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      Same-day discharge after elective percutaneous transluminal coronary angioplasty: An instruction manual and call for increased uptake in a burdened National Health Service Translated title: Alta no próprio dia após intervenção coronária percutânea eletiva: manual de instruções e repto a maior utilização num Serviço Nacional de Saúde sobrecarregado

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          Abstract

          Percutaneous transluminal coronary angioplasty (PTCA) celebrates its 43rd birthday in 2020. Since Andreas Gruntzig first performed this technique in 1977, and Ricardo Seabra-Gomes introduced it to Portugal in 1984, countless technological and procedural developments have significantly increased the success and safety of PTCA. What first started as a high-risk procedure, with cardiac surgery on standby, is currently an outpatient procedure in many places. Early mobilization and discharge after angioplasty enable same-day discharge (SDD), instead of an overnight stay (ONS). In spite of this, the use of SDD varies dramatically according to country and even among centers located close to each other. In Portugal, SDD after PTCA is not the standard of care. In this issue of the Portuguese Journal of Cardiology, Centro Hospitalar de Gaia/Espinho, V. N. Gaia (CH Gaia), paves the way for increasing SDD in Portugal by publishing the first Portuguese report that describes ONS and SDD populations and compares outcomes after elective PTCA. The study by Alberto Rodrigues et al. 1 is a contemporary (2018), prospective, observational, single-center cohort study that included 155 consecutive patients who underwent elective (scheduled or ad-hoc) PTCA over one-year. Patients were routinely placed in a nurse-led eight bed recovery room, where they stayed until hospital discharge. Importantly, CH Gaia's current practice does not include post-procedure electrocardiogram (ECG) or enzyme assay unless there is clinical suspicion of complications, and the minimum in-hospital surveillance was of four hours. Despite the existence of a locally approved protocol for SDD that selects non-complex patients/procedures, the operator was free to decide patient's course at his or her discretion, professional opinion and specific context. Femoral access did not preclude SDD, especially when vascular closure devices were successfully used. SDD patients received telephone follow-up at 24 h and 30 days post-procedure. The investigators found that patient convenience (28.8%, caused primarily by the end of the procedure after 16:00 hours) and operator preference (22.5%) were the main reasons for ONS. Regarding safety, all relevant complications were intraprocedural or early after the procedure, supports the case for a four-hour observation period post-PTCA being sufficient for surveillance. There were no major adverse cardiac and cerebrovascular event between 4 and 24 hours, nor at 30 days. At 24 hours and between one and 30 days, more SDD patients had unplanned visits (9.3% vs. 0.9%, p=0.02); most cases were non-procedure-related or were easily managed with patient reassurance. SDD after elective PTCA is not, by any means, novel; the first reports of its use date back to the mid-1990s. 2 The study by Alberto Rodrigues et al. further confirms the safety of SDD in a national cohort, but this is not its greatest merit – SDD safety has been demonstrated in randomized clinical trials and even meta-analysis.3, 4 This evidence led the influential Society for Cardiovascular Angiography and Interventions to endorse SDD in 2018. 5 In my opinion, the call to action for an increased uptake of SDD in Portugal and how to implement it are the take-home messages from Rodrigues’ paper. Certainly, all Portuguese interventional cardiology laboratories have at some point discharged an elective PTCA on the same day of the intervention - usually a morning surgery patient who underwent a straightforward intervention, on a day where there was a particular shortage of hospital beds. Needless to say, the current COVID-19 pandemic will become an even more likely trigger for SDD. So, what can other laboratories learn from CH Gaia's study? First, that a nearby recovery room, led by nursing staff with on-demand support from an interventional cardiologist, is necessary. This so-called Radial Lounge, 6 with dedicated reclining chairs and commodities such as television or WIFI, allows for a four to six-hour period of observation with telemetry and full equipment for emergencies. Second, the short four-hour observation after PTCA in the present study was previously described twenty years ago 7 and is safe. The option not to include post-procedure ECG or enzyme assay, unless there is clinical suspicion of complications, is still a matter for discussion. The high cutoffs 8 necessary for clinical impact are unlikely to occur in asymptomatic patients, and as such the strategy of testing only symptomatic patients is an established practice in many centers. Third, the need for a systematic 24 h and 30-day telephone follow-up that enables safety monitoring and patient education and reassurance. Fourth, the need for local discussion and acceptance of standard criteria for SDD or ONS. It is well known that SDD is more frequently used among male and younger patients with fewer comorbidities. Rodrigues et al. defined ONS criteria, but in routine practice, the interventional cardiologist's immediate post-PTCA assessment and patient willingness to be same-day discharged, if they live within an acceptable hospital distance, are probably more important. Not discussed by the authors, but also very important, is the issue of reimbursement. This has been suggested as the likely reason for a very limited uptake of SDD in healthcare systems in the United States of America 9 or Australia, 10 in contrast with the United Kingdom 11 or Canada. 12 In Portugal, some hospitals require overnight stay for full reimbursement of PTCA. Since SDD has a well-established economic advantage, 9 this issue must be addressed with the hospital and upstream payors (the national healthcare system or the insurance companies). In conclusion, we must praise Alberto Rodrigues and colleagues from CH Gaia for challenging the Portuguese cardiology community to embrace same-day discharge after PTCA. It is safe and it is cheaper, so why shouldn’t we offer it to our patients? Conflicts of interest The author has no conflicts of interest to declare.

