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Piris A, Garcia-Linacero LM, Ortega-Perez R, Rivas-Garcia S, Martinez-Moya R, Sanmartin M, Zamorano JL. Safety of an Early Discharge Strategy (≤48 h) after ST-Elevation Myocardial Infarction. J Clin Med 2024; 13:3827. [PMID: 38999393 PMCID: PMC11242729 DOI: 10.3390/jcm13133827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Early discharge following ST-segment-elevation myocardial infarction (STEMI) confers notable advantages for both patients and healthcare systems. However, the adoption of a very early discharge strategy for selected patients remains limited due to safety considerations. We aimed to provide some insight into the safety of a discharge program with a hospital stay lasting <48 h after a primary percutaneous coronary intervention (PCI). Methods: Using a registry of 1105 patients undergoing primary PCI for STEMI in our hospital between January 2015 and October 2023, we enrolled all the patients who had a hospital stay ≤48 h, according to a prespecified institutional protocol. The primary objective was a combined rate of non-fatal stroke, non-fatal acute myocardial infarction, or cardiovascular death within 30 days of discharge. Emergency department visits or hospitalizations due to cardiovascular causes, along with the all-cause mortality, were measured during the same period. Results: A total of 453 (41%) patients were discharged ≤48 h after admission for a STEMI. The mean age was 62.4 (±12.5 years), 24.3% were women, and 17.9% were people with diabetes. Up to 96% of the procedures had been performed through radial artery access, and there were no major vascular complications. Regarding the primary endpoint, there was one event (0.2%; one patient suffered a non-fatal myocardial infarction). There were no cardiovascular deaths or deaths from other causes. Only five patients (1.1%) were re-hospitalized or visited the emergency department due to cardiovascular causes. Conclusions: An early discharge strategy for patients within 48 h of experiencing STEMI and undergoing primary PCI appears feasible and safe.
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Affiliation(s)
- Antonio Piris
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Luis Manuel Garcia-Linacero
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Rodrigo Ortega-Perez
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Sonia Rivas-Garcia
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
| | - Rafael Martinez-Moya
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Unidad Críticos Cardiovasculares, Hospital Universitario Ramon y Cajal, Carretera de Colmenar Viejo 9100, 28034 Madrid, Spain
| | - Marcelo Sanmartin
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Unidad Críticos Cardiovasculares, Hospital Universitario Ramon y Cajal, Carretera de Colmenar Viejo 9100, 28034 Madrid, Spain
- Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (A.P.); (L.M.G.-L.); (R.O.-P.); (S.R.-G.); (R.M.-M.); (J.L.Z.)
- Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
- Centro de Investigación en Red en Enfermedades Cardiovasculares, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (UAH), 28034 Madrid, Spain
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Yousif N, Chachar TS, Subbramaniyam S, Vadgaonkar V, Noor HA. Safety and Feasibility of 48 h Discharge After Successful Primary Percutaneous Coronary Intervention. J Saudi Heart Assoc 2021; 33:77-84. [PMID: 33936941 PMCID: PMC8084303 DOI: 10.37616/2212-5043.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 11/20/2022] Open
Abstract
Background The aim of the current study is to determine the safety of early discharge (ED) within 48 hours (h) for ST-elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (PPCI) and to define the criteria of low-risk patients that can be considered for ED. Methods This is a single-center retrospective study that took place at Mohammed bin Khalifa Cardiac Centre in the Kingdom of Bahrain. 301 patients who underwent PPCI between January 2018 and March 2019 were included. Endpoints at 30 days follow-up comprised cardiac re-admission, cardiovascular death, non-fatal myocardial infarction, stroke, and major adverse cardiovascular and cerebrovascular events. Results Of the 301 patients included in our study, 74 (24.5%) were discharged within 48 h (group 1) compared with 227 (75.5%) hospitalized for more than 48 h after PPCI (group 2) (<0.0001). In terms of baseline characteristics, group 2 had higher proportions of chronic kidney disease (P = 0.051), mean HbA1c (P = 0.016) and mean CPK (P < 0.0001) compared to their group 1 counterparts. The prevalence of anterior STEMI was twice as high among group 2 (P < 0.0001), with a significantly higher prevalence of left main stenting (P = 0.025). Additionally, larger proportion of group 2 required inotropic therapy (P = 0.031), oral anticoagulation (P = 0.005) and had a significantly lower ejection fraction (LVEF) (P < 0.0001) with more procedural complications (P = 0.005). LVEF exerts a large effect on ED, as reflected by a high deviance R2 = 20.4%, and was able to correctly classify the subjects into their pertaining discharge group with an accuracy of 80.4%, a specificity of 82.7%, and a sensitivity of 71.2%. According to the fitted LVEF values using the logistic equation, each 1% increase in LVEF is associated with a 3.5% increase in the chance of ED. The two groups recorded fairly similar clinical outcomes at 30-day. Conclusion Preserved LV systolic function is a good predictor of early and safe discharge after successful PPCI. The presented data support the practice of ED, with length of stay even shorter than current guidelines recommendation in selected low-risk patients.
