JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 65, NO. 12, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2015.01.030
EDITORIAL COMMENT
Balloon-to-Door Time Emerging Evidence for Shortening Hospital Stay After Primary PCI for STEMI* Frederic S. Resnic, MD, Sachin P. Shah, MD
N
early 250,000 patients have an ST-segment
power of 5 days) were older, had more
relevant to the contents of this paper to disclose.
comorbidities,
and
were
more
likely
to
have
Resnic and Shah
JACC VOL. 65, NO. 12, 2015 MARCH 31, 2015:1172–4
Shortening Hospital Stays After STEMI PCI
multivessel coronary disease or cardiogenic shock
(representing patients with a same-day or next-day
compared with patients with a medium (4 to 5 days)
discharge). These 1,244 patients had a 30-day mor-
or short (#3 days) LOS. Compared with a short LOS,
tality rate twice that of patients discharged after 3 to
patients with a long LOS had a higher 30-day mor-
4 days of hospitalization. These results are intriguing,
tality rate (unadjusted 0.9% vs. 3.5%, respectively).
but they may simply highlight the limitations of the
These findings are not unexpected. Differences in
dataset analyzed. This group of patients represents
baseline characteristics or differences in the severity
only 3.7% of the entire study population. In addition,
of and complications related to myocardial infarction
just as confounders such as comorbidities and
are likely to have driven the major adverse cardio-
severity of illness are likely to affect mortality in pa-
vascular event (MACE) and mortality rates, as well as
tients with a very long LOS, certain confounders may
the LOS. These investigators attempted to adjust for
also play a role in patients with a very short LOS.
differences in severity of illness and comorbidities,
Patients leaving against medical advice or patients
but undoubtedly unmeasured confounders exist. The
transferred to another health care facility (potentially
principal finding of this observational study, even
as a result of clinical instability) comprise potential
with the limitations noted, was that there appeared to
factors that may increase the risk profile of the cohort
be no difference in 30-day mortality and MACE be-
with a very short LOS. These limitations significantly
tween patients with a short (#3 days) LOS and pa-
affect the ability to make any conclusions about this
tients with a medium (4 to 5 days) LOS.
small subset of patients discharged after a very short
An additional important finding is the significant
LOS.
that
Unfortunately, the lack of a large randomized trial
seemed to affect LOS. Smaller hospitals and those in
assessing the safety of an early discharge after pri-
the West and Midwest regions of the United States
mary PCI for STEMI leaves clinicians with incomplete
were much more likely to have a short LOS. Specif-
evidence with which to make decisions. The paper
ically, 35% of patients in the West compared with
by Swaminathan et al. (16) helps affirm that the
only 16% of patients in the Northeast had a short
current practice to discharge lower-risk patients
LOS. This variation in practice may provide an
early (#3 days) is likely as safe as longer hospital
opportunity for a substantial reduction in resource
stays. Given the observed geographic variation, there
utilization at those hospitals and regions with a
is probably an opportunity to apply this practice
geographic
and
hospital-related
variation
generally longer LOS after primary PCI for STEMI.
more broadly, thereby achieving significant health
Although clinical outcomes and quality must be
care cost savings while maintaining the quality of
carefully monitored with such change in practice, the
STEMI care.
adjusted analysis by Swaminathan et al. (16) indicates that such outcomes can be achieved with a shorter
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
LOS.
Frederic S. Resnic, Department of Cardiovascular
In
a
secondary
analysis,
these
investigators
Medicine, Lahey Hospital and Medical Center, 41 Mall
examine the mortality rates in a small subset of pa-
Road,
tients who were hospitalized for 1 to 2 days
[email protected].
Burlington,
Massachusetts
01805.
E-mail:
REFERENCES 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a
5. Berger AK, Duval S, Jacobs DR, et al. Relation of length of hospital stay in acute myocardial
9. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management
report from the American Heart Association. Circulation 2014;129:e28–292.
infarction to post discharge mortality. Am J Cardiol 2008;101:428–34.
2. Agarwal S, Garg A, Parashar A, Jaber WA, Menon V. Outcomes and resource utilization in STelevation myocardial infarction in the United States: evidence for socioeconomic disparities. J Am Heart Assoc 2014;3:e001057.
