PARIS – Same-day discharge after uncomplicated transradial-access percutaneous coronary intervention (PCI) in patients with stable coronary artery disease is both feasible and safe, according to the findings of a multicenter prospective Spanish registry study.
Under the Spanish investigators’ protocol for same-day discharge, roughly three-quarters of patients successfully completed the 4- to 12-hour post-PCI surveillance period and were expeditiously sent home without spending a night in the hospital, Juan Gabriel Cordoba Soriano, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.
Dr. Juan Gabriel Cordoba Soriano
The other 26% of patients were admitted, most often because they showed clinical instability during the surveillance period, less frequently due to a suboptimal angiographic result, explained Dr. Cordoba Soriano of the University of Albacete, Spain.
The rationale for same-day discharge post PCI – provided it has first been shown to be safe, as was the case using the Spanish criteria – is that it reduces costs by avoiding an expensive hospital bed. Also, most patients prefer to sleep in their own bed and avoid a hospital stay, he continued.
Eligibility for same-day discharge in the Spanish study was restricted to patients with stable coronary artery disease undergoing elective transradial PCI with no complications during the procedure and with clinical stability during the subsequent 4- to 12-hour observation period. Patients undergoing complex PCIs – for example, treatment of left main lesions, complex bifurcation lesions, or chronic total occlusions – were ineligible.
Why restrict eligibility to patients undergoing transradial PCI? Multiple studies convincingly show it is safer than femoral access. And outside of the United States, it is by far the more popular access route. In a show of hands, virtually all of Dr. Cordoba Soriano’s audience indicated they perform more than 70% of their PCIs via transradial access. And patients with stable CAD are less likely to experience stent thrombosis or acute occlusion of the treated artery or side branches, he continued.
Of 989 patients who presented to the three participating Spanish medical centers for elective PCI, 257 were immediately excluded from the registry because they underwent elective femoral access. That left 732 patients, 74% of whom got same-day discharge.
The same-day discharge and hospital admission groups were closely similar in terms of baseline characteristics with two exceptions: The prevalence of peripheral arterial disease in the same-day discharge group was less than half of the 10% figure in the hospitalized group, and kidney function was better in patients who ultimately received same-day discharge as evidenced by a serum creatinine of 0.9 mg/dL, half that of the hospitalized patients.
Procedural characteristics were mostly similar for the two groups as well. Although the same-day discharge group had a 26-minute shorter median procedure time, were less likely to undergo multivessel PCI, and had fewer stents implanted per patient, in a multivariate regression analysis the only independent predictors of admission post PCI were the presence of peripheral arterial disease, with an associated 2.2-fold increased risk; multivessel PCI, with a 1.8-fold risk; ad hoc as opposed to a scheduled PCI, with a 4.0-fold increased risk; and a history of prior transradial catheterization, which cut the risk of hospitalization in half.
Turning to the safety of same-day discharge, the cardiologist deemed the rate of major complications in the first 24 hours to be acceptable at 0.18% for a single case of significant bleeding. Minor complications were confined to a 1.8% incidence of hematomas greater than 5 cm in size.
The major complication rate from 24 hours to 30 days post PCI was 0.54% (two deaths, one stroke), with a 2.2% incidence of minor complications.
Dr. Cordoba Soriano noted that investigators at the Quebec Heart and Lung Institute have published a meta-analysis of 13 studies of same-day discharge after PCI totaling more than 111,000 patients (JACC Cardiovasc Interv. 2013 Feb;6[2]:99-112). The investigators concluded that a definitive randomized trial would require more than 17,000 subjects, and in the absence of such evidence same-day discharge after uncomplicated PCI “seems a reasonable approach in selected patients.”
Stanford University investigators have published a separate meta-analysis of same-day discharge after PCI in nearly 13,000 patients in 30 observational and 7 randomized controlled trials. They concluded that it appears to be as safe as overnight observation (J Am Coll Cardiol. 2013 Jul 23;62[4]:275-85).
Nevertheless, the Society for Cardiovascular Angiography and Interventions has yet to update its 2009 expert consensus document stating that the standard of care is an overnight stay following PCI (Catheter Cardiovasc Interv. 2009 Jun 1;73[7]:847-58), Dr. Cordoba Soriano observed.