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Affiliation(s)
- Nooraldaem Yousif
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | - Tarique S Chachar
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | | | - Vinayak Vadgaonkar
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
| | - Husam A Noor
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Riffa, Kingdom of Bahrain
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Marbach JA, Alhassani S, Chong AY, MacPhee E, Le May M. A Novel Protocol for Very Early Hospital Discharge After STEMI. Can J Cardiol 2020; 36:1826-1829. [PMID: 32841675 PMCID: PMC7443159 DOI: 10.1016/j.cjca.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/22/2020] [Accepted: 08/11/2020] [Indexed: 11/28/2022] Open
Abstract
Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients who present with STEMI continues to require significant health care resources. Earlier hospital discharge in low-risk patients who present with STEMI has been an area of focus in an attempt to reduce health care costs. As a result, discharge within 48-72 hours after successful primary percutaneous coronary intervention has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on health care systems to find ways to increase bed capacity, preserve resources, and reduce the risk of exposure to patients and health care workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, 4-step algorithm designed to accurately and efficiently identify low-risk STEMI patients who can be safely discharged between 20 and 36 hours after successful primary percutaneous coronary intervention. When deemed eligible for VEHD predischarge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via virtual care (48 hours, 7 days, 30 days), and in the outpatient cardiology clinic (4-6 weeks). Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, in terms of patient satisfaction and clinical outcomes, while concurrently decreasing the risk of nosocomial infections, and reducing resource utilization.
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Affiliation(s)
- Jeffrey A Marbach
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Saad Alhassani
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun-Yeong Chong
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Erika MacPhee
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michel Le May
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Jneid H. Invasive Strategy After Non-ST-Segment Elevation Acute Coronary Syndrome: Timing and Controversies. JACC Cardiovasc Interv 2018; 9:2277-2279. [PMID: 27884353 DOI: 10.1016/j.jcin.2016.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Hani Jneid
- Division of Cardiology, Baylor College of Medicine; and the Michael E. DeBakey VA Medical Center, Houston, Texas.
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Javat D, Heal C, Banks J, Buchholz S, Zhang Z. Regional to tertiary inter-hospital transfer versus in-house percutaneous coronary intervention in acute coronary syndrome. PLoS One 2018; 13:e0198272. [PMID: 29927947 PMCID: PMC6013182 DOI: 10.1371/journal.pone.0198272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 05/16/2018] [Indexed: 11/19/2022] Open
Abstract
RATIONALE To address the inaccessibility of interventional cardiac services in North Queensland a new cardiac catheterisation laboratory (CCL) was established in Mackay Base Hospital (MBH) in February 2014. OBJECTIVE To determine whether the provision of in-house angiography and/or percutaneous coronary intervention (PCI) 1) minimises treatment delays 2) further reduces the risk of mortality, recurrent myocardial infarction (MI) and recurrent ischaemia 3) improves patient satisfaction and 4) minimises cost expenditure compared with inter-hospital transfer for patients with acute coronary syndrome (ACS). METHODS We compared ACS patients who were transferred to tertiary centres from July 2012 to June 2013 with those who received in-house angiography and/or PCI from February 2015 to January 2016. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (MI) or recurrent ischaemia at six months. Pre-specified secondary outcomes were the composite of all-cause mortality, recurrent MI or recurrent ischaemia at one month, a summated patient satisfaction score and the proportional cost savings generated between 2015 and 2016. RESULTS We included consecutive samples of 203 patients from July 2012 to June 2013 and 229 patients from February 2015 to January 2016. There was a reduction in the median time to treatment of 3.2 days and a reduction in the median length of stay of four days amongst all ACS patients receiving in-house angiography and/or PCI. The primary outcome occurred in 14 (6.9%) patients in the 2012 to 2013 group, as compared with 18 (7.9%) patients in the 2015 to 2016 group (OR = 0.71, 95% CI 0.24-2.1, P = 0.54). The secondary outcome at one month occurred in four (2.0%) patients in the 2012 to 2013 group, as compared with three (1.3%) patients in the 2015 to 2016 group (OR = 1.2, 95% CI 0.11-13.1, P = 0.87). There was a statistically significant improvement in the summated patient satisfaction score amongst patients who received in-house angiography and/or PCI (U = 1918, P <0.05 two tailed). A calculation of estimated cost savings showed a reduction in proportional cost of $14 481 (51%) per ACS patient receiving in house angiography and/or PCI between 2015 and 2016. CONCLUSION This study suggests that the provision of regional in-house angiography and/or PCI for the treatment of ACS minimises delays to invasive treatment by 3.2 days, minimises the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however, it appears that that in-house treatment does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.
