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Study Overview
Objective: To assess the safety and efficacy of early hospital discharge (EHD) for selected low-risk patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).
Design: Single-center retrospective analysis of prospectively collected data.
Setting and participants: An EHD group comprised of 600 patients who were discharged at <48 hours between April 2020 and June 2021 was compared to a control group of 700 patients who met EHD criteria but were discharged at >48 hour between October 2018 and June 2021. Patients were selected into the EHD group based on the following criteria, in accordance with recommendations from the European Society of Cardiology, and all patients had close follow-up with a combination of structured telephone follow-up at 48 hours post discharge and virtual visits at 2, 6, and 8 weeks and at 3 months:
- Left ventricular ejection fraction ≥40%
- Successful primary PCI (that achieved thrombolysis in myocardial infarction flow grade 3)
- Absence of severe nonculprit disease requiring further inpatient revascularization
- Absence of ischemic symptoms post PCI
- Absence of heart failure or hemodynamic instability
- Absence of significant arrhythmia (ventricular fibrillation, ventricular tachycardia, or atrial fibrillation or atrial flutter requiring prolonged stay)
- Mobility with suitable social circumstances for discharge
Main outcome measures: The outcomes measured were length of hospitalization and a composite primary endpoint of cardiovascular mortality and major adverse cardiovascular event (MACE) rates, defined as a composite of all-cause mortality, recurrent MI, and target lesion revascularization.
Main results: The median length of stay of hospitalization in the EHD group was 24.6 hours compared to 56.1 hours in the >48-hour historical control group. On median follow-up of 271 days, the EHD group demonstrated 0% cardiovascular mortality and a MACE rate of 1.2%. This was shown to be noninferior compared to the >48-hour historical control group, which had mortality of 0.7% and a MACE rate of 1.9%.
Conclusion: Selected low-risk STEMI patients can be safely discharged early with appropriate follow-up after primary PCI.
Commentary
Patients with STEMI have a higher risk of postprocedural adverse events such as MI, arrhythmia, or acute heart failure compared to patients with stable ischemic heart disease, and thus are monitored after primary PCI. Although patients were traditionally monitored for 5 to 7 days a few decades ago,1 with improvements in PCI techniques, devices, and pharmacotherapy as well as in door-to-balloon time, the in-hospital complication rates for patients with STEMI have been decreasing, leading to earlier discharge. Currently in the United States, patients are most commonly monitored for 48 to 72 hours post PCI.2 The current guidelines support this practice, recommending early discharge within 48 to 72 hours in selected low-risk patients if adequate follow-up and rehabilitation are arranged.3
Given the COVID-19 pandemic and decreased hospital bed availability, Rathod et al took one step further on the question of whether low-risk STEMI patients with primary PCI can be discharged safely within 48 hours with adequate follow-up. They found that at a median follow-up of 271 days, EHD patients had 2 COVID-related deaths, with 0% cardiovascular mortality and a MACE rate of 1.2%, including deaths, MI, and ischemic revascularization. The median time to discharge was 25 hours. This was noninferior to the >48-hour historical control group, which had mortality of 0.7% (P = 0.349) and a MACE rate of 1.9% (P = .674). The results remained similar after propensity matching for mortality (0.34% vs 0.69%, P = .410) or MACE (1.2% vs 1.9%, P = .342).
This is the first prospective study to systematically assess the safety and feasibility of discharge of low-risk STEMI patients with primary PCI within 48 hours. This study is unique in that it involved the use of telemedicine, including a virtual platform to collect data such as heart rate, blood pressure, and blood glucose, and virtual visits to facilitate follow-up and reduce clinic travel, cost, and potential COVID-19 exposure. The investigators’ protocol included virtual follow-up by cardiology advanced practitioners at 2, 6, and 8 weeks and by an interventional cardiologist at 12 weeks. This protocol led to an increase in patient satisfaction. The study’s main limitation is that it is a single-center trial with a smaller sample size. Further studies are necessary to confirm the safety and feasibility of this approach. In addition, further refinement of the patient selection criteria for EHD should be considered.
Applications for Clinical Practice
In low-risk STEMI patients after primary PCI, discharge within 48 hours may be considered if close follow-up is arranged. However, further studies are necessary to confirm this finding.
—Thai Nguyen, MD, Albert Chan, MD, and Taishi Hirai MD
1. Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967-72. doi:10.1016/s0735-1097(98)00031-x
2. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018;92:717-731. doi:10.1002/ccd.27637
3. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119-177. doi:10.1093/eurheartj/ehx393
Study Overview
Objective: To assess the safety and efficacy of early hospital discharge (EHD) for selected low-risk patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).
