Editorial comment
Same-day discharge after elective percutaneous transluminal coronary angioplasty: An instruction manual and call for increased uptake in a burdened National Health Service
Alta no próprio dia após intervenção coronária percutânea eletiva: manual de instruções e repto a maior utilização num Serviço Nacional de Saúde sobrecarregado
Miguel Borges Santos
Serviço de Cardiologia, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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"apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920303081?idApp=UINPBA00004E" "url" => "/21742049/0000003900000008/v1_202012171044/S2174204920303081/v1_202012171044/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S217420492030307X" "issn" => "21742049" "doi" => "10.1016/j.repce.2019.10.002" "estado" => "S300" "fechaPublicacion" => "2020-08-01" "aid" => "1575" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2020;39:443-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Same-day discharge after elective percutaneous coronary intervention: A single center experience" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "449" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Alta no próprio dia após intervenção coronária percutânea eletiva – Experiência de um centro" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1587 "Ancho" => 1079 "Tamanyo" => 53278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PCI patient distribution (19 February 2018-22 February 2019). CCU: Coronary Care Unit; ONS: overnight stay; PCI: percutaneous coronary intervention; SDD: same day discharge.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alberto Rodrigues, Mariana Silva, Carla Almeida, Francisco Castro Ferreira, Gustavo Pires de Morais, Lino Santos, Bruno Melica, Pedro Braga" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Alberto" "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "Mariana" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Carla" "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Francisco Castro" "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "Gustavo Pires de" "apellidos" => "Morais" ] 5 => array:2 [ "nombre" => "Lino" "apellidos" => "Santos" ] 6 => array:2 [ "nombre" => "Bruno" "apellidos" => "Melica" ] 7 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420492030307X?idApp=UINPBA00004E" "url" => "/21742049/0000003900000008/v1_202012171044/S217420492030307X/v1_202012171044/en/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S217420492030307X" "issn" => "21742049" "doi" => "10.1016/j.repce.2019.10.002" "estado" => "S300" "fechaPublicacion" => "2020-08-01" "aid" => "1575" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2020;39:443-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Same-day discharge after elective percutaneous coronary intervention: A single center experience" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "449" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Alta no próprio dia após intervenção coronária percutânea eletiva – Experiência de um centro" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1587 "Ancho" => 1079 "Tamanyo" => 53278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PCI patient distribution (19 February 2018-22 February 2019). CCU: Coronary Care Unit; ONS: overnight stay; PCI: percutaneous coronary intervention; SDD: same day discharge.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alberto Rodrigues, Mariana Silva, Carla Almeida, Francisco Castro Ferreira, Gustavo Pires de Morais, Lino Santos, Bruno Melica, Pedro Braga" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Alberto" "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "Mariana" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Carla" "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Francisco Castro" "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "Gustavo Pires de" "apellidos" => "Morais" ] 5 => array:2 [ "nombre" => "Lino" "apellidos" => "Santos" ] 6 => array:2 [ "nombre" => "Bruno" "apellidos" => "Melica" ] 7 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420492030307X?idApp=UINPBA00004E" "url" => "/21742049/0000003900000008/v1_202012171044/S217420492030307X/v1_202012171044/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Same-day discharge after elective percutaneous transluminal coronary angioplasty: An instruction manual and call for increased uptake in a burdened National Health Service" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "451" "paginaFinal" => "452" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Miguel Borges Santos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Miguel" "apellidos" => "Borges Santos" "email" => array:1 [ 0 => "c.miguel.santos@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Alta no próprio dia após intervenção coronária percutânea eletiva: manual de instruções e repto a maior utilização num Serviço Nacional de Saúde sobrecarregado" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Percutaneous transluminal coronary angioplasty (PTCA) celebrates its 43rd birthday in 2020. Since Andreas Gruntzig first performed this technique in 1977, and Ricardo Seabra-Gomes introduced it to Portugal in 1984, countless technological and procedural developments have significantly increased the success and safety of PTCA. What first started as a high-risk procedure, with cardiac surgery on standby, is currently an outpatient procedure in many places. Early mobilization and discharge after angioplasty enable same-day discharge (SDD), instead of an overnight stay (ONS). In spite of this, the use of SDD varies dramatically according to country and even among centers located close to each other. In Portugal, SDD after PTCA is not the standard of care.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology, Centro Hospitalar de Gaia/Espinho, V. N. Gaia (CH Gaia), paves the way for increasing SDD in Portugal by publishing the first Portuguese report that describes ONS and SDD populations and compares outcomes after elective PTCA. The study by Alberto Rodrigues et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> is a contemporary (2018), prospective, observational, single-center cohort study that included 155 consecutive patients who underwent elective (scheduled or ad-hoc) PTCA over one-year. Patients were routinely placed in a nurse-led eight bed recovery room, where they stayed until hospital discharge. Importantly, CH Gaia's current practice does not include post-procedure electrocardiogram (ECG) or enzyme assay unless there is clinical suspicion of complications, and the minimum in-hospital surveillance was of four hours. Despite the existence of a locally approved protocol for SDD that selects non-complex patients/procedures, the operator was free to decide patient's course at his or her discretion, professional opinion and specific context. Femoral access did not preclude SDD, especially when vascular closure devices were successfully used. SDD patients received telephone follow-up at 24 h and 30 days post-procedure. The investigators found that patient convenience (28.8%, caused primarily by the end of the procedure after 16:00 hours) and operator preference (22.5%) were the main reasons for ONS. Regarding safety, all relevant complications were intraprocedural or early after the procedure, supports the case for a four-hour observation period post-PTCA being sufficient for surveillance. There were no major adverse cardiac and cerebrovascular event between 4 and 24 hours, nor at 30 days. At 24 hours and between one and 30 days, more SDD patients had unplanned visits (9.3% vs. 0.9%, p=0.02); most cases were non-procedure-related or were easily managed with patient reassurance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">SDD after elective PTCA is not, by any means, novel; the first reports of its use date back to the mid-1990s.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> The study by Alberto Rodrigues et al. further confirms the safety of SDD in a national cohort, but this is not its greatest merit – SDD safety has been demonstrated in randomized clinical trials and even meta-analysis.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4</span></a> This evidence led the influential Society for