Artículo de Revisión
Same-day hospital discharge percutaneous transluminal angioplasty: can we consider it the strategy of choice during the COVID-19 pandemic?
Gabriel Dionisio, Alicia Terragno, Sergio Centeno
Revista Argentina de Cardioangiología Intervencionista 2020;(3): 0106-0108 | Doi: 10.30567/RACI/20203/0106-0108
The better understanding of ischemic heart disease, associated with the progress of endovascular techniques, has positioned percutaneous coronary intervention (PCI) as a safe and effective therapeutic method. Currently, scheduled PCI is a procedure with a very low probability of presenting a serious complication in the first 24 hours. Various protocols have successfully applied the same-day discharge PCI strategy in selected patients, with good results. This initially very restricted strategy is impressive to represent a viable alternative. This review attempts to address the issue, its relevance in routine practice, and in this particular moment of healthcare medicine during the COVID-19 pandemic.
Palabras clave: percutaneous coronary interventions, same day discharge PCI, COVID-19 pandemic.
El mejor entendimiento de la cardiopatía isquémica, asociado al progreso de las técnicas endovasculares, ha posicionado a la angioplastia transluminal coronaria (ATC) como un método terapéutico seguro y eficaz. Actualmente, la ATC programada constituye un procedimiento con una muy baja probabilidad de presentar una complicación grave en las primeras 24 horas. Diversos protocolos de trabajo han logrado aplicar la estrategia de ATC con alta en el mismo día, en pacientes seleccionados, con buenos resultados. Esta estrategia, inicialmente muy restringida, impresiona representar una alternativa viable. La presente revisión intenta abordar el tema, su relevancia en la práctica habitual y el lugar que ocuparía en este particular momento de la medicina asistencial durante la pandemia COVID-19.
Keywords: angioplastia coronaria, angioplastia coronaria con alta en el día, pandemia COVID-19.
Los autores declaran no poseer conflictos de intereses.
Fuente de información Colegio Argentino de Cardioangiólogos Intervencionistas. Para solicitudes de reimpresión a Revista Argentina de Cardioangiología intervencionista hacer click aquí.
Recibido 2020-06-23 | Aceptado 2020-07-30 | Publicado 2020-09-30
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.
Cardiovascular disease is a major health issue in developed countries1.1 In this context, the better understanding of ischemic heart disease associated with the advance of endovascular techniques has turned the percutaneous transluminal angioplasty (PTA) into a safe and therapeutic procedure. Twenty-five years ago, a high percentage of patients who required myocardial revascularization surgery (MRS) withday-or-week long hospital stays and who had other associated comorbidities can now be treated with a PTA withregular follow-up 24 hours after the procedure2.
Currently, eligiblePTAsare a procedure with very low chances of serious complications within the first 24 hours after the procedure3. Also, radial access facilitates very fast recoveries and avoids the risk of femoral artery bleeding that can lead to serious complications.2 Over the past two decades, several proposals have been made to shorten the hospital stay of patients treated with PTA by using the same-day modality.
CRITERIA PROPOSED BY THE SOCIETY
FOR CARDIAC ANGIOGRAPHY AND
INTERVENTIONS FOR THE SELECTION
OF PATIENTS ELIGIBLE TO UNDERGO PTA
WITH SAME-DAY HOSPITAL DISCHARGE
The criteria initially proposed by the Society for Cardiac Angiography and Interventions (SCAI) to include a patient in a same-day hospital discharge program are4,5:
• Stable angina or silent ischemia.
• Normal ejection fraction.
• Preload with thienopyridines.
• Lack of comorbidities.
• Single-vessel disease.
• Single-vessel PTAwith only 1 stent < 28 mm via radial, humeral or femoral access with an occluder device or safe manual compression.
• Lack of complications.
• A distance of less than 32 kilometers from the patient’s home to the PCI-capable center.
• Proper home care at and access to the emergency system.
