An analysis of data from 600 patients who were deemed to be low risk for early major adverse cardiovascular events (MACE) revealed that these patients were safely released from hospital after a median of 24.6 hours, according to the study published in the Journal of the American College of Cardiology.
The study's main message "is that it is possible with integrated and structural multidisciplinary virtual follow up to safely and successfully discharge low risk patients 24 hours after primary PCI for STEMI," said study coauthor Daniel Jones, clinical senior lecturer at Queen Mary University of London and consultant cardiologist at Barts Heart Centre. "Not only did we shorten hospital admission times, but we also decreased the risk of nosocomial infections, optimized resource utilization, and importantly at the same time enhanced the quality of post discharge care with high levels of patient satisfaction."
The researchers "were expecting the pathway to be safe, but we were taken by surprise at how well it worked," Jones said in an email. "From our own anecdotal experience, we often felt that low risk patients that had been successfully treated for their heart attacks were waiting in hospital for longer than necessary, being very well and keen to go much sooner than guidelines allow. This project showed that using established risk sources we can select these patients and safely discharge them."
To take a closer look at whether patients could be discharged earlier than guidelines suggest, Jones and his team conducted a prospective, observational study of patients who underwent primary PCI at Barts Heart Centre, the tertiary cardiovascular center for north central and northeast London.
The researchers designed and implemented a novel early (less than 48 hours) hospital discharge pathway (EHD), which included structured virtual follow-up, for low-risk patients following PCI.
Jones and his team included patients who had a diagnosis of STEMI and who survived to hospital discharge following primary PCI between October 2018 and June 2021 in their analysis. They split the patients into three groups: 600 patients discharged on the EHD pathway between April 2020 and June 2021, 700 patients who served as the control group and who were discharged after 48 hours between October 2018 and June 2021, and 650 patients who were discharged on normal pathways between April 2020 and June 2021.
The mean age in the EHD group was 59.2; 86.0% were men and 56% were Caucasian. A quarter of the patients had diabetes mellitus, 24.8% had a history of previous revascularization (20.8% PCI and 4.0% CABG), and 14.8% had a history of previous MI.
In the EHD group, the median time to discharge was 24.6 hours, with an interquartile range of 22.7-30.0 hours. Forty percent were discharged within 24 hours, 76% within 30 hours, and 100% within 40 hours. All patients were contacted after discharge and none were lost to follow-up. During a median follow-up of 271 days two patients died from COVID-19, while there was 0% cardiovascular mortality and MACE rates of 1.2%.
The researchers noted that those results compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for more than 48 hours, and for whom the median stay was 56.1 hours (IQR: 48-75.0 hours).
"We believe this pathway can be the default pathway for discharge of all low-risk patients following the treatment of heart attacks and that it's generalizable across all UK and worldwide heart attack centers," Jones said. "We are looking for sites to pilot the pathway outside of our center and are happy to share data, policies and SOPs. Any interested centers are welcome to contact me directly."
The new study's results "are remarkable, with no cardiac mortality or adverse events in the first 30 days post-discharge," said Dr. Catalin Toma, an interventional cardiologist at the University of Pittsburgh Medical Center (UPMC). The readmission rates were low."
"This is the result of years of advances in STEMI care, spanning from systematic interventions to decrease the symptom-to-reperfusion time to improved procedural safety with radial access" Dr. Toma said in an email. "The capacity to ensure patient education on discharge and adherence to the follow-up are critical elements in early transitioning to outpatient care. Current U.S. practice is already changing in a similar direction, with the early discharge of low-risk MI patients, at a critical time in care delivery in the era of COVID-strained hospital resources."
SOURCE: https://bit.ly/3DRvMGg and https://bit.ly/3GFfqlX Journal of the American College of Cardiology, online December 13, 2021.
By Linda Carroll
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