When early discharge after percutaneous coronary intervention is much too early

The early bird catches the worm
William Camden

The recent preliminary study on feasibility of same-day discharge after percutaneous coronary intervention (PCI) published in Polish Archives of Internal Medicine seems to provide a clear and straightforward message – it is both safe and feasible [1]. While important given its scope, stance, and size, the results of this work are largely in line with several other studies that have been published so far [2, 3]. The COVID pandemic has certainly pushed the issue forward and created space for discussion [4].
A recent study by Rathod et al. has also given us observational evidence for a staggering reduction of hospital stay with a median of 24 h in ST-elevation myocardial infarction (STEMI) patients without any apparent additional short or long term risk for patients [5]. We agree clearly that early or same day discharge after PCI or even after primary PCI (PPCI) for STEMI in a preselected low risk group is possible and should be incorporated into clinical practice based on evidence and strict patient flow algorithms [6]. However, some questions naturally arise: what are we really pursuing with the results of such studies? Is ambulatory or drive-through PCI the next available (and desirable) scenario even though over 20% of patients initially scheduled for same-day discharge were disqualified in the discussed study [1]? Have we reached the reasonable discharge time window limit and is patient safety the only reason we keep them for a median of 2 days in a non-complicated PCI nowadays? Furthermore, while cost savings are apparent with same-day discharge, the potential cost-effectiveness of such a strategy which involves telemonitoring and additional follow-up is yet to be determined, hopefully in a pragmatic randomized trial. Also the rationale for renal function testing after several days in potentially renal compromised elderly patients as well as no additional follow-up until day 30 from PCI needs scientific confirmation.
Notably, the major issue that early discharge unfortunately neglects is effective and comprehensive secondary prevention, encompassing the constellation of education measures [7]. When should they be implemented if the patient does not stay overnight and is discharged the same day? From a patient perspective this would seem like an ambulatory procedure with negligible risk with early mobilization (especially easier with the radial approach used in the majority...


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