Transradial PCI allows more patients to be discharged the same day.
San Diego, CA – Same-day discharge following radial-artery PCI is possible for many patients, including patients not considered candidates for same-day discharge by current criteria . Investigators report that older and diabetic patients and those who underwent complex procedures, as well as those who live many miles from the treating hospital, could be safely discharged the same day of the radial-access procedure.
“When these procedures are done through the femoral artery, as is commonly done in the US, patients are kept overnight in the hospital,” lead investigator Dr Ian Gilchrist (Penn State College of Medicine, Hershey, PA) told heartwire. “The primary reason to keep someone overnight following angioplasty is to watch for bleeding, and the biggest benefit of the radial procedure is that patients don’t bleed. The radial artery is such a small vessel, you don’t get the life-threatening bleeds that can happen if something goes wrong with the femoral artery. The approach negates the primary reason to keep the patient overnight.”
Presenting the results here today at the Society for Cardiovascular Angiography and Interventions (SCAI) 2010 Scientific Sessions, Gilchrist said that the American College of Cardiology (ACC) and SCAI recently published a practice statement outlining suitable patients for outpatient PCI procedures.
The joint statement, said Gilchrist, is a “bit restrictive,” in that only a “narrow sliver” of patients whom clinicians see would qualify for same-day discharge. The reason, he continued, is that the SCAI/ACC guidelines are written from a groin-oriented, femoral-artery perspective, because most PCIs in the US are performed via this route. While other countries, including Canada, Norway, China, India, and others, have adopted transradial PCI, with many using it as the default approach, less than 5% of procedures in the US are done via the radial artery.
80% wouldn’t have been candidates for same-day discharge
The purpose of this retrospective review was to compare the last 100 patients undergoing transradial PCI and discharged the same day with the appropriateness criteria of the 2009 SCAI/ACC statements on outpatient PCI.
Overall, 106 elective procedures were performed by Gilchrist and colleagues at Hershey Medical Center. The median age of the patients was 62 years, although 26 patients were older than 70 years. Five patients had insulin-dependent diabetes, one patient had a decreased estimated glomerular filtration rate, four patients had contrast allergies, and eight patients had chronic obstructive pulmonary disease. Also, 23 patients underwent complex PCI, including five patients with left main coronary artery disease, 12 patients with proximal left anterior descending disease, and three patients with multivessel disease. Six patients had peripheral vascular disease, congestive heart failure, or a prior heart transplant.
“Patients can be very successfully sent home the same day,” Gilchrist told heartwire, “and of the ones we sent home, 80% of them, according to [ACC/SCAI] guidelines published a year ago, probably should have been kept in the hospital overnight.”
At their medical center, nurse practitioners follow up with discharged patients with further education and to make sure they have filled their prescriptions for clopidogrel and are taking aspirin. Of the 100 patients, none were readmitted to the hospital or experienced any complications following PCI.
The current appropriateness criteria for same-day discharge outline a “perfect patient,” said Gilchrist, noting that those who qualify are usually younger patients with no cardiac problems, no diabetes, and no lung disease who require only a very simple angioplasty. A lot of these criteria are based on patient characteristics before the procedure, rather than the presence or absence of complications following the procedure.
“What is often underestimated is that the hospital is not safe place to be, and it isn’t a place where people want to be,” Gilchrist told heartwire. “Patients feel better at home, they can’t get an infection from the hospital at home, there aren’t any medication errors, they can’t fall out of bed and break their hip on a hard hospital floor, and they get a good night’s sleep. In the hospital, most of these patients look like deer caught in the headlights the next morning when you go in to talk to them. They’re not receptive to learning anything new at that point; the only thing that’s in their mind is that they want to get out of there.”
Gilchrist I, Rhodes D, Zimmerman H. Real world, same-day transradial PCI patients in the US: Do the guidelines fit practice? Society for Cardiovascular Angiography and Interventions 2010 Scientific Sessions; May 5, 2010; San Diego, CA. Abstract A-045.