Same-day discharge after coronary angioplasty is increasingly popular but still not the gold standard

The length of hospital stay after elective coronary angioplasty varies significantly among operators and hospitals, according to a recent survey of interventional cardiologists in the United States (US), Canada, and the United Kingdom (UK), published in Catherization and Cardiovascular Interventions.

While same-day discharge is a routine proceeding in the UK, most interventional cardiologists surveyed mentioned that they were not aware of the existence of any guideline featuring criteria differentiating patients that can be safely discharged from those who should stay at least overnight.

The most reliable reference available on this subject matter was the expert consensus statement issued by the Society for Cardiovascular Angiography and Interventions  (SCAI), published in 2009. However, advancements in technology and clinical practice in itself have rendered this document obsolete.

The current dilemma is the length of observation for patients who have undergone elective coronary angioplasty. Some physicians, based on a mixture of randomized and observational evidence, are convinced that same-day discharge is safe, appropriate, and cost-effective. Others, based on their own criteria, prefer keeping these patients in observation.

Nowadays, it seems as if same-day discharge was a routine proceeding in some sites, while others are not even open to that alternative.

The wide difference between physicians in the US and those in the UK and Canada is entirely unsurprising. US physicians traditionally favor the transfemoral approach, which constitutes a significant hindrance for same-day discharge.

The SCAI expert consensus statement should be updated as regards the length of stay after scheduled coronary angioplasty, taking into account the vast randomized and controlled evidence on the issue published since 2009.

A temporary solution till the creation of a supporting document on this subject matter would be to have each institution adopt its own protocol. This would be more beneficial for high-volume operators and institutions.

Other variables that should be considered are harder to measure because they are related to each individual patient. His/her ability to understand instructions, his/her social support system, and the distance between the hospital and his/her home are factors that should be taken into account while deciding on the possibility of an early same-day discharge.

Conclusion

While there is considerable variation among physicians, most still prefer overnight observation for patients who have undergone a scheduled coronary angioplasty. Current evidence warrants the update of clinical practice guidelines.

Editorial

A large randomized study assessing both strategies should be carried out. Until that study is finalized, same-day discharge after angioplasty without complications is a reasonable course of action in selected patients.

Theoretically, the aforementioned randomized study needed should include over 17,000 patients in order to have the statistical power to reach a definitive conclusion (given the low frequency of events). The availability of this information in the short term, if ever, seems unlikely.

Original title: Variation in practice and concordance with guideline criteria for length of stay after elective percutaneous coronary intervention.

Reference: Din JN et al. Cath Cardiovasc Interv. 2017;Epub ahead of print.

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