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Let Me Out of Here! How Long to Remain Hospitalized After an MI COPYRIGHT © 2017, ALL RIGHTS RESERVED From the Publishers of Consult Guys
Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2017
Guys: Wonder if you can help me out. I am involved in a “friendly” disagreement with another member of my practice and when it comes to unbiased, expert, and “to the point advice” it’s the two of you who come to mind. So here is a question that for me has been a real stumper. For years I’ve thought that the patient who is treated for STEMI by angioplasty and is deemed “low risk” should remain in the hospital for at least 5-6 days just to be sure that no complications occur in the immediate post MI – post revascularization period. One of my colleagues says that it is safe to discharge a STEMI patient home 48 hours after angioplasty if they are stable. I’ve checked guidelines and surprisingly there is no clear answer. So what do you guys think? Is it 48 hours and out or should the uncomplicated post STEMI patient wait it out for a total of 5 days? Copyright © 2017
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al; American College of Emergency Physicians. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:485-510. [PMID: 23256913] doi:10.1016/j.jacc.2012.11.018
Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al; Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569-619. [PMID: 22922416] doi:10.1093/eurheartj/ehs215
Grines CL, Marsalese DL, Brodie B, Griffin J, Donohue B, Costantini CR, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967-72. [PMID: 9561995]
PAMI-II 1998Low riskAge < 70 No arrhythmias after PTCAOne- or two-vessel CADLVEF > 45%Successful PTCA of infarct arteryLength of stay, 4.2 days vs 7.1 daysNo difference at 6 months237 patients accelerated care; 234 standard care Grines CL, Marsalese DL, Brodie B, Griffin J, Donohue B, Costantini CR, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967-72. [PMID: 9561995]
James Herrick, MDMay 14, 1912 Association of American Physicians Annual Meeting Patients may survive myocardial infarctionLinked clinical observation to autopsy results.Reported cases where old coronary occlusions and myocardial scar found in those who died from noncardiac causes.Landmark observation. Copyright © 2017
James Herrick, MD1918Linked clinical findings, ECG, autopsy results Widespread acceptance of the role of technology in MI diagnosisEmpirical MI careBedrest to allow infarct to heal Copyright © 2017
Arthur Master, MD1936 The Mt. Sinai (NYC) approach to care of the patient with uncomplicated MI MI was a “wound” of the heart. For the heart to heal physical activity, mental activity, digestion had to be minimized6 weeks of complete and absolute bedrestWeek 7–Bed to chairWeek 8–Walk with assistance“Undernutrition” therapy–800 cal / dayIncreased nutrition led to increased cardiac outputFewer calories, less demand on the heart Copyright © 2017
Editorial 1950Strict bedrest standard of care for almost 40 yearsThere is no evidence that bedrest affects MI outcome Copyright © 2017
Armchair Treatment LEVINE SA, LOWN B. "Armchair" treatment of acute coronary thrombosis. J Am Med Assoc. 1952;148:1365-9. [PMID: 14907380]
40 Years After Herrick’s Original PaperArmchair treatment of acute coronary thrombosisSitting in a chair is less cardiac work than lying supine Bedrest: Constipation, DVT, pneumonia, urine retentionProtocol: OOB to chair day 1 or 281 patientsAnecdotal results, coincidental findingsOutcomes so dramatic that it was the beginning of the end for strict bedrest Copyright © 2017
64-year-old with epigastric painECG 12 hours after onset of symptoms: Acute anterior MIRx: O2, MSO4, warfarin, bedrestDay 4 post MI: Armchair therapy of MI Chair twice daily. Initially 15 minutes increased to 45 minutesDay 9 post MI (day 5 armchair therapy). Pleuritic chest pain while sitting. Armchair therapy aborted. Conventional therapy (strict bedrest) begunVisitor4th week post MI OOB to chair5th week post MI, sat up with assistance7th week post MI, walkingBeginning 8th week post MI discharged to home Copyright © 2017
Harpur JE, Conner WT, Hamilton M, Kellett RJ, Galbraith HJ, Murray JJ, et al. Controlled trial of early mobilisation and discharge from hospital in uncomplicated myocardial infarction. Lancet. 1971;2:1331-4. [PMID: 4108259]
First randomized study of early ambulation vs bedrest59 years after Herrick’s paper (1971)Early ambulation: Bedrest 7 days, mobilization day 8, discharge day 15Standard care: Bedrest 20 days, mobilization day 21, discharge day 28No difference in outcome Copyright © 2017
1976: NIH Consensus ConferenceGuideline for the uncomplicated patientBedrest: 4 days Increasing activity: 5-10 daysDischarge day: 9-14 Copyright © 2017
The Current EraBeta-blockers Coronary artery revascularizationCopyright © 2017
Acute Revascularization in STEMI Has Decreased Mechanical Complications French JK, Hellkamp AS, Armstrong PW, Cohen E, Kleiman NS, O'Connor CM, et al. Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI). Am J Cardiol. 2010;105:59-63. [PMID: 20102891] doi:10.1016/j.amjcard.2009.08.653
Acute Revascularization in STEMI Has Decreased Mechanical Complications Free wall rupture 0.52% Acute ventricular septal defect 0.17% (fibrinolytic rx)Papillary muscle rupture 0.26%Median incidence first 24 hours after initial symptomsRisk factorsOlder age (> 68)FemalePulmonary edemaQ waves on ECGHigh Troponin French JK, Hellkamp AS, Armstrong PW, Cohen E, Kleiman NS, O'Connor CM, et al. Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI). Am J Cardiol. 2010;105:59-63. [PMID: 20102891] doi:10.1016/j.amjcard.2009.08.653
Ventricular Arrhythmias in the STEMI Patient Treated With PCIVT/VF 5.7% incidence66% before the conclusion of the PCI procedure90% within first 48 hours of presentationRevascularization and beta-blockers associated with reduced incidenceMehta RH, Starr AZ, Lopes RD, Hochman JS, Widimsky P, Pieper KS, et al; APEX AMI Investigators. Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention. JAMA. 2009;301:1779-89. [PMID: 19417195] doi:10.1001/jama.2009.600
Key “times”Door to needleDoor to balloonDoor to device Revascularization to door time Copyright © 2017
Swaminathan RV, Rao SV, McCoy LA, Kim LK, Minutello RM, Wong SC, et al. Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2015;65:1161-71. [PMID: 25814223] doi:10.1016/j.jacc.2015.01.028
National Cardiovascular Data Registry (NCDR)2004–200933,000 patientsSTEMI, age > 65LOS (CMS) = Discharge date – Admit date + 1Ex: Admit Monday, discharge Wednesday= LOS 3Low risk Copyright © 2017
Length of StayOutcomes discharge 48-72 hours post PPCI similar to LOS 4-5 days LOS 1-2 days had mortality twice that of LOS 3-4 day(Transferred elsewhere because of complexity or instability?) Copyright © 2017
Consult Guys’ ResponseYes, in the low risk stable patient who has undergone successful primary PCI as treatment of STEMI, it is probably safe to discharge 48-72 hours after PCIMechanical complications are uncommon and most would have occurred during this period Copyright © 2017
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