Design: Single-center retrospective analysis of prospectively collected data.
Setting and participants: An EHD group comprised of 600 patients who were discharged at <48 hours between April 2020 and June 2021 was compared to a control group of 700 patients who met EHD criteria but were discharged at >48 hour between October 2018 and June 2021. Patients were selected into the EHD group based on the following criteria, in accordance with recommendations from the European Society of Cardiology, and all patients had close follow-up with a combination of structured telephone follow-up at 48 hours post discharge and virtual visits at 2, 6, and 8 weeks and at 3 months:
- Left ventricular ejection fraction ≥40%
- Successful primary PCI (that achieved thrombolysis in myocardial infarction flow grade 3)
- Absence of severe nonculprit disease requiring further inpatient revascularization
- Absence of ischemic symptoms post PCI
- Absence of heart failure or hemodynamic instability
- Absence of significant arrhythmia (ventricular fibrillation, ventricular tachycardia, or atrial fibrillation or atrial flutter requiring prolonged stay)
- Mobility with suitable social circumstances for discharge
Main outcome measures: The outcomes measured were length of hospitalization and a composite primary endpoint of cardiovascular mortality and major adverse cardiovascular event (MACE) rates, defined as a composite of all-cause mortality, recurrent MI, and target lesion revascularization.
Main results: The median length of stay of hospitalization in the EHD group was 24.6 hours compared to 56.1 hours in the >48-hour historical control group. On median follow-up of 271 days, the EHD group demonstrated 0% cardiovascular mortality and a MACE rate of 1.2%. This was shown to be noninferior compared to the >48-hour historical control group, which had mortality of 0.7% and a MACE rate of 1.9%.
Conclusion: Selected low-risk STEMI patients can be safely discharged early with appropriate follow-up after primary PCI.
Commentary
Patients with STEMI have a higher risk of postprocedural adverse events such as MI, arrhythmia, or acute heart failure compared to patients with stable ischemic heart disease, and thus are monitored after primary PCI. Although patients were traditionally monitored for 5 to 7 days a few decades ago,1 with improvements in PCI techniques, devices, and pharmacotherapy as well as in door-to-balloon time, the in-hospital complication rates for patients with STEMI have been decreasing, leading to earlier discharge. Currently in the United States, patients are most commonly monitored for 48 to 72 hours post PCI.2 The current guidelines support this practice, recommending early discharge within 48 to 72 hours in selected low-risk patients if adequate follow-up and rehabilitation are arranged.3
Given the COVID-19 pandemic and decreased hospital bed availability, Rathod et al took one step further on the question of whether low-risk STEMI patients with primary PCI can be discharged safely within 48 hours with adequate follow-up. They found that at a median follow-up of 271 days, EHD patients had 2 COVID-related deaths, with 0% cardiovascular mortality and a MACE rate of 1.2%, including deaths, MI, and ischemic revascularization. The median time to discharge was 25 hours. This was noninferior to the >48-hour historical control group, which had mortality of 0.7% (P = 0.349) and a MACE rate of 1.9% (P = .674). The results remained similar after propensity matching for mortality (0.34% vs 0.69%, P = .410) or MACE (1.2% vs 1.9%, P = .342).
This is the first prospective study to systematically assess the safety and feasibility of discharge of low-risk STEMI patients with primary PCI within 48 hours. This study is unique in that it involved the use of telemedicine, including a virtual platform to collect data such as heart rate, blood pressure, and blood glucose, and virtual visits to facilitate follow-up and reduce clinic travel, cost, and potential COVID-19 exposure. The investigators’ protocol included virtual follow-up by cardiology advanced practitioners at 2, 6, and 8 weeks and by an interventional cardiologist at 12 weeks. This protocol led to an increase in patient satisfaction. The study’s main limitation is that it is a single-center trial with a smaller sample size. Further studies are necessary to confirm the safety and feasibility of this approach. In addition, further refinement of the patient selection criteria for EHD should be considered.
Applications for Clinical Practice
In low-risk STEMI patients after primary PCI, discharge within 48 hours may be considered if close follow-up is arranged. However, further studies are necessary to confirm this finding.
—Thai Nguyen, MD, Albert Chan, MD, and Taishi Hirai MD
Study Overview
Objective: To assess the safety and efficacy of early hospital discharge (EHD) for selected low-risk patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).
Design: Single-center retrospective analysis of prospectively collected data.
