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Sending patients home the same day as receiving percutaneous coronary intervention (PCI) is safe and comparable to going home after overnight observation, according to results of a large meta-analysis published online April 23, 2013, ahead of print in the Journal of the American College of Cardiology.
Researchers led by Kimberly M. Brayton, MD, of the Stanford University School of Medicine (Stanford, CA), examined 37 published studies (7 randomized controlled trials and 30 observational studies) conducted between 1999 and 2011, totaling 12,803 patients.
In the randomized trials, no difference was observed between same-day discharge and overnight observation for the primary composite endpoint of death/MI/TLR or for major bleeding/vascular complications (table 1).
Table 1. RCTs of Same-Day Discharge vs. Overnight Stay
Discharge(n = 1,256)
Overnight Observation(n = 1,482)
Additionally, no significant differences in any of the secondary endpoints—readmission or individual components of the composite endpoint—were observed between the 2 strategies.
Among randomized studies restricted to patients undergoing femoral PCI, no difference in major bleeding/vascular complications was seen between same-day discharge and overnight stay (OR 0.75; 95% CI 0.19-2.98; P = 0.69), although a significant difference in death/MI/TLR favoring same-day discharge was found (OR 0.50; 95% CI 0.20-0.90; P = 0.021), driven primarily by a reduction in MI (OR 0.45; 95% CI 0.20-1.00; P = 0.050).
Randomized studies looking only at radial PCI, meanwhile, found similar risk levels after same- vs. next-day discharge for both death/MI/TLR (OR 1.80; 95% CI 0.50-7.40; P = 0.36) and major bleeding/vascular complications (OR 2.40; 95% CI 1.00-5.60; P = 0.052). Choice of access site appeared to modify the risk of death/MI/TLR (P = 0.04) but not major bleeding/vascular complications (P = 0.08).
In the observational studies, the primary composite endpoint occurred at a pooled rate of 1.00% and major bleeding/vascular complications at a pooled rate of 0.68%. Again, secondary endpoint event rates were low, and they were similar to those of the randomized trials.
According to Dr. Brayton and colleagues, while the meta-analysis of randomized trials yields a higher level of evidence, the data from observational studies “provides complementary information about the safety of same-day discharge in a real-world context, and across a much larger pool of patients.”
Although event rates were higher in the randomized trials than in the observational studies, the authors credit an excess of MI events in a single trial that included ACS patients and incorporated routine biomarker measurement, leading to a high number of periprocedural MI diagnoses in both treatment groups.
Importantly, patients with major comorbidities were excluded from most of the studies in the meta-analysis, including those with LVEF less than 30% and those with chronic kidney disease (CKD).
“Thus, while the aggregate findings from this meta-analysis provide support for the safety of same-day discharge, the caveat remains that these findings were derived from carefully selected patients,” the study authors write.
Going Home May Be Safer for Patients
But according to Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA), who has practiced same-day discharge for radial PCI patients for over a decade, once a practice of same-day discharge has been established within a carefully-controlled interventional cardiology program, it may be unnecessary to be so conservative with patient selection.
In a telephone interview with TCTMD, Dr. Gilchrist said he routinely sends patients with low LVEF, CKD, and other conditions excluded from the research studies home the same day.
“My feeling is, if they were stable and they were fine at home yesterday, why aren’t they okay to go home after PCI?” he said. “The [PCI procedure] really doesn’t shake the boat much.
“Certainly, if someone is having problems after the procedure we don’t send them home, but most people want to go home and sleep in their own bed,” Dr. Gilchrist continued. “Then we contact them the next day after they’ve slept and had breakfast. We see how they’re doing, and make sure they [filled their prescriptions], and understand everything that went on the day before. It many ways it’s a much better way [to interact with the patient], because when they stay overnight they look like a deer in the headlights the next morning. You’re trying to explain everything to them and they’re just thinking ‘get me out of here’ and not listening anyway.”
Dr. Gilchrist said many older patients, particularly those with tenuous neurologic status, are safer in many respects being cared for at home with a family member or other adult caregiver than staying overnight in the hospital. In a recent study, he examined his own single-center experience and compared it with published guidelines regarding same-day PCI (Gilchrist IC, et al. Catheter Cardiovasc Interv. 2012;79:583-587). Approximately 80% of Dr. Gilchrist’s same-day PCI patients violated the recommendations yet none had any complications that would have been avoided by an overnight stay, he said.
In an e-mail communication with TCTMD, Sunil V. Rao, MD, of Duke University Medical Center (Durham, NC), added that while many misconceptions persist regarding same-day PCI, he senses attitudes are changing.
“When we did our JAMA paper on same-day [in 2011], no one was really even thinking about it. But now with the changes in reimbursement, there has been a surge of interest,” Dr. Rao said (Rao SV, et al. JAMA. 2011;306:1461-1467). “I don't have any hard data since we haven't surveyed the [National Cardiovascular Data Registry] again, but anecdotally, I get calls every other week from hospitals interested in exploring a same-day discharge program.”
Reassuring and Confirmatory
Drs. Rao and Gilchrist co-authored a similar meta-analysis recently (Abdelaal E, et al. J Am Coll Cardiol Intv. 2013;Epub ahead of print), which essentially mirrored the current results.
“It’s definitely confirmatory of our prior meta-analysis, and that’s always a good thing,” Dr. Gilchrist said. “Superficially, both meta-analyses are saying that in this patient population events are very low and clinically you don’t see much difference. You still have a situation where we cannot say definitely from a statistical standpoint that [same-day discharge or overnight stay] are exactly the same. But certainly, if there is a difference between them, it’s very small and I think that’s reassuring for those of us who are sending our patients home the same day.”
In the randomized trials, two-thirds had stable CAD, 27.4% had multivessel CAD, and 60.8% underwent transradial access. In the observational studies, 97.5% had stable CAD, 28.9% had multivessel CAD, and 30% underwent transradial access.