TCT-524 Does the Zwolle Percutaneous Coronary Intervention Risk Index Identify Low Risk ST-Elevation Myocardial Infarction Patients for Early Discharge?

Abstract

National Audit Project (MINAP) database and patient notes. Mortality data was confirmed using the Office of National Statistics database with follow-up ranging from 3 to 44 months. Results: The mean age was 60Ϯ14years and 80.3% patients were male. The incidence of previous coronary disease in the cohort was 27.8%, 32.8% patients were hypertensive, 37.7% smokers, 24.6% hypercholesterolaemic and 8.2% had known diabetes. 45% patients had a witnessed arrest and 43.4% were directly conveyed to the pPCI centre. Mean arrest-to-arrival time in the cohort was 115Ϯ24mins with a mean call-to-balloon time of 168Ϯ24mins. The rate of successful pPCI in the cohort was 85% with 21.7% having 3-vessel disease. Shock was present in 16% and severe left ventricular impairment in 25% patients. The in-hospital mortality within the cohort was 21%. Of the patients who died 14 were cardiovascular deaths, 3 being shortly after return of spontaneous circulation in the catheterisation laboratory, and 6 of all deaths were secondary to hypoxic brain injury in Intensive Care. 79% of all patients survived to discharge. Of the patients who survived 92% were discharged with no neurological deficit. At follow-up (12-44 months in 62% patients) 100% of patients who survived to discharge were still alive. Conclusions: Here we present descriptive data of a large, contemporary cohort of STEMI admissions for pPCI that are complicated by OOHCA. Here we show a 79% survival rate to discharge, a higher proportion than previously reported, with good long term prognosis after discharge.Background: ST elevation myocardial infarction (STEMI) complicated by out of hospital cardiac arrest (OOHCA) is associated with significant mortality. Small observational studies have shown survival benefit with primary percutaneous coronary intervention (pPCI) in this setting. We sought to identify clinical characteristics and predictors of outcome in STEMI complicated by OOHCA in a large patient cohort in the era of pPCI. Methods: Between January 2008 and October 2011, STEMI admissions to a regional cardiac centre were retrospectively analysed. 122 patients with OOHCA in the context of STEMI were identified. Clinical and procedural data was collected from the UK Myocardial Ischaemia National Audit Project (MINAP) database and patient notes. All cause mortality data was confirmed using the Office of National Statistics mortality database with follow-up ranging from 3 to 44 months. Results: The mean age of patients was 60Ϯ14years, 80.3% were male and 43% were direct admissions via the ambulance service, 57% being transferred from district hospitals. The in-hospital mortality within the cohort was 21% with 96/122 patients surviving to discharge. There were no significant differences in patient demographics, previous cardiac history, arrest rhythm or referral source between patients who survived to discharge compared with those who died. Patients who died had significantly higher incidence of cardiogenic shock (pϭ0.0289), 3-vessel coronary disease (pϭ0.0125), severe left ventricul...

From D2B to B2D: Value based STEMI care!

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Use of the CADILLIAC Risk Score can accurately identify patients for safe early discharge after PCI for STEMI.

Early discharge has the potential to both improve the quality and decrease the cost of care for STEMI patients.

Prospective validation of this risk score and formal cost analysis would facilitate widespread utilization.

Evolving clinical practice, patient demands and economic pressures have combined to shift the focus in healthcare from volume to value [1]. First, while the CADILLAC Score represents one tool to risk stratify STEMI patients, others such as the TIMI, GRACE, PAMI, and Zwolle Scores have also been proposed and validated in the literature [3][4][5]. Frequently used and high cost interventions, such as percutaneous coronary intervention (PCI), are examples of areas in which value based care are vital to continued growth.

One of the most expensive aspects of the care we provide comes from the length of time patients spend in the hospital.

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“…Classically defined as quality over cost, the value model encourages providers to ensure that care is not just high quality, but also cost effective. The protocol recommended eligible low risk patients not be admitted to the CCU and have a goal for discharge in < 48 hr [5].Preliminary prospective results indicate 75% of eligible patients utilized the early discharge protocol and the yearly savings were nearly 1 million dollars. We further know that prolonged hospitalizations put patients at risk for complications.…”

“…First, while the CADILLAC Score represents one tool to risk stratify STEMI patients, others such as the TIMI, GRACE, PAMI, and Zwolle Scores have also been proposed and validated in the literature [3][4][5]. Although the results support the potential safety of early discharge of low risk STEMI patients, they only provide a hint at potential cost benefit that could be realized by the healthcare system.…”

“…The protocol recommended eligible low risk patients not be admitted to the CCU and have a goal for discharge in < 48 hr [5]. The protocol recommended eligible low risk patients not be admitted to the CCU and have a goal for discharge in < 48 hr [5].…”