Highly selected low-risk patients can be safely sent home about 24 hours after successful percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) when supported by intense, multidisciplinary virtual follow-up, a prospective study suggests for the first time.
The risk for major adverse cardiac events (MACE) in STEMI patients following an early hospital discharge (EHD) pathway was similar at 9 months to that seen for propensity-matched historic control subjects who met the same EHD criteria but were discharged later than 48 hours.
The stay in almost half (48%) the early discharge group was 24 hours or less, according to the study, published December 13 in the Journal of the American College of Cardiology.
“We’ve shown that if we use appropriate risk criteria and instigate the appropriate, safe follow-up that it’s safe to select and discharge low-risk patients at an earlier time period, such as 24 hours,” senior author Daniel A. Jones, PhD, Barts Heart Centre, London, told theheart.org | Medscape Cardiology.
“Obviously, it’s one center in one city in the world,” he said. “Whether it’s applicable at other heart site centers, I believe it is but I think we need more data to be able to change guidelines.”
Current European Society of Cardiology guidelines say that select patients should be considered for early discharge 48 to 72 hours after STEMI, but the COVID-19 pandemic incentivized the team to try and push that window.
“The COVID pandemic essentially brought a focus on resources, on minimizing the risk to our patient population in terms of catching COVID within hospital,” he said. “It became clear that to maintain the heart site service, we probably needed to get people out a bit quicker than we did before, so we came up with this pathway.”
Between March 2020 and June 2021, 600 patients presenting with STEMI were entered into the EHD pathway if they met the following pre-existing criteria for 48- to 72-hour discharge:
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Left ventricular ejection fraction 40% or greater
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Successful primary PCI with TIMI flow grade 3
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Absence of bystander disease requiring inpatient revascularization
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No recurrent ischemic symptoms
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No heart failure
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No significant arrhythmias
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No hemodynamic instability
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No significant comorbidity
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Suitable social circumstances for early discharge.
The patients were given cardiac rehabilitation counseling over the phone within 48 hours and blood pressure machines if not available at home. At weeks 2 and 8, they spoke virtually with a dedicated cardiology advanced care practitioner who up-titrated medications and answered any questions. At week 12, they were seen by an interventional cardiologist or at a high-risk prevention clinic.
Their mean age was 59.2 years, 86% were male, the median symptom-to-balloon time was 80 minutes, and median door-to-balloon time was 50 minutes.
The early discharge patients were compared with 700 historic control subjects who met the EHD criteria and were discharged after 48 hours from October 2018 to June 2021 and 560 patients discharged on standard-care pathways between April 2020 and June 2021.
Those discharged after 48 hours were more likely to have an anterior MI, multivessel disease, and multivessel PCI.
Comparable Outcomes
The median length of stay was 24.6 hours (minimum 17 hours, maximum 40 hours) for the EHD group, 56.1 hours for historic control subjects, and 78.9 hours for the standard-care group.
The introduction of the EHD pathway significantly reduced the overall length of stay for all STEMI patients compared with the pre-pathway period of October 2018 to March 2020 (median, 3 vs 2 days; P < .0001).
Length of stay varied among patients; however, 420 patients stayed 1 less night in the hospital with the remaining patients staying about 8 to 12 fewer hours, resulting in approximate savings of £450,000, the authors note.
Over a median follow-up of 271 days, there were no cardiovascular deaths, two deaths from COVID-19, and a MACE rate of 1.2% (two deaths, three unscheduled revascularizations, and two further MI presentations) in the EHD group. That compares with a 0.7% mortality and 1.9% rate of MACE among historic control subjects, neither of which were significantly different.
There was also no difference in mortality (0.34% vs 0.69%; P = .410) or MACE (1.2% vs 1.9%; P = .342) among 560 pairs of propensity-matched EHD patients and historic control subjects.
Mortality was 4.1% in the standard-care group; cardiovascular mortality was 2.2%, and the rate of MACE was 8.6%.
When patients were surveyed, 85% were “satisfied” or “very satisfied” with the EHD pathway, whereas 73% of control and standard-care patients were satisfied with their care. Three-fourths of EHD patients also reported saving money and 62.5% saved time off work because of the virtual follow-up.
Judgment Calls
“They didn’t really tell us much about the patients who didn’t qualify into this ultra-low-risk group but, obviously, it’s highly selected,” Cindy Grines, MD, Northside Hospital Cardiovascular Institute, Lawrenceville, Georgia, said in an interview. “In the US, you don’t get those chest pain onset-to-reperfusion in 80 minutes. So that was really kind of shocking.”
It also suggests that early discharge was applied to patients who may have had minimal myocardial damage from the STEMI, she suggested. “Even in their own hospital system, a lot of patients who met the criteria on paper were kept longer than 48 hours. So a lot of it’s a judgement call.”
Additional red flags where physicians may overrule the early discharge protocol are very late perfusion, advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic coronavirus, Grines and J. Jeffrey Marshall, MD, also from Northside, observe in an accompanying editorial.
About 60% of patients were suitable for the EHD pathway, Jones said. “Typically, they are quite low risk but we still had four in 10 anterior infarct and about 25% had left ventricular function between 40% and 45%. So even though the majority are low risk, there are patients in there that you would consider to have had a decent infarct.”
“I think this is applicable to patients at most centers, and probably anywhere between a third to a fifth of all patients presenting to heart centers would be suitable for this discharge pathway,” he said.
Grines said the pathway is “definitely feasible” but there aren’t enough patients studied to know with 100% certainty whether it’s safe. A single observational study also isn’t enough to change guidelines, which in the United States do not comment on length of stay.
“In the ultra-low-risk patients — such as the ones where you got them in very early and you almost aborted the infarct or if it was a very small infarct — you can kind of treat them like an unstable angina patient, where you can do the PCI and potentially discharge them in 24 hours,” Grines said. “I think most of us might agree on that.”
“The other thing you have to weigh is the risk/benefit ratio,” she said. “If you have no beds available, you end up rationing care to some extent. So if you have a patient that’s otherwise doing well after a very small MI and have an emergency room full of people that need to be admitted and they’re sicker, then you end up making those judgement calls.”
Jones pointed out that current guidelines are based largely on observational data and that the team is planning to pilot the EHD pathway at five to 10 centers around the United Kingdom or potentially in Europe or the United States.
“This is an area where a [randomized controlled trial] RCT would be expensive, whereas a well-coordinated multicenter registry would probably provide enough information to change guidelines,” he said. “We’re not suggesting that every STEMI patient is suitable but people that are low risk that you would already be considering for early discharge I think can go a bit quicker.”
Jones has received funding from the Barts Charity and financial support for blood pressure machines from the Barts Guild. First author Krishnaraj Rathod has received funding from the National Institute for Health and Research in the form of an Academic Clinical Lectureship. All other authors, Grines, and Marshall report having no relevant financial relationships.
J Am Coll Cardiol. 2021;78:2550-2560, 2561-2562. Abstract, Editorial
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