6. Spencer FA, Lessard D, Gore JM, Yarzebski J, Goldberg RJ. Declining length of hospital stay for acute myocardial infarction and postdischarge outcomes: a community-wide perspective. Arch Intern Med 2004;164:733–40.
of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61: e78–140.
3. Levine SA, Lown B. “Armchair” treatment of acute coronary thrombosis. JAMA 1952;148:
7. Kociol RD, Lopes RD, Clare R, et al. International variation in and factors associated with hospital
1365–9.
readmission after myocardial infarction. JAMA 2012;307:66–74.
4. Topol EJ, Burek K, O’Neill WW, et al. A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion. N Engl J Med 1988;318: 1083–8.
8. Chin CT, Weintraub WS, Dal D, et al. Trends and predictors of length of stay after primary percutaneous coronary intervention: a report from the CathPCI Registry. Am Heart J 2011;162:1052–61.
10. Bax JJ, Baumgartner H, Ceconi C, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. Eur Heart J 2012;33:2569–619. 11. Newby LK, Eisenstein EL, Califf RM, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med 2000;342:749–55. 12. Noman A, Zaman AG, Schechter C, Balasubramaniam K, Das R. Early discharge after primary
1173
1174
Resnic and Shah
JACC VOL. 65, NO. 12, 2015 MARCH 31, 2015:1172–4
Shortening Hospital Stays After STEMI PCI
percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2013;2:262–9. 13. Kotowycz MA, Cosman TL, Tartaglia C, et al. Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction: a prospective and randomized trial in low risk primary percutaneous coronary intervention patients (the Safe-Depart Trial). Am Heart J 2010;159:117. e1–66.
14. Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. J Am Coll Cardiol 1998;31:
16. Swaminathan RV, Rao SV, McCoy LA, et al. Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry.
967–72.
J Am Coll Cardiol 2015;65:1161–71.
15. Jirmar R, Widimsky P, Capek J, Hlinomaz O, Groch L. Next day discharge after successful primary angioplasty for acute ST elevation myocardial infarction: an open randomized study “Prague-5.” Int Heart J 2008;49:653–9.
KEY WORDS length of stay, percutaneous coronary intervention, ST-segment elevation myocardial infarction
VOL. 65, NO. 12, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2015.01.030
EDITORIAL COMMENT
Balloon-to-Door Time Emerging Evidence for Shortening Hospital Stay After Primary PCI for STEMI* Frederic S. Resnic, MD, Sachin P. Shah, MD
N
early 250,000 patients have an ST-segment
power of 5 days) were older, had more
relevant to the contents of this paper to disclose.
comorbidities,
and
were
more
likely
to
have
Resnic and Shah
JACC VOL. 65, NO. 12, 2015 MARCH 31, 2015:1172–4
Shortening Hospital Stays After STEMI PCI
multivessel coronary disease or cardiogenic shock
(representing patients with a same-day or next-day
compared with patients with a medium (4 to 5 days)
discharge). These 1,244 patients had a 30-day mor-
or short (#3 days) LOS. Compared with a short LOS,
tality rate twice that of patients discharged after 3 to
patients with a long LOS had a higher 30-day mor-
4 days of hospitalization. These results are intriguing,
tality rate (unadjusted 0.9% vs. 3.5%, respectively).
but they may simply highlight the limitations of the
These findings are not unexpected. Differences in
dataset analyzed. This group of patients represents
baseline characteristics or differences in the severity
only 3.7% of the entire study population. In addition,
of and complications related to myocardial infarction
just as confounders such as comorbidities and
are likely to have driven the major adverse cardio-
severity of illness are likely to affect mortality in pa-
vascular event (MACE) and mortality rates, as well as
tients with a very long LOS, certain confounders may
the LOS. These investigators attempted to adjust for
also play a role in patients with a very short LOS.
differences in severity of illness and comorbidities,
Patients leaving against medical advice or patients
but undoubtedly unmeasured confounders exist. The
transferred to another health care facility (potentially
principal finding of this observational study, even
as a result of clinical instability) comprise potential
with the limitations noted, was that there appeared to
factors that may increase the risk profile of the cohort
be no difference in 30-day mortality and MACE be-
with a very short LOS. These limitations significantly
tween patients with a short (#3 days) LOS and pa-
affect the ability to make any conclusions about this
tients with a medium (4 to 5 days) LOS.
