Safety of Same-Day Discharge After Percutaneous Coronary Intervention in Selected Patients With Non-ST Elevation Acute Coronary Syndrome
Abstract
Objectives. We aimed to investigate the safety of same-day discharge (SDD) after percutaneous coronary intervention (PCI) for non-ST segment elevation acute coronary syndrome (NSTEACS), and to investigate the reduction in duration of hospitalization achievable by SDD. Background. Previous studies have established the safety of SDD after elective PCI, while the safety of SDD after non-elective PCI for acute coronary syndrome has only been sparsely studied. Methods. A single-center, observational, retrospective study of 923 consecutive procedures in patients with NSTEACS who had PCI was performed. The procedures were divided into 2 groups based on postprocedural management: SDD (n = 195) and non-SDD (n = 728). Results. No differences were seen in the total number of adverse events at 1 month (1.5% SDD vs 1.4% non-SDD; P=.74), 3 months (2.5% SDD vs 2.3% non-SDD; P=.80), and 6 months (3.5% SDD vs 3.3% non-SDD; P=.84) after discharge, and there were no deaths in the SDD group. No difference was found in unplanned rehospitalizations within 6 months (20.5% SDD vs 25.3% non-SDD; P=.17), while unplanned revascularizations were more frequent in non-SDD patients (5.6% SDD vs 13.4% non-SDD; P<.01). Median duration of hospitalization was 1.3 days shorter for SDD patients than for non-elderly, uncomplicated non-SDD patients. Conclusions. SDD after PCI in a selected group of NSTEACS patients was associated with low rates of adverse events, unplanned rehospitalizations, and revascularizations. SDD was associated with a shorter hospitalization duration.
J INVASIVE CARDIOL 2021 January 21 (Epub Ahead of Issue).
Key words: acute coronary syndrome, complications, coronary heart disease, percutaneous coronary intervention
The diagnosis and treatment of acute coronary syndrome (ACS) is responsible for a significant part of total healthcare costs. It leads to approximately 5 million yearly hospitalizations in Europe and the Unites States alone,1,2 and many of these patients undergo invasive diagnostics and intervention. In patients with non-ST segment elevation ACS (NSTEACS) and high-risk features, it is recommended to perform invasive coronary angiography during admission to stratify risk and determine an invasive treatment strategy.3 Percutaneous coronary intervention (PCI) can, in many cases, be performed in the same setting.
A minimum in-hospital stay of 1 day after any type of PCI has previously been recommended. However, as device technology and techniques (and thus safety) have improved, it has become routine to discharge most patients with stable coronary disease after uncomplicated elective PCI on the same day as the procedure (SDD). Several studies have shown this to be safe, provided there is a minimum of 4 hours of observation after the procedure.4-10 A few studies have suggested that SDD could also be reasonable in selected patients after PCI for NSTEACS,11,12 but guidelines still recommend at least 24 hours of observation for ACS patients after PCI.3 For patients transferred from local hospitals to an invasive center, this mandatory observation period often entails another transfer back to the local hospital.
At our invasive center, a policy of SDD in selected cases of NSTEACS patients with successful PCI has been in effect for the last several years. After PCI for NSTEACS, if the PCI operator finds it safe and reasonable, patients are offered SDD and referred to outpatient follow-up at their local hospital, including mandatory cardiac rehabilitation when applicable.
The primary purpose of this study was to evaluate this policy of selective SDD after PCI for NSTEACS. We aimed to do the following: (1) describe the frequency of SDD in the NSTEACS population after PCI and determine the characteristics of the patients and their PCI procedures that were selected for SDD; (2) describe the timing of procedure-related adverse events; (3) determine the safety of SDD in terms of postdischarge adverse events and unplanned readmissions and revascularizations; and (4) investigate the potential reduction in patient transfers and hospital days achievable by SDD.
Methods
Design and study population. The study is based on data from an internal database used for quality control at the Department of Cardiology at Gentofte University Hospital, Denmark. For this database, data on invasive procedures and outcome were retrospectively obtained from the electronic medical records and individually reviewed before entry. We obtained data on all cases of non-elective PCI performed on NSTEACS patients at Gentofte University Hospital from October 1, 2016 to July 31, 2018. Data were obtained on the following: patient demographics; comorbidities; prior cardiovascular events; timing of admission, transfers, procedure, and discharge; procedural details and procedure-related complications; adverse events during admission and after final discharge; and information regarding rehospitalization and revascularization. The electronic medical records contain records regarding all hospitalizations in the eastern part of Denmark, and status regarding death and date of death was available through the electronic medical records for all patients for the full period of observation.
