麻豆传媒

During the COVID-19 pandemic, one hospital found that it was possible to get some heart attack patients discharged very quickly after primary percutaneous coronary intervention (PCI).

Under a novel early discharge pathway, 600 low-risk patients who received early reperfusion for ST-segment elevation MI (STEMI) from March 2020 to June 2021 were discharged at a median of just 24.6 hours, compared with the historical median of 65.9 hours, reported Daniel Jones, PhD, of Barts Heart Centre in London, and colleagues.

No cardiovascular deaths occurred over a median follow-up of 271 days, and major adverse cardiovascular event (MACE) rates reached just 1.2%. There were two deaths, both occurring more than a month after discharge and attributed to COVID-19, the group noted in the .

These rates compared favorably to the 0.7% mortality and 1.9% MACE rates observed in a cohort of 700 similarly low-risk patients who had been selected to stay longer in the high-volume heart attack center from October 2018 to June 2021.

"Moreover, there were no cases of nosocomial COVID-19 infection in this patient group, and all patients were followed up with early postdischarge consultations in a structured, multidisciplinary program that achieved an 85% patient satisfaction rate," the authors noted.

"Although the implementation of this pathway was driven by the necessity to adapt to the COVID-19 pandemic to shorten hospital admission times, optimize resource use, and decrease the risk of nosocomial infection, it has the potential to change standard practice in this patient group," they asserted.

European guidelines currently recommend early discharge at 48 to 72 hours for select low-risk STEMI patients.

"Although the U.S. guidelines do not comment on length of stay, early discharge after primary PCI is widely embraced, even among selected older patients. With the advent of radial access for PCI and performance of outpatient elective PCI, it was only a matter of time before length of stay was further shortened after primary PCI," wrote Cindy Grines, MD, and J. Jeffrey Marshall, MD, both of Northside Hospital Cardiovascular Institute in Atlanta.

The study authors "should be congratulated on their outstanding results and ability to move the target discharge time even shorter than previously attempted," they wrote in an .

Jones and colleagues conducted their prospective study at Barts Heart Centre, a tertiary center serving North Central and North East London.

The study included 600 low-risk patients successfully discharged within 48 hours (mean age 59, 86.0% men). All met criteria for early discharge, which included absence of heart failure, no recurrence of ischemic symptoms, and patient mobility.

The cohort tended to have STEMIs treated very early, with median symptom-to-balloon and door-to-balloon times of 80 and 50 minutes, respectively.

Because of their short stay in the hospital, the patients received cardiac rehab counseling after discharge, during a telephone call at 48 hours, and those lacking a blood pressure machine at home received one to facilitate medication uptitration.

Virtual follow-up appointments were scheduled at 2, 6, and 8 weeks and at 3 months. All patients were reachable using a smartphone app, with none lost to follow-up.

The study was limited by its relatively small sample and non-randomized nature, Jones' group acknowledged.

"However, the low event rate and mortality in the selected group offers the opportunity to improve resource use for a large cohort of STEMI patients," they argued.

"With the implementation of this pathway, overall median length of stay was reduced from 3 days before its introduction to 2 days. This equates to a cost saving of 400 bed-days in the coronary care unit over the time period studied. This is not only cost-effective, but it would also free beds for improving wider interventional service delivery to address the ever-increasing workload of regional heart attack centers," Jones and colleagues wrote.

Grines and Marshall suggested some patient groups -- namely those with late reperfusion, advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic COVID-19 -- were less appropriate for very early discharge.

For now, the guidelines are not likely to change based on a single observational report, the editorialists noted.

Comment