These recommendations limited access toPTAwith same-day hospital discharge percutaneous transluminal angioplasty (SDHD-PTA) to a small group of patients despite the good results reported by several clinical trials, reviews, and meta-analyses with much wider criteria6-9. Back in 2018, SCAI published an expert consensus document update extending the indication to the following groups10:
• Preload with thienopyridines (not exclusive).
• Presence of compensated comorbidities: diabetes, heart failure, COPD, chronic kidney disease, peripheral vascular disease.
• Multi-vessel PTA, chronic total coronary occlusions without limits to the number or length of the stents used.
The first large scale clinical trials ever conducted were the EPOS and the EASY6,7. The first one published in 2007 included 800 patients randomized to undergo an elective angioplasty followed by 4-hour hospital discharges versus 24-hour hospital stays. Patients with previous PTA or myocardial revascularization surgery, left main coronary artery disease or multivessel disease were treated with an elective angioplasty. The presence of comorbidities or heart failure were not considered exclusion criteria. Femoral access was used with doses of 100 mg of aspirin followed by the intra-arterial administration of 5000 units of sodium heparin or 7500 units for procedures over 90 minutes. In cases of stent implantation an additional 100 mg of aspirin, 300 mg of IV clopidogrel, and 75 mg/day for a month were administered. Hemostasis was manual. Although the inter-group results did not show any significant differences, there was a non-negligible crossing rate towards the hospital stay group.
The EASY trial was published in 2018 included 1005 patients between 2003 and 2005 following an angioplasty performed via radial access in the NSTEACS (non-ST-segment elevation acute coronary syndrome) setting. Patients were randomized to a single bolus of abciximab and SDHD-PTA vs a 12-hour continuous infusion bolus without same-day hospital discharge. No differences were seen between the 2 groups.
The CathPCI registry included over 107,000 patients and showed that elderly patients (69 years to 78 years) with comorbidities, femoral access, ventricular dysfunction, and angioplasty of complex lesions had good results in selected cases8.
Successive reviews and meta-analyses showed no differences of mortality, myocardial infarction, and MACE between the SDHD-PTA strategy and conventional postprocedural management with hospital stays beyond 24-hour mark9-11.
Several observational national experiences have been developed with good results. Back in 2009 an observational protocol included 100 very low-risk patients treated with SDHD-PTA via radial access without complications. Other additional protocols have been designed including more complex patients in the NSTEACS (non-ST-segment elevation acute coronary syndrome) setting. The results of one of these protocols was reportedat the annual Argentine Congress of Cardiology of 201612.
An observational, retrospective clinical trial conducted in 2018 included over 600 patients treated via right radial access. The characteristics of patients treated with SDHD-PTA were compared to those of patients who remained hospitalized. Many of the patients from the SDHD-PTA group were over 70 years and had ventricular dysfunction, some with left main coronary artery disease or previous revascularization surgery and other high-risk criteria. The results of this study did not vary between both groups13.
In 2019 we presented the AHORA 6 clinical trial (coronary angioplasty with fast hospital discharge in 6 hours)14. This trial was our very first randomized, prospective, and comparative approach on the management of selected patients to undergo a coronary angioplasty with fast hospital discharge in just 6 hours. We compared a group of patients < 75 years with stable chronic angina, and an ejection fraction of 30% or higher, no previous MRS, left main coronary artery disease or a single patent vessel. Radial access was used, and patients were divided into 2 cohorts: the intervention group (G1) and the control group (G2). The G1 was closely monitored for 6 hours if the PTA results were optimal and after an independent core lab reviewed the operators performing the procedure.In the absence of symptoms or postprocedural electrocardiographic changes, the patients were discharged the same day with telephone follow-ups that night and the next day. The G2 was treated using the routine clinical practice and was discharged the next day.
After treating nearly 100 patients, we did not see a higher risk in the PTAs performed via radial access with hospital discharges at the 6-hour mark compared to the conventional strategy in selected patients.
The same-day hospital discharge percutaneous transluminal angioplasty has proven to be a safe alternative in selected patients. However, some health professionals and institutions are still reluctant to establish programs with this procedure in their therapeutic armamentarium.
The COVID-19 pandemic has impacted the care provided to cardiovascular patients. Recent publications confirm a significant reduction of outpatient practice15.