For all complications, adverse events, rehospitalizations, and revascularizations, the date and time of its discovery (defined as first entry in the medical records) were noted and related to the start of the procedure. Rehospitalization was defined as unplanned readmission to a hospital caused by any cardiac or vascular event, including cerebrovascular, within 6 months after discharge. Revascularization was defined as unplanned revascularization of 1 or more vessels either by PCI or coronary artery bypass grafting (CABG) within 6 months.
Statistical analyses. Frequential and descriptive analyses were applied to describe the baseline characteristics and frequency of complications and adverse events in each group. Continuous variables are reported as mean ± standard deviation, except duration of hospitalization, which is reported as median (25th percentile–75th percentile) due to its non-normal distribution. Student’s t-test was applied to comparison of continuous variables between groups. Comparisons of categorical variables were performed with Pearson’s Chi-squared tests or with Fisher’s Exact test when any group count was <10 (which was the case for all comparisons regarding complications and adverse events). A 2-tailed P-value <.05 was used to signify statistical significance. No adjustments were made for multiple comparisons. All statistical analyses were performed using SPSS Statistics, version 25 (IBM Corporation).
Results
Baseline characteristics. In the studied time span of 22 months, a total of 2147 PCI procedures were performed at Gentofte University Hospital. Of these, 1007 procedures (47%) were non-elective. We excluded procedures for which the indication for non-elective PCI was not NSTEACS (84 procedures), primarily patients with ST-elevation myocardial infarction irrespective of symptom duration, and patients with resuscitated cardiac arrest. The remaining 923 procedures were then divided into 2 groups based on the type of discharge: the SDD group, where patients were discharged the same day as the procedure (n = 195; 21.1%); and the non-SDD group, where the patient either stayed overnight, was observed for a longer period, or was transferred to another hospital (n = 728; 78.9%).
The 923 procedures were performed in 876 individual patients. Table 1 demonstrates the baseline characteristics of all 876 patients divided into SDD and non-SDD groups based on the first procedure if a patient had >1 procedure performed. The prevalence of men was higher, the mean age was lower, and the mean estimated glomerular filtration rate (eGFR) was higher in the SDD group than in the non-SDD group. The prevalence of diabetes and hypertension was similar in the 2 groups, as was the frequency of prior myocardial infarction and revascularizations.
Table 2 shows the procedural information and data on procedure-related complications and adverse events during admission for all 923 procedures, divided according to SDD and non-SDD postprocedure management. Fewer procedures were performed in the setting of elevated coronary biomarkers (representing a diagnosis of non-ST segment elevation myocardial infarction) in the SDD group. Radial access was used more frequently in SDD patients, while sheath size and number of vessels treated did not differ between groups. SDD patients had somewhat less-complex lesions than non-SDD patients, with a higher frequency of type A and B1 lesions. The use of closure devices (68.7% SDD vs 76.0% non-SDD) and radial compression bands (TR Bands [Terumo], 29.7% SDD vs 21.1% non-SDD) paralleled the use of femoral and radial access in the SDD and non-SDD groups. Use of manual compression alone for hemostasis was not performed in any SDD procedures and occurred only rarely in non-SDD procedures (0.0% SDD vs 0.8% non-SDD).
The total number of complications during procedures was low for both groups, with coronary artery complications the most common in both groups. Patients with procedure-related complications were only rarely discharged on the same day, so the SDD group included fewer patients with procedure-related complications than the non-SDD group. Similarly, no patients who had adverse events after the procedure during admission were discharged on the same day.
Adverse events after discharge. Table 3 shows the number of adverse events within 1 month, 3 months, and 6 months post discharge and the frequency of rehospitalization and revascularizations in the 2 groups.
The only significant differences between the groups was seen in the prevalence of acute myocardial infarction and death within 6 months. SDD patients experienced acute myocardial infarction more often than non-SDD patients, who experienced no acute myocardial infarctions within 6 months post discharge. Conversely, non-SDD patients had a significantly higher rate of death than SDD patients.
Readmissions and revascularizations. Table 3 shows the frequency of unplanned rehospitalizations and unplanned revascularizations for both groups. Out of the total 923 SDD and non-SDD patients, 224 patients (24.3%) were rehospitalized within 6 months after the PCI, while 108 (11.7%) underwent revascularization by either PCI (10.5%) or CABG (1.2%). The rehospitalization rates of the 2 groups were similar, while the revascularization rates were higher in the non-SDD group (5.1% SDD vs 12.0% non-SDD).
