Same-Day Discharge After PCI
ABSTRACT & COMMENTARY
By Andrew J. Boyle, MBBS, PhD
Assistant Professor of Medicine, Interventional Cardiology, University of California, San Francisco
Dr. Boyle reports no financial relationships in this field of study.
This article originally appeared in the September 2013 issue of Clinical Cardiology Alert. It was edited by Michael H. Crawford, MD, Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco, and peer reviewed by Ethan Weiss, MD, Assistant Professor of Medicine, Division of Cardiology and CVRI, University of California, San Francisco. Dr. Crawford reports no financial relationships relevant to this field of study, and Dr. Weiss is a scientific advisory board member for Bionovo.
Complication rates following percutaneous coronary intervention (PCI) have fallen in recent years. Overnight observation in the hospital after PCI remains the standard of care in the United States. However, because of the low complication rates, there has been a move toward same-day discharge in some countries. In the current environment of cost containment, this approach may represent a way for the health care system to realize substantial cost savings. The Society for Cardiac Angiography and Intervention (SCAI) and the American College of Cardiology (ACC) released a consensus statement in 2009 identifying patients suitable for same-day discharge following PCI, but this has not become part of the ACC/AHA guidelines for PCI. Thus, the use of same-day discharge after PCI remains low in the United States. In this study, Brayton and colleagues update our evidence base by performing a study-level meta-analysis of 37 clinical studies of same-day discharge after PCI.
Their meta-analysis includes 30 studies (enrolling 10,065 patients) that were observational and seven studies (enrolling 2738 patients) that were randomized controlled trials (RCTs). Two-thirds of patients underwent PCI for stable coronary artery disease (CAD). There were some differences between the RCTs and observational study cohorts, in particular the use of transradial PCI was 61% in the randomized trials and 30% in the observational studies. The authors focused mainly on the RCTs to limit selection bias. Their primary efficacy endpoint was the rate of death/myocardial infarction (MI)/target lesion revascularization (TLR) and their primary safety endpoint was the rate of major bleeding/vascular complications. In the RCTs, there was no difference in the incidence of the primary efficacy endpoint of death/MI/TLR (odds ratio [OR] 0.90; P = 0.78), or in the rates of major bleeding/vascular complications (OR 1.69; P = 0.15) between patients randomized to same-day discharge vs overnight observation. In the observational studies, the incidence of death/MI/TLR was 1.0% and bleeding/vascular complications was 0.7% in those discharged on the same day as PCI, confirming low actual event rates in real-world practice. Importantly, the results were largely consistent in studies conducted within the United States vs elsewhere, in studies that included acute coronary syndrome patients and those that did not, and whether radial or femoral arterial access was used.
In patients randomized to same-day discharge, 13% were not actually discharged the same day. When the authors drilled down on the reasons, they found that around half of these were from a trial that randomized patients before PCI instead of after. Deferral of same-day discharge in the other trials was due to access site complications (33%), physician preference (30%), patient preference (17%), recurrent chest pain (11%), noncardiac reasons (4.9%), orthostasis (2.4%), and arrhythmias (1.2%). The authors conclude that in selected patients undergoing largely elective PCI, same-day discharge was associated with a low rate of major complications and appeared to be as safe as routine overnight observation.
Commentary
Technical advances in PCI technique have resulted in lower rates of cardiac complications following PCI. In addition, the use of bleeding avoidance strategies, such as radial access, use of smaller guide catheters, and the more widespread use of bivalirudin, have resulted in lower bleeding rates. The rationale for overnight observation of patients after PCI appears to be less compelling in the modern era. However, clinical trial data supporting same-day discharge have been lacking. In particular, there has been concern about the rates of uncommon but serious complications, and most trials to date are underpowered to detect differences in uncommon outcomes. The strength of meta-analyses such as this one is that they have large numbers of patients, allowing detection of less common outcomes. However, there are some important limitations to this paper. First, this is a study level meta-analysis and individual patient-level data were not available to the authors, which may confound the data. Second, the studies that they reported had varied outcomes over different periods of observation, making standardization difficult. Third, the event rates were not always specified as occurring in the 24 hours after PCI and may have occurred later, but the timing was not reported in some of the original studies. Fourth, each study had its own inclusion and exclusion criteria, making extrapolation to different patient groups difficult. Despite these limitations, this paper shows us that in carefully selected patients, largely elective PCI for stable CAD, same-day discharge after PCI is a reasonable alternative. The observational data presented in concert with the RCT data confirm that the actual event rates are low in real-world settings. The authors go on to offer a protocol for choosing patients for same-day discharge after PCI. Our practice has been that patients having elective PCI for stable, single-vessel CAD are considered for same-day discharge if the procedure is uncomplicated, the patients are at low risk for complications, and there are adequate home supports. However, the patient and lesion characteristics that are optimal for same-day discharge still need to be defined by large prospective, randomized trials.
