Stent and Send: How Does Same-Day Discharge Post-PCI Compare to Overnight Stay? (JACC in a Flash)
Several smaller, single-center studies have attested to the safety and feasibility of same-day discharge (SDD) post-PCI, but in the absence of definitive evidence from larger studies, overnight hospitalization remains the standard of care—even in the case of simple, uncomplicated PCI. However, as Kimberly Brayton, MD, JD, and colleagues point out in a recent JACC article, newer PCI techniques and anticoagulation strategies have significantly decreased the risk of periprocedural adverse events. However, hospitalization carries its own set of risks (increased likelihood of infection or improper drug administration), begging the question, "Is overnight hospitalization really that much safer than same-day discharge?"
Dr. Brayton and colleagues conducted a meta-analysis to evaluate the safety of same-day discharge, reporting procedural characteristics and rates of adverse outcomes (death/MI/target lesion revascularization [TLR] and major bleeding/vascular complications) in a broad range of patients and practice settings. They identified 37 studies—seven randomized controlled trials and 30 observational studies.
Of the 2,738 patients enrolled in the randomized controlled trials, 1,256 patients were randomized to same-day discharge; 87.3% of these were successfully discharged the same day of PCI. The decision to extend to overnight hospitalization in these cases was most often due to access site complications, physician or patient preference, and recurrent chest pain. In terms of the primary safety outcomes, there was no significant difference between same-day discharge and overnight observation (7.17% vs. 6.07% for death/MI/TLR; 1.88% vs. 1.29% for major bleeding/vascular complications). When enrolled patients with ACS were excluded from the analysis, the event rates were markedly lower. These findings held up when the investigators restricted their analysis to femoral access PCI, although there was a slight trend towards lower risk for death/MI/TLR with same-day discharge.
Similar rates of adverse events were found among the observational studies, which included 14,032 patients—10,065 of whom were successfully discharged on same day of PCI. The primary composite endpoint of death/MI/TLR occurred at a pooled rate of 1.00% and major bleeding/vascular complications occurred at a pooled rate of 0.68% with same-day discharge.
The findings from this meta-analysis are encouraging, but, as the authors point out, their analysis was restricted to patients without serious comorbidities (i.e., left ventricular ejection fraction <30%, ACS, and chronic kidney disease). "Thus, while the aggregate findings from this meta-analysis provide support for the safety of same-day discharge," the authors write, "the caveat remains that these findings were derived from carefully selected patients."
Dr. Brayton and colleagues have several suggestions for future study (including a cost-effectiveness comparison and a patient satisfaction survey), but for the present, they advise that PCI centers establish formal criteria for identifying appropriate same-day discharge patients, as well as a system for close follow-up.
Brayton KM, Patel VG, Stave C, et al. J Am Coll Cardiol. 2013;62:275-85.
Keywords: Follow-Up Studies, Chest Pain, Standard of Care, Comorbidity, Patient Satisfaction, Stroke Volume, Probability, Patient Discharge, Hospitalization, Patient Preference, Renal Insufficiency, Chronic, Stents
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