Timing of early adverse events. Figure 1 illustrates the timing of early postprocedure adverse events (Death, acute myocardial infarction, stroke, and vascular complications) for both groups within the first 72 hours, obtained by calculating the time interval between procedure onset and occurrence of postprocedure adverse events. Early adverse events include events during admission and post discharge. Revascularizations and rehospitalizations are not included.
A total of 21 early adverse events occurred (2.3% of all procedures); 11 of these (52%) occurred within the first 24 hours, while 10 (48%) occurred between 24 to 72 hours post PCI. Most early adverse events occurring within 24 hours (10 out of 11; 91%) arose within the first 9 hours after procedure start.
Duration of hospital admission and use of interhospital transfers. Figure 2 illustrates the duration of hospitalization and number of patient transfers for SDD and non-SDD patients, including the timelines of the following 3 groups: SDD patients; non-SDD patients; and uncomplicated, non-elderly (age <80 years), non-SDD patients. SDD patients were all discharged directly from the invasive center, while in more than half of all cases, non-SDD patients were transferred to another hospital after PCI.
Median hospitalization duration was 1.33 days shorter for SDD patients than for uncomplicated, non-elderly, non-SDD patients. The time from admission to procedure was nearly identical (2.96 days vs 2.83 days) in SDD patients vs uncomplicated, non-elderly, non-SDD patients, respectively. The difference in median procedure-to-discharge time between SDD patients vs uncomplicated, non-elderly, non-SDD patients was 0.96 days for non-transferred patients and 1.17 days for patients who were transferred to another hospital.
The mean duration of hospitalization (admission to discharge) was 3.66 ± 2.26 days for SDD patients, 6.49 ± 6.13 days for non-SDD patients, and 5.97 ± 5.41 days for uncomplicated, non-elderly, non-SDD patients. Thus, there was a difference of 2.31 days in mean hospitalization duration between SDD and uncomplicated, non-elderly, non-SDD patients.
Discussion
This is a retrospective, observational study of 923 consecutive procedures in patients with NSTEACS who underwent non-elective PCI during admission at a single tertiary center, of which 195 (21%) were managed with discharge on the same day as PCI. We investigated the association between SDD and PCI-related complications and adverse events, duration of hospitalization, readmissions, and revascularizations. We show that in this group of patients, SDD post PCI was associated with a low incidence of postdischarge adverse events, a low mortality rate, and few readmissions. The reduction in length of hospital stay and in the need for patient transfers achieved with SDD in this population was substantial.
Discharge on the same day occurred in only 21% of all cases. This reflects the fact that SDD was not the routine option, but a possibility that was considered based on individualized patient evaluations. The SDD group was found to be broadly similar to the overall population, albeit somewhat younger and with better average renal function, and had simpler coronary lesions. This indicates that operators selected healthier patients for SDD. The higher use of radial access in SDD patients may reflect greater confidence in sufficient hemostasis after this procedure, compared with femoral access.
Naturally, the frequency of complications during procedure and admission was higher in non-SDD patients than in SDD patients, since the occurrence of any complication will normally lead to at least overnight observation. Accordingly, only a few patients with procedural complications and no patients with postprocedural adverse events during admission were discharged the same day.
Adverse events after discharge were similar between the 2 groups, but there was a higher prevalence of unplanned revascularizations in non-SDD patients. This can probably be linked to the baseline characteristics of non-SDD patients, who were older and had more complex lesion types.
Early adverse events (those occurring up to 72 hours post procedure) affected 2.2% of the NSTEACS patients. No early adverse events were serious and there were no deaths. During the first 24 hours after the procedure, adverse events were found to mainly occur within the first 9 hours — a finding that supports the safety of SDD. It should be noted that timing of early complications was calculated from the start of the procedure, and that the time stamp of the first electronic health record note describing the complication was used to define when the complication occurred. The recorded timing is therefore an overestimation of the duration from the end of the procedure completion to first observation of the complication, which is the relevant period for determining the appropriate duration of postprocedural observation.
The total reduction in length of hospitalization and use of patient transfer that was obtained with selective SDD as applied in our population was large; however, there is a potential for even greater benefits if the strategy were extended to more patients. The relevant group of patients is non-elderly without procedural or immediate postprocedural complications. When we compared the SDD group to a group of patients who had these characteristics but were not handled with SDD (531 procedures; 58%), we found a difference in median hospitalization stay of 1.33 days (32 hours). It is reasonable to assume many of these patients could be safely handled with SDD.
