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.
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.
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.
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
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,
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
Second, the short four-hour observation after PTCA in the present study was previously
described twenty years ago
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
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
in contrast with the United Kingdom
In Portugal, some hospitals require overnight stay for full reimbursement of PTCA.
Since SDD has a well-established economic advantage,
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.