Early to bed and early to rise makes a patient healthy, a hospital wealthy, and a doctor wise, or not?

Patients with ST-segment elevation myocardial infarction (STEMI) require immediate clinical vigilance, heart rhythm monitoring and medical therapy due to the risk of malignant arrhythmias, heart failure and other complications. Reperfusion therapy – primary percutaneous coronary intervention (PPCI) or thrombolysis with later coronary angiography – provided as soon as possible is the cornerstone of treatment, with continuation of initial clinical risk stratification (by knowledge of coronary anatomy), becoming the first step before hospitalization, where clinical observation is continued, risk stratification completed, acute and preventive medical therapy started, complications corrected when needed, education and preparation for future chronic care launched.

The widespread use of PPCI and evidence-based medical therapy has led to a major reduction in hospital mortality and complications rate,^1–3 with an improvement in early post-infarct left ventricular ejection fraction (LVEF),¹ reducing the need for monitoring and clinical observation as well as the need for therapies mandatory for heart failure or left ventricular dysfunction, such as beta-blockers or angiotensin-converting-enzyme inhibitors, which may require progressive dosing and titration, often lasting several days. The length of stay for STEMI has changed proportionally,^4,5 and now a substantial proportion of these patients may be considered for an earlier discharge, which should be determined on an individual basis, according to the patient cardiac risk, comorbidities, functional status and social support.⁶

The 2017 European Society of Cardiology (ESC) STEMI guidelines recommend considering early discharge between the second and third day in selected low-risk patients.⁶ A number of initial randomized trials^7–10 and later observational studies with discharge as soon as within the first two days,^11–13 coming after an older, very small trial of next-day discharge,¹⁴ suggest that it is a safe practice in selected patients.

In this issue of European Journal of Cardiovascular Prevention, Gong et al. publish a meta-analysis including the five randomized controlled trials that evaluated the safety of early discharge for patients with STEMI treated with PPCI in 1575 patients in total. Although the results are clear – shortening the length of stay in selected patients with STEMI has no effect in short-term mortality and readmission rates – there are several limitations that should be taken into consideration. First, only 806 patients were included in the early discharge strategy arms. Second, early discharge was defined differently in the trials, ranging from 24 to 30 h to a maximum of 72 h. Third, the criteria used to define ‘low-risk’ also varied among trials. Fourth, follow-up was limited to 30 days in four out of five trials. The notion that shortening length of hospital stay reduces hospital costs is intuitive and has been proven.⁷ It may also reduce the stress suffered by patients and relatives, and perhaps their perception of wellbeing. However, the optimal length of stay for each patient is not well known, and the safety of this approach remains ill defined.

Selecting the appropriate candidates for early discharge after PPCI is one of the challenges. A number of criteria have been developed to predict patients at lowest risk of complications. The PAMI-2 criteria select as low risk patients those under 70 years, with left ventricular ejection ventricular fraction >45%, one- or two-vessel disease, successful revascularization and no persistent arrhythmias.⁷ Low risk patients according to the Zwolle PPCI index are those with Killip class I, Thrombolysis in Myocardial Infarction (TIMI) flow grade following angioplasty 3, age <60 years, one- or two-vessel disease, non-anterior infarction and ischaemic time ≤4 h.¹⁵ According to the CADILLAC risk score, low-risk patients are those with 0–2 points calculated from seven variables weighted according to their odds ratio for one-year mortality: LVEF <40% (four points), Killip class 2/3 (three points), renal insufficiency (three points), TIMI flow grade after PCI 0 to 2 (two points), age >65 years (two points), anaemia (two points) and triple-vessel disease (two points).¹⁶ No face to face comparison between these scores has been performed and therefore no evidence-base recommendation can be given. However, in our view, in addition to the simplicity, it is difficult to ignore the success of the reperfusion procedure and the absence of left ventricular dysfunction and arrhythmias when determining a very early discharge in a STEMI patient. More recently, the FASTEST mnemonic rule (Femoral approach, Age >65, Systolic dysfunction, postprocedural TIMI flow <3, Elevated creatinine level >1.5 mg/dL, Stenosis of left-main coronary artery and Two or higher Killip class) has been proposed for very early discharge after PPCI but prospective validation is needed.¹³

One critical point highlighted by the ESC STEMI Guidelines is that early discharge may be considered in selected low-risk patients only if early rehabilitation and adequate follow-up are arranged.⁶ Starting patient education and setting a comprehensive preventive plan, including cardiac rehabilitation, lifestyle changes and secondary prevention therapies as soon as possible after myocardial infarction, is of critical importance.¹⁷ Using a multidisciplinary approach and engaging patients, relatives and caregivers is equally important. One potential disadvantage of very short hospital stays is the misperception that suffering a STEMI is something that can be quickly and ‘easily’ solved and, in the end, is not really such a serious matter. This may act as a disincentive for patients to engage in cardiac rehabilitation and comply with lifestyle recommendations and secondary prevention measures. The 2017 ESC STEMI Guidelines alert that short hospital stay implies limited time for proper patient education and up-titration of secondary prevention treatments and, consequently, these patients should have early post-discharge consultations with a cardiologist, primary care physician or specialized nurse scheduled and be rapidly enrolled in a formal rehabilitation programme, either in hospital or on an outpatient basis, highlighting the importance of close collaboration between all stakeholders.⁶ It is, therefore, essential that future randomized trials not only test the short-term safety of very early discharge but assess long-term effects on lifestyle, self-care, control of risk factors and, ultimately, a potential increase in late clinical events.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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