SDD after PCI has been previously examined in a number of single-center studies,6,10,13-22 consisting of both randomized trials and observational studies, and in meta analyses and systematic reviews.4,5,7 These studies focus primarily on elective PCI in patients with stable coronary artery disease, although Abdelaal et al4 included a few low-risk ACS patients from the observational study by Khater et al.23 In accord with our results, the overall findings are similar rates of adverse events after discharge in SDD and non-SDD patients.
A few studies that include ACS patients have been performed. In a single-center study of 1059 patients,11 with one-third of patients having ACS, very low rates of adverse events (1 event) within the first 6 hours, and no events between 6 to 24 hours were reported. The EASY trial24 randomized 1005 patients who had undergone successful transradial PCI to SDD vs overnight stay. Of the 1005 patients, two-thirds presented with unstable angina and 18% had elevated troponins. At 30 days and 1 year, they found no difference in adverse events, confirming the safety of SDD in these patients after uncomplicated transradial PCI.
The findings of our study support the implementation of SDD programs in selected patients after PCI for NSTEACS. SDD can reduce resource use and hospital costs, increase bed availability, and improve patient satisfaction, without compromising safety or increasing adverse patient outcomes.25 The most important potential disadvantage of SDD is the risk of complications occurring after early discharge that would have otherwise been prevented, mitigated, or treated in an observed hospital environment. If the low rates of adverse events found in this study are to be replicated in daily routine elsewhere, individualized clinical judgment is crucial and any concern or suspicion about a complication should lead to extended observation.
Although most patients prefer SDD, some patients do not.25 Often, these patients are less well informed about their disease and the procedure, risks, and possible complications, which leads to patients feeling unsafe without the postprocedural presence of medical experts. The core components of a protocol for selecting and handling SDD-patients include: (1) accurate assessment of suitability for SDD; (2) excellent procedural outcomes; (3) rapid and reliable stabilization of the vascular access site, allowing for early and safe ambulation; (4) reliable provision of dual-antiplatelet therapy; and (5) postprocedural patient education, routine follow-up, and tracking of outcomes, as described by Shroff et al.25
Future research might focus on the effective implementation of SDD in PCI after NSTEACS in a prospective design involving both referring centers and the interventional center. Ultimately, a randomized trial on SDD vs overnight stay after PCI in a broad population of patients with NSTEACS could determine its benefits and safety.
Limitations. Several limitations to this study should be noted, mostly caused by the retrospective, observational, single-center design. First, the lack of randomization makes it inappropriate to draw any causal link between the management strategy and outcomes. SDD patients were a carefully selected group, and it seems likely that the few observed differences between the groups were related to differences in baseline characteristics, and not to management strategy. Second, it can furthermore be assumed that several important factors influencing the decision to offer SDD to individual patients were not recorded in our database, eg, other comorbidities or social factors, thus making our characterization of the patient groups incomplete. Third, the retrospective design may also have led to missing data and inaccurate registrations of available data. Important data that were not available were information about patients’ social support, how far the patients lived from the PCI facility, and patient preference regarding postprocedural management. Fourth, the data were collected from 1 center and the number of patients in the SDD group was relatively low, which may reduce the generalizability of the findings. Fifth, the main analysis was performed on a per-procedure basis, with some patients occurring more than once; however, this did not impact the results. The findings did not differ when we performed the same analyses as seen in Tables 1, 2, and 3 on the first procedure only (n = 876) for all patients.
Conclusion
SDD after non-elective PCI was performed in 195 out of 923 procedures (21%) in patients with NSTEACS in this retrospective, observational study. The patients selected for SDD were younger, had better renal function, and had less-severe coronary lesions than patients not managed with SDD, and radial access was used more frequently in SDD patients. In this selected population, SDD was safe and associated with a low rate of postdischarge adverse events, unplanned rehospitalizations, and revascularizations, with no difference in outcomes compared with non-SDD patients, and no patients treated with SDD died within 6 months. SDD was associated with shorter duration of hospital stay and fewer interhospital transfers.
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From the Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no financial relationships or conflicts of interest regarding the content herein.
Final version accepted June 22, 2020.
Address for correspondence: Niels Thue Olsen, MD, PhD, Dept. of Cardiology, Gentofte University Hospital, Hospitalsvej 1, DK-2900 Hellerup, Denmark. Email: niels.thue.olsen@regionh.dk
