Is Same-Day Discharge After Elective PCI in the Elderly Ready for Prime Time?

   In the modern era of elective cardiac catheterization, there is a major difference in hospital discharge after a diagnostic and interventional procedure. While the majority of diagnostic catheterization is performed on an outpatient basis, overnight stay is still the standard practice for patients who undergo percutaneous coronary intervention (PCI). This discrepancy is primarily due to concerns of access-site complications and abrupt vessel closure after discharge, especially in elderly patients who are more likely to have multiple comorbidities.¹ The primary advantages of same-day discharge after PCI are the potential reduction in healthcare expenditure, improved utilization of hospital beds and better quality of life for patients.² There is a mounting body of evidence establishing the safety of this approach, mostly in low-risk and younger patients.³ However, there are limited data on elderly patients for outpatient PCI. In this issue, Ranchord and colleagues⁴ investigated the feasibility and safety of same-day discharge after PCI in the elderly cohort in a single-center observational study in New Zealand. In total, 212 patients aged 75 years or older were compared to their younger control counterpart (1,365). This study found that there was no difference in major adverse cardiac events (MACE) in-hospital, at discharge and at 30-day follow up between the two groups. Surprisingly, the majority of elderly patients were successfully discharged on the same day (84%) despite higher-risk PCIs such as chronic total occlusion, saphenous vein graft and left main stem lesions. Overall, the incidence of transfemoral access-site complications was relatively low, even though there was very low usage of femoral vascular closure devices and bilvalirudin. Interestingly, all elderly patients who underwent transradial PCI (9%) were discharged the same day without complications. Given the findings of this study, the authors concluded that same-day discharge after PCI is safe in the elderly population if certain criteria were met including detailed preprocedural discharge planning, a minimum of 6-hour post-procedural observation and exclusion of patients with suboptimal angiographic results or periprocedural complications. The emergence of day-case angioplasty is driven by the increasing number of PCI procedures along with the pressure to reduce bed occupancy and hospital costs. Vascular complications following a successful PCI are a major factor limiting same-day discharge.⁵ The virtual absence of major access-site complications combined with rapid mobilization makes transradial PCI ideal for outpatient PCI. In fact, there are extensive data showing the safety and feasibility of transradial PCI in comparison to transfemoral PCI, in day-case PCI, in high risk PCI, in adjunctive PCI with use of glycoprotein IIb/IIIa inhibitors and in elderly patients above age 75.^6–10 The caveat is that there is a learning curve and time investment for radial access intervention before this technique can be applied and become efficient in the management of the interventional workload.¹¹ Once this technique is adopted, most elective PCI patients can potentially be managed as day cases with no early bleeding or cardiac complications. More importantly, use of the radial approach also leads to improved quality of life after the procedure compared to the femoral approach and is preferred by the majority of patients.¹² Currently, the 2009 Society for Cardiovascular Angiography and Interventions (SCAI) consensus statement cautions against same-day discharge after most PCI cases.¹³ Furthermore, health insurance companies have not provided incentives for this type of efficient and effective method of care. It should be in their interest to reimburse appropriately given the potential cost reduction with outpatient PCI. The evolution of PCI practice will lead towards transradial cardiac catheterization and day-case angioplasty as the gold standard for routine elective PCI. We believe that same-day discharge after PCI is safe in all spectrums of patients, whether young or old, whether with multiple or no comorbidities, or with high- or low-risk lesion characteristics, especially if the procedure is performed via the transradial approach given the robust data supporting it. From the Division of Cardiology, Beth Israel Medical Center, New York, New York. The authors report no conflicts of interest regarding the content herein. Address for correspondence: Tak W. Kwan, MD, Division of Cardiology, Beth Israel Medical Center, 16 Street at 1st Avenue, New York, NY 10013. References

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