across lengths of stay. Bleeding requiring readmission after initial discharge was infrequent overall, but its likelihood increased in conjunction with length of stay.

Very short stays—with discharge on the day of or day after PCI—were rare (3.7%) but associated with worse 30-day outcomes. Compared with patients having very short stays, those with 3- or 4-day stays were less likely to die (OR 0.41; 95% CI 0.21-0.81) and to experience MACE (OR 0.52; 95% CI 0.33-0.80) by 30 days on propensity-matched analysis.

A Call for ‘Balloon-to-Door’ Recommendations

“These data suggest that selected patients with STEMI who do not develop postprocedural complications may be eligible for an earlier discharge without an increase in 30-day adverse events,” Dr. Swaminathan and colleagues write.

While guidelines for door-to-balloon times in STEMI care are well-established, none exist for optimal length of stay or “balloon-to-door” time, the authors write. “Large-scale changes in the way post-STEMI care is delivered and reductions in [length of stay] nationally may be accompanied by unintended consequences,” they note. “Therefore, it is critical to examine the safety and understand the effects of such changes, particularly among Medicare beneficiaries with substantial comorbidities.”

The low mortality and MACE rates at 30 days are “reassuring” in an older population, the authors continue. Yet, it still “remains unknown whether shorter [length of stay] and reduced hospital costs align with effects on care continuity and patients’ preferences,” they write.

Dr. Swaminathan and colleagues attribute the high risk of events associated with very early discharge to the fact that PCI-associated hazards—acute stent thrombosis, bleeding, and renal failure—are highest within the first 48 hours postprocedure. “Thus, longer observation may be required to avert these complications,” they write, adding that patients discharged very early were not optimally treated with post-MI medications.

“The current data highlight the importance of implementing standardized protocols for STEMI discharge and postdischarge follow-up in patients with very short [stays], in addition to the need for further clinical evidence that a very early discharge strategy can be safely applied in contemporary practice,” the authors conclude.

Cost-Saving Potential

In an editorial accompanying the study, Frederic S. Resnic, MD, MSc, and Sachin P. Shah, MD, of the Lahey Hospital and Medical Center (Burlington, MA), claim that reducing hospital length of stay among all STEMI patients “would likely result in dramatic cost savings for the US healthcare system.”

However, along with growing financial pressure to shorten hospitalization, there is “a lurking concern [that] goals for hospital efficiency may outpace medical evidence and may place patients at risk for harm from hospitalization that is too short after STEMI,” Drs. Resnic and Shah write. While there is insufficient evidence on the best length of stay after primary PCI, they add, this study “helps affirm that the current practice to discharge lower-risk patients early (≤ 3 days) is likely as safe as longer hospital stays.”

The editorialists note the importance of the geographic discrepancies observed in the study, writing that the patterns could “provide an opportunity for a substantial reduction in resource utilization at those hospitals and regions with a generally longer [length of stay].”

The subanalysis of very short stays is “intriguing,” they say, but potentially only hypothesis generating given the small percentage of the overall population discharged within 48 hours. “In addition, just as confounders such as comorbidities and severity of illness are likely to affect mortality in patients with a very long [length of stay], certain confounders may also play a role in patients with a very short [length of stay],” the editorialists write.

Sources:

1. Swaminathan RV, Rao SV, McCoy LA, et al. Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2015;65:1161-1171.

2. Resnic FS, Shah SP. Balloon-to-door time: emerging evidence for shortening hospital stay after primary PCI for STEMI [editorial]. J Am Coll Cardiol. 2015;65:1172-1174.

• Drs. Swaminathan and Shah report no relevant conflicts of interest.

• Dr. Resnic reports serving as a consultant for St. Jude Medical.

Related Stories:

• Early Discharge Safe for ManySTEMI Patients After Primary PCI

• Longer Hospital Stay Linkedwith Less Evidence-Based Care in NSTEMI

• In-Hospital STEMI Deadlier,More Expensive Than Out-of-Hospital STEMI