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          Most cited references 12

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          Randomized trial comparing same-day discharge with overnight hospital stay after percutaneous coronary intervention: results of the Elective PCI in Outpatient Study (EPOS).

          Percutaneous coronary intervention (PCI) in a day-case setting might reduce logistic constraints on hospital resources, but data on safety are limited. We evaluated the safety and feasibility of same-day discharge after PCI.
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            Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions.

            Since the publication of the 2009 SCAI Expert Consensus Document on Length of Stay Following percutaneous coronary intervention (PCI), advances in vascular access techniques, stent technology, and antiplatelet pharmacology have facilitated changes in discharge patterns following PCI. Additional clinical studies have demonstrated the safety of early and same day discharge in selected patients with uncomplicated PCI, while reimbursement policies have discouraged unnecessary hospitalization. This consensus update: (1) clarifies clinical and reimbursement definitions of discharge strategies, (2) reviews the technological advances and literature supporting reduced hospitalization duration and risk assessment, and (3) describes changes to the consensus recommendations on length of stay following PCI (Supporting Information Table S1). These recommendations are intended to support reasonable clinical decision making regarding postprocedure length of stay for a broad spectrum of patients undergoing PCI, rather than prescribing a specific period of observation for individual patients.
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              Is Open Access

              Same Day Discharge versus Overnight Stay in the Hospital following Percutaneous Coronary Intervention in Patients with Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

              Background New research in interventional cardiology has shown the demand for percutaneous coronary interventions (PCI) to have increased tremendously. Effective treatment with a lower hospital cost has been the aim of several PCI capable centers. This study aimed to compare the adverse clinical outcomes associated with same day discharge versus overnight stay in the hospital following PCI in a population of randomized patients with stable coronary artery disease (CAD). Methods The National Library of Medicine (MEDLINE/PubMed), the Cochrane Registry of Randomized Controlled Trials and EMBASE databases were searched (from March to June 2016) for randomized trials comparing same-day discharge versus overnight stay in the hospital following PCI. Main endpoints in this analysis included adverse cardiovascular outcomes observed during a 30-day period. Statistical analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) and 95% confidence intervals (CIs) were calculated with respect to a fixed or a random effects model. Results Eight randomized trials with a total number of 3081 patients (1598 patients who were discharged on the same day and 1483 patients who stayed overnight in the hospital) were included. Results of this analysis showed that mortality, myocardial infarction (MI) and major adverse cardiac events (MACEs) were not significantly different between same day discharge versus overnight stay following PCI with OR: 0.22, 95% CI: 0.04–1.35; P = 0.10, OR: 0.68, 95% CI: 0.33–1.41; P = 0.30 and OR: 0.45, 95% CI: 0.20–1.02; P = 0.06 respectively. Blood transfusion and re-hospitalization were also not significantly different between these two groups with OR: 0.64, 95% CI: 0.13–3.21; P = 0.59 and OR: 1.53, 95% CI: 0.88–2.65; P = 0.13 respectively. Similarly, any adverse event, major bleeding and repeated revascularization were also not significantly different between these two groups of patients with stable CAD, with OR: 0.42, 95% CI: 0.05–3.97; P = 0.45, OR: 0.73, 95% CI: 0.15–3.54; P = 0.69 and OR: 0.67, 95% CI: 0.14–3.15; P = 0.61 respectively. Conclusion In terms of adverse cardiovascular outcomes, same day discharge was neither superior nor inferior to overnight hospital stay following PCI in those patients with stable CAD. However, future research will have to emphasize on the long-term consequences.
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                Author and article information

                Contributors
                Journal
                Rev Port Cardiol
                Rev Port Cardiol
                Revista Portuguesa De Cardiologia
                Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U.
                0870-2551
                2174-2030
                5 August 2020
                5 August 2020
                Affiliations
                Serviço de Cardiologia, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
                Article
                S0870-2551(20)30288-2
                10.1016/j.repc.2020.07.002
                7403124
                © 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U.

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