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      Adoption of same day discharge following elective left main stem percutaneous coronary intervention

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          Abstract

          Background

          This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI.

          Methods

          We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality.

          Results

          SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30–1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17–1.41) and those requiring ON stay (OR 0.58 95%CI 0.25–1.34).

          Conclusions

          We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

          Highlights

          • •

            In a national analysis of 6452 elective procedures undertaken for left main stem disease in United Kingdom, SDD practice was associated with similar risk of 30 day mortality compared to ON stay despite an increase complexity of procedure.

          • •

            SDD did not appear inferior to ON stay even in highly complex left main stem PCI procedures.

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          Most cited references44

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          Multiple Imputation After 18+ Years

          Donald B Rubin (1996)
          Article 0 comments Cited 217 times – based on 0 reviews     Review now
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            Impact of bleeding on mortality after percutaneous coronary intervention results from a patient-level pooled analysis of the REPLACE-2 (randomized evaluation of PCI linking angiomax to reduced clinical events), ACUITY (acute catheterization and urgent intervention triage strategy), and HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trials.

            Michel Bertrand, Harvey White, Roxana Mehran … (2011)
            This study sought to develop a risk score predictive of bleeding in patients undergoing percutaneous coronary intervention (PCI) and to investigate the impact of bleeding on subsequent mortality. Bleeding complications after PCI have been independently associated with early and late mortality. This study represents a patient-level pooled analysis including 17,034 patients undergoing PCI from 3 large, randomized trials of bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitors, including the REPLACE-2 (Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trials. We developed a risk score to predict noncoronary artery bypass graft (CABG)-related TIMI (Thrombolysis In Myocardial Infarction) major bleeding and evaluated the impact of various types of bleeding on 1-year mortality. A non-CABG-related TIMI major bleed occurred within 30 days in 267 patients (1.6%), and death occurred in 497 patients (2.9%) within 1 year. A risk score was developed to predict the bleeding risk of patients undergoing PCI, consisting of 7 variables (serum creatinine, age, sex, presentation, white blood cell count, cigarette smoking, and randomized treatment). The TIMI major bleeding rates increased by bleeding risk score groups: from 0.4% for those in the lowest to 5.8% for those in the highest risk group. Non-CABG-related TIMI major bleeding and the occurrence of myocardial infarction within 30 days were independent predictors of subsequent mortality, with respective hazard ratios of 4.2 and 2.9, each p < 0.001. Ranked in order of severity, TIMI major bleeding, blood transfusion without TIMI bleed, TIMI minor bleeding requiring blood transfusion, and TIMI minor bleeding not requiring blood transfusion were independent predictors of subsequent mortality with hazard ratios of 4.89, 2.91, 2.73, and 1.66, respectively. Isolated hematomas were not predictive of subsequent mortality. Non-CABG-related bleeding within 30 days is strongly associated with an increased risk of subsequent mortality at 1 year in patients undergoing PCI for all indications. A risk score was established to calculate the bleeding risk for patients undergoing PCI, allowing therapeutic decision making to minimize the incidence of bleeding. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
            Article 0 comments Cited 76 times – based on 0 reviews     Review now
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              A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation.

              Paul Poirier, O Bertrand, … (2006)
              Systematic use of coronary stents and optimized platelet aggregation inhibition has greatly improved the short-term results of percutaneous coronary interventions. Transradial percutaneous coronary interventions have been associated with a low risk of bleeding complications. It is unknown whether moderate- and high-risk patients can be discharged safely the same day after uncomplicated transradial percutaneous coronary interventions. We randomized 1005 patients after a bolus of abciximab and uncomplicated transradial percutaneous coronary stent implantation either to same-day home discharge and no infusion of abciximab (group 1, n=504) or to overnight hospitalization and a standard 12-hour infusion of abciximab (group 2, n=501). The primary composite end point of the study was the 30-day incidence of any of the following events: death, myocardial infarction, urgent revascularization, major bleeding, repeat hospitalization, access site complications, and severe thrombocytopenia. The noninferiority of same-day home discharge and bolus of abciximab only compared with overnight hospitalization and abciximab bolus and infusion was evaluated. Two thirds of patients presented with unstable angina and approximately 20% presented with high-risk acute coronary syndrome prior to the procedure. The incidence of the primary end point was 20.4% in group 1 and 18.2% in group 2 (P=0.017 for noninferiority) with a troponin T-based definition of myocardial infarction; the incidence of the primary end point was 11.1% in group 1 and 9.6% in group 2 (P=0.0004 for noninferiority) with a creatinine kinase myocardial band-based definition of myocardial infarction. No death occurred. Rate of major bleeding in both groups was extremely low at 0.8% and 0.2%, respectively. From 504 patients randomized in group 1, 88% were discharged home the same day. Our data suggest that same-day home discharge after uncomplicated transradial coronary stenting and bolus only of abciximab is not clinically inferior, in a wide spectrum of patients, to the standard overnight hospitalization and a bolus followed by a 12-hour infusion. This novel approach offers a safe strategy for same-day home discharge after uncomplicated coronary intervention.
              Article 0 comments Cited 58 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Mamas A. Mamas
                Journal
                Journal ID (nlm-ta): Int J Cardiol
                Journal ID (iso-abbrev): Int. J. Cardiol
                Title: International Journal of Cardiology
                Publisher: Elsevier B.V.
                ISSN (Print): 0167-5273
                ISSN (Electronic): 1874-1754
                Publication date PMC-release: 30 July 2020
                Publication date (Electronic): 30 July 2020
                Affiliations
                [a ]Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
                [b ]University Hospital of Wales, Cardiff, UK
                [c ]Coronary Research Group, University Hospital Southampton, Faculty of Medicine, University of Southampton, UK
                [d ]John Radcliffe Hospital, Oxford, UK
                [e ]Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
                [f ]Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
                Author notes
                [* ]Corresponding author at: Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK. doctorrashid7@ 123456gmail.com
                Article
                Publisher ID: S0167-5273(20)33486-0
                DOI: 10.1016/j.ijcard.2020.07.038
                PMC ID: 7392050
                SO-VID: fdf6382f-317c-4934-b85d-90b5bed60fed
                Copyright © © 2020 Elsevier B.V. All rights reserved.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 17 April 2020
                Date revision received : 4 June 2020
                Date accepted : 24 July 2020
                Categories
                Subject: Article

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: elective percutaneous coronary intervention,same day discharge,mortality,outcomes,bcis, british cardiovascular intervention society,cabg, coronary artery bypass graft,mi, myocardial infraction,on, overnight stay,or, odds ratio,pci, percutaneous coronary intervention,sdd, same day discharge
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: elective percutaneous coronary intervention, same day discharge, mortality, outcomes, bcis, british cardiovascular intervention society, cabg, coronary artery bypass graft, mi, myocardial infraction, on, overnight stay, or, odds ratio, pci, percutaneous coronary intervention, sdd, same day discharge

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