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Affiliation(s)
- Delara Javat
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- * E-mail:
| | - Clare Heal
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- Mackay Institute for Research and Innovation (MIRI), Mackay, QLD, Australia
| | - Jennifer Banks
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- Mackay Institute for Research and Innovation (MIRI), Mackay, QLD, Australia
| | - Stefan Buchholz
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- HeartCare Western Australia, Suite 21, St John of God Hospital, Southwest Health Campus, Bunbury, WA, Australia
| | - Zhihua Zhang
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
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Gong W, Li A, Ai H, Shi H, Wang X, Nie S. Safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials. Eur J Prev Cardiol 2018. [PMID: 29537296 DOI: 10.1177/2047487318763823] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early discharge after successful primary angioplasty is common, but the evidence supporting the practice is still lacking. We therefore performed a meta-analysis assessing the safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction (STEMI). Methods Randomised controlled trials were identified and extracted from PubMed, Embase, Cochrane Library databases and reference lists of relevant papers. Heterogeneity was analysed using the I2 test. If there was a lack of heterogeneity, fixed effects models would be used for the meta-analysis, otherwise random effects models were used. Statistical analyses were performed using Review Manager 5.3. Results Five randomised controlled trials involving 1575 STEMI patients met the criteria. Meta-analysis showed that the early discharge strategy group had a significantly shortened length of hospital stay compared to the conventional discharge strategy group (standardised mean difference -1.46, 95% confidence interval (CI) -2.04 to -0.88; P < 0.0001), and there was no difference in mortality and readmission rates between the two groups (risk ratio 0.78, 95% CI 0.50 to 1.22; P = 0.41). Conclusions The findings of this meta-analysis suggested that the early discharge strategy after successful primary angioplasty is safe among selected low-risk STEMI patients. A shorter hospital stay could benefit both the patients and the healthcare systems.
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Affiliation(s)
- Wei Gong
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Aobo Li
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Hui Ai
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Han Shi
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Xiao Wang
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Shaoping Nie
- 1 Emergency and Critical Care Center, Beijing Anzhen Hospital, China.,2 Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
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Jneid H. Merits of Invasive Strategy in Diabetic Patients With Non-ST Elevation Acute Coronary Syndrome. J Am Heart Assoc 2017; 6:JAHA.117.005773. [PMID: 28528325 PMCID: PMC5524111 DOI: 10.1161/jaha.117.005773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hani Jneid
- Division of Cardiology, Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston, TX
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Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified. Int J Cardiol 2016; 228:615-620. [PMID: 27880927 DOI: 10.1016/j.ijcard.2016.11.276] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Early discharge protocols have been proposed for ST-segment elevation myocardial infarction (STEMI) low risk patients despite the existence of few but significant cardiovascular events during mid-term follow-up. We aimed to identify a subgroup of patients among those considered low-risk in which prognosis would be particularly good. METHODS We analyzed 30-day outcomes and long-term follow-up among 1.111 STEMI patients treated with reperfusion therapy. RESULTS Multivariate analysis identified seven variables as predictors of 30-day outcomes: Femoral approach; age>65; systolic dysfunction; postprocedural TIMI flow<3; elevated creatinine level>1.5mg/dL; stenosis of left-main coronary artery; and two or higher Killip class (FASTEST). A total of 228 patients (20.5%), defined as very low-risk (VLR), had none of these variables on admission. VLR group of patients compared to non-VLR patients had lower in-hospital (0% vs. 5.9%; p<0.001) and 30-day mortality (0% vs. 6.25%: p<0.001). They also presented fewer in-hospital complications (6.6% vs. 39.7%; p<0.001) and 30-day major adverse events (0.9% vs. 4.5%; p=0.01). Significant mortality differences during a mean follow-up of 23.8±19.4months were also observed (2.2% vs. 15.2%; p<0.001). The first VLR subject died 11months after hospital discharge. No cardiovascular deaths were identified in this subgroup of patients during follow-up. CONCLUSIONS About a fifth of STEMI patients have VLR and can be easily identified. They have an excellent prognosis suggesting that 24-48h in-hospital stay could be a feasible alternative in these patients.
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Rinfret S, Potter BJ. Weekend warriors: can early invasive management of stable non-ST-elevation acute coronary syndromes save health care dollars? Can J Cardiol 2015; 31:250-2. [PMID: 25746017 DOI: 10.1016/j.cjca.2014.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Stéphane Rinfret
- Interventional Cardiology and Health Services Research, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada.
| | - Brian J Potter
- Interventional Cardiology and Healthcare Services Research, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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