Setting and participants: An EHD group comprised of 600 patients who were discharged at <48 hours between April 2020 and June 2021 was compared to a control group of 700 patients who met EHD criteria but were discharged at >48 hour between October 2018 and June 2021. Patients were selected into the EHD group based on the following criteria, in accordance with recommendations from the European Society of Cardiology, and all patients had close follow-up with a combination of structured telephone follow-up at 48 hours post discharge and virtual visits at 2, 6, and 8 weeks and at 3 months:
- Left ventricular ejection fraction ≥40%
- Successful primary PCI (that achieved thrombolysis in myocardial infarction flow grade 3)
- Absence of severe nonculprit disease requiring further inpatient revascularization
- Absence of ischemic symptoms post PCI
- Absence of heart failure or hemodynamic instability
- Absence of significant arrhythmia (ventricular fibrillation, ventricular tachycardia, or atrial fibrillation or atrial flutter requiring prolonged stay)
- Mobility with suitable social circumstances for discharge
Main outcome measures: The outcomes measured were length of hospitalization and a composite primary endpoint of cardiovascular mortality and major adverse cardiovascular event (MACE) rates, defined as a composite of all-cause mortality, recurrent MI, and target lesion revascularization.
Main results: The median length of stay of hospitalization in the EHD group was 24.6 hours compared to 56.1 hours in the >48-hour historical control group. On median follow-up of 271 days, the EHD group demonstrated 0% cardiovascular mortality and a MACE rate of 1.2%. This was shown to be noninferior compared to the >48-hour historical control group, which had mortality of 0.7% and a MACE rate of 1.9%.
Conclusion: Selected low-risk STEMI patients can be safely discharged early with appropriate follow-up after primary PCI.
Commentary
Patients with STEMI have a higher risk of postprocedural adverse events such as MI, arrhythmia, or acute heart failure compared to patients with stable ischemic heart disease, and thus are monitored after primary PCI. Although patients were traditionally monitored for 5 to 7 days a few decades ago,1 with improvements in PCI techniques, devices, and pharmacotherapy as well as in door-to-balloon time, the in-hospital complication rates for patients with STEMI have been decreasing, leading to earlier discharge. Currently in the United States, patients are most commonly monitored for 48 to 72 hours post PCI.2 The current guidelines support this practice, recommending early discharge within 48 to 72 hours in selected low-risk patients if adequate follow-up and rehabilitation are arranged.3
Given the COVID-19 pandemic and decreased hospital bed availability, Rathod et al took one step further on the question of whether low-risk STEMI patients with primary PCI can be discharged safely within 48 hours with adequate follow-up. They found that at a median follow-up of 271 days, EHD patients had 2 COVID-related deaths, with 0% cardiovascular mortality and a MACE rate of 1.2%, including deaths, MI, and ischemic revascularization. The median time to discharge was 25 hours. This was noninferior to the >48-hour historical control group, which had mortality of 0.7% (P = 0.349) and a MACE rate of 1.9% (P = .674). The results remained similar after propensity matching for mortality (0.34% vs 0.69%, P = .410) or MACE (1.2% vs 1.9%, P = .342).
This is the first prospective study to systematically assess the safety and feasibility of discharge of low-risk STEMI patients with primary PCI within 48 hours. This study is unique in that it involved the use of telemedicine, including a virtual platform to collect data such as heart rate, blood pressure, and blood glucose, and virtual visits to facilitate follow-up and reduce clinic travel, cost, and potential COVID-19 exposure. The investigators’ protocol included virtual follow-up by cardiology advanced practitioners at 2, 6, and 8 weeks and by an interventional cardiologist at 12 weeks. This protocol led to an increase in patient satisfaction. The study’s main limitation is that it is a single-center trial with a smaller sample size. Further studies are necessary to confirm the safety and feasibility of this approach. In addition, further refinement of the patient selection criteria for EHD should be considered.
Applications for Clinical Practice
In low-risk STEMI patients after primary PCI, discharge within 48 hours may be considered if close follow-up is arranged. However, further studies are necessary to confirm this finding.
—Thai Nguyen, MD, Albert Chan, MD, and Taishi Hirai MD
1. Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967-72. doi:10.1016/s0735-1097(98)00031-x
2. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018;92:717-731. doi:10.1002/ccd.27637
3. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119-177. doi:10.1093/eurheartj/ehx393
1. Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967-72. doi:10.1016/s0735-1097(98)00031-x
2. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018;92:717-731. doi:10.1002/ccd.27637
3. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119-177. doi:10.1093/eurheartj/ehx393