small subset of patients discharged after a very short
An additional important finding is the significant
LOS.
that
Unfortunately, the lack of a large randomized trial
seemed to affect LOS. Smaller hospitals and those in
assessing the safety of an early discharge after pri-
the West and Midwest regions of the United States
mary PCI for STEMI leaves clinicians with incomplete
were much more likely to have a short LOS. Specif-
evidence with which to make decisions. The paper
ically, 35% of patients in the West compared with
by Swaminathan et al. (16) helps affirm that the
only 16% of patients in the Northeast had a short
current practice to discharge lower-risk patients
LOS. This variation in practice may provide an
early (#3 days) is likely as safe as longer hospital
opportunity for a substantial reduction in resource
stays. Given the observed geographic variation, there
utilization at those hospitals and regions with a
is probably an opportunity to apply this practice
geographic
and
hospital-related
variation
generally longer LOS after primary PCI for STEMI.
more broadly, thereby achieving significant health
Although clinical outcomes and quality must be
care cost savings while maintaining the quality of
carefully monitored with such change in practice, the
STEMI care.
adjusted analysis by Swaminathan et al. (16) indicates that such outcomes can be achieved with a shorter
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
LOS.
Frederic S. Resnic, Department of Cardiovascular
In
a
secondary
analysis,
these
investigators
Medicine, Lahey Hospital and Medical Center, 41 Mall
examine the mortality rates in a small subset of pa-
Road,
tients who were hospitalized for 1 to 2 days
[email protected].
Burlington,
Massachusetts
01805.
E-mail:
REFERENCES 1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a
5. Berger AK, Duval S, Jacobs DR, et al. Relation of length of hospital stay in acute myocardial
9. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management
report from the American Heart Association. Circulation 2014;129:e28–292.
infarction to post discharge mortality. Am J Cardiol 2008;101:428–34.
2. Agarwal S, Garg A, Parashar A, Jaber WA, Menon V. Outcomes and resource utilization in STelevation myocardial infarction in the United States: evidence for socioeconomic disparities. J Am Heart Assoc 2014;3:e001057.
6. Spencer FA, Lessard D, Gore JM, Yarzebski J, Goldberg RJ. Declining length of hospital stay for acute myocardial infarction and postdischarge outcomes: a community-wide perspective. Arch Intern Med 2004;164:733–40.
of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61: e78–140.
3. Levine SA, Lown B. “Armchair” treatment of acute coronary thrombosis. JAMA 1952;148:
7. Kociol RD, Lopes RD, Clare R, et al. International variation in and factors associated with hospital
1365–9.
readmission after myocardial infarction. JAMA 2012;307:66–74.
4. Topol EJ, Burek K, O’Neill WW, et al. A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion. N Engl J Med 1988;318: 1083–8.
8. Chin CT, Weintraub WS, Dal D, et al. Trends and predictors of length of stay after primary percutaneous coronary intervention: a report from the CathPCI Registry. Am Heart J 2011;162:1052–61.
10. Bax JJ, Baumgartner H, Ceconi C, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. Eur Heart J 2012;33:2569–619. 11. Newby LK, Eisenstein EL, Califf RM, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med 2000;342:749–55. 12. Noman A, Zaman AG, Schechter C, Balasubramaniam K, Das R. Early discharge after primary
1173
1174
Resnic and Shah
JACC VOL. 65, NO. 12, 2015 MARCH 31, 2015:1172–4
Shortening Hospital Stays After STEMI PCI
percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2013;2:262–9. 13. Kotowycz MA, Cosman TL, Tartaglia C, et al. Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction: a prospective and randomized trial in low risk primary percutaneous coronary intervention patients (the Safe-Depart Trial). Am Heart J 2010;159:117. e1–66.
14. Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. J Am Coll Cardiol 1998;31:
16. Swaminathan RV, Rao SV, McCoy LA, et al. Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry.
967–72.
J Am Coll Cardiol 2015;65:1161–71.
15. Jirmar R, Widimsky P, Capek J, Hlinomaz O, Groch L. Next day discharge after successful primary angioplasty for acute ST elevation myocardial infarction: an open randomized study “Prague-5.” Int Heart J 2008;49:653–9.
KEY WORDS length of stay, percutaneous coronary intervention, ST-segment elevation myocardial infarction
