Early Discharge Safe for Many STEMI Patients After Primary PCI

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Discharge within 2 days is safe and feasible in almost two-thirds of patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) receiving percutaneous coronary intervention (PCI). Results from a large, single-center study were published online February 14, 2013, ahead of print in the European Heart Journal: Acute Cardiovascular Care.

Researchers led by Azfar G. Zaman, MD, of Newcastle University, Freeman Hospital (Newcastle upon Tyne, United Kingdom), retrospectively assessed 2,448 STEMI patients who received primary PCI between March 2008 and June 2011 at their institution and survived until discharge. Patients were analyzed according to whether they were discharged early (within 2 days of PCI, 63.0%; n = 1,542) or late (after 2 days, 37%; n = 906).

Better Survival in Early Discharge Group

The 30-day post-discharge mortality rate was 1.06% for the entire cohort: 0.71% in the early group and 1.66% in the late group.

Over about 19.5 months follow-up, mortality was 4.3% in the early group and 12.3% in the late group. Kaplan-Meier survival curves showed an advantage with early discharge out to 36 months (P < 0.0001).

Patients discharged early showed a reduced mortality risk on regression analysis as well as after propensity matching and adjustment (table 1).

Table 1. Risk of Mortality with Early Discharge After Primary PCI

Patients in the early discharge group were younger (61 years vs. 65 years; P < 0.0001) with less comorbidities and were more likely to have undergone successful primary PCI (TIMI flow 3 post procedure; 94.1% vs. 89.6%; P < 0.0001).

Mean door-to-balloon times were longer in the late discharge group (26 minutes vs. 24 minutes; P = 0.0003), but onset-to-balloon times were similar (166 minutes vs. 168 minutes; P = 0.81).

All patients had cardiac rhythm monitoring for 24 hours post procedure and hemodynamic parameters were recorded every 4 hours. Patients with TIMI 3 flow in the infarct-related artery and without hemodynamic or arrhythmic complications were considered for early discharge at the discretion of the attending physician. Mean length of hospital stay was 1.4 days in the early discharge group and 5.1 days in the late discharge group.

On multivariable regression analysis, radial access for primary PCI was the only factor that increased the likelihood of early discharge (OR 1.30; 95% CI 1.06-1.59; P < 0.013). Rates of radial access were 72.6% in the early discharge group vs. 64.1% in the late discharge group (P < 0.0001).

Practice Changing Potential Touted

“The main finding from this study,” the authors conclude, “in an unselected cohort of consecutive ‘real-world’ STEMI patients is that low-risk patients can be safely discharged within 2 days following [primary PCI].”

They note that the early discharge strategy “may be feasible in almost two-thirds” of primary-PCI treated patients with STEMI, and that the findings “have the potential to change existing practice in the studied patient population.”

They add that while the decision for early discharge was based on hemodynamic and rhythm monitoring, “it is likely that several factors other than the recognized cardiovascular risk factors that were recorded influenced length of hospital stay, such as non-cardiac comorbidities and social and home circumstances.”

Dr. Zaman and colleagues also note the potential cost advantages, observing that “the finding that early discharge is safe has the potential to reduce the health cost of providing a primary PCI service.”

According to Carl L. Tommaso, MD, of Skokie Hospital (Skokie, IL), most US clinicians try to discharge STEMI patients who are stable after primary PCI within 48 to 72 hours. “For the patient with single-vessel disease who has an MI, gets stented, has no complications, no further chest pain or dysrhythmia [and] no heart failure, I think 48 to 72 hours is probably the norm, at least in the US community,” he told TCTMD in a telephone interview.

Data on a Rarely Studied Topic

Dr. Tommaso added that the true contribution of the study is that it provides valuable information for an area with few data. “The results confirm most people’s clinical feeling about discharge after MI,” he said. Having data on 1,500 patients who were discharged home within 48 hours is important, he said, “because there’s no data regarding when you should discharge after stenting for acute MI.”

But Dr. Tommaso cautioned that the value of radial access in this setting should not be overstated. “If you’re talking about same-day discharge for elective PCI, then radial access becomes important, but you’re going to keep [STEMI] patients overnight anyway, so I don’t think radial is that much of an issue,” Dr. Tommaso said. “[Skokie Hospital is] almost strictly a femoral institution, and we’re sending [STEMI] patients home in 48 to 72 hours after primary PCI.”

In terms of the profile of an early-discharge patient, “we’re talking about the relatively young patient, probably up to or near age 75, who comes in with a relatively uncomplicated MI, gets to the cath lab quickly, and gets a good result,” he said. “You monitor for arrhythmias for 24 hours, get them up and around the next day, educate them regarding statins, the importance of aspirin, etc, and you get them out in 48 to 72 hours.”

Such patients show lower mortality rates, Dr. Tommaso said, not because they are discharged early, but “because they’re in better shape.”

Source:

Noman A, Zaman AG, Schechter C, et al. Early discharge after primary percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2013;Epub ahead of print.

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