Actually, this is a multifactor phenomenon. Having to create spaces for confinement purposes has reduced the capacity of hospitals to have stay areas available for patients in the intensive care setting. Detecting a patient who tests positive for COVID-19 means even fewer hospital stay areas following the activation of confinement protocols. Finally, in many cases, patients say they do not want to seek medical attention because they fear they may get infected.
Offering an alternative with a short hospital stay in a “green”or “clean” intermediate care setting may be a viable and cost-effective option for the healthcare system. Another important aspect is the need to inform the population on the safety profile of this therapeutic approach.
The new challenge that the COVID-19 pandemic poses for all of us can be an opportunity to rethink our routine clinical practice.
Braunwald E, Zipes DP, Libby P. Braunwald’s Cardiología. Madrid, Marbán Libros, S. L. 2004: Prefacio.
Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and impact on major bleeding and ischemic events: A systematic review and meta-analysis of randomized trials. Am Heart J 2009;157:132-40.
Cutlip DE, Baim DS, Ho KKL, et al. Stent thrombosis in the modern era a pooled analysis of multicenter coronary stent clinical trial. Circulation 2001;103:1967-71.
Chambers CE, Dehmer GJ, Cox DA, et al. Deﬁning the length of stay following percutaneous coronary intervention: An expert consensus document from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2009;73:847-58.
SCAI Expert Consensus Statement: 2016 Best Practices in the Cardiac Catheterization Laboratory. Catheter Cardiovasc Interv 2016;88(3):407-23.
Heyde GS, Koch KT, de Winter RJ, et al. Randomized trial comparing same-day discharge with overnight hospital stay after percutaneous coronary intervention: Results of the Elective PCI in Outpatient Study (EPOS). Circulation 2007;115:2299-306.
Bertrand OF, Rodes-Cabau J, Larose E, et al. One-year clinical outcome after abciximab bolus-only compared with abciximab bolus and 12-hour infusion in the Randomized EArly Discharge after Transradial Stenting of CoronarY Arteries (EASY) Study. Am Heart J 2008;156:135-40.
Rao SV, Kaltenbach LA, Weintraub WS, et al. Prevalence and outcomes of same-day dis- charge after elective percutaneous coronary intervention among older patients. JAMA 2011;306:1461-7.
Brayton KM, Patel VG, Stave C, de Lemos JA, Kumbhani DJ. Same- day discharge after percutaneous coronary intervention: A meta- analysis. J Am Coll Cardiol 2013;62:275-85.
Bundhun PK, Soogund MZ, Huang WQ. Same day discharge versus overnight stay in the hospital following percutaneous coronary intervention in patients with stable coronary artery disease: A sys- tematic review and meta-analysis of randomized controlled trials. PLoS One 2017;12:e0169807.
Abdelaal E, Rao SV, Gilchrist IC, et al. Same-day discharge com- pared with overnight hospitalization after uncomplicated percutaneous coronary intervention: A systematic review and meta- analysis. J Am Coll Cardiol Cardiovasc Interv 2013;6:99-112.
Telayna JM, et al. Angioplastia coronaria ambulatoria en pacientes de riesgo coronario intermedio. Estudio ACA II. 42º Congreso Argentino de Cardiología. Octubre 2016.
Nau G, Abud M, Pedernera G. Implementación de un programa de angioplastia coronaria ambulatoria en pacientes con riesgo incrementado. Revista Argentina de Cardiología. Vol 86 número 3 / junio 2018.
Dionisio G, Terragno A, Puerta L, et al. Resultados preliminares de un estudio randomizado sobre angioplastia coronaria con alta en el día: estudio AHORA 6 (Angioplastia con alta Hospitalaria Rápida en 6 horas). 45 Congreso Argentino de Cardiología de la Sociedad Argentina de Cardiología.
Rodríguez Leor O, Cid Álvarez B, Ojeda S, et al. Impacto de la pandemia COVID 19 sobre la actividad asistencial en cardiología intervencionista en España. REC Interv Cardiol. 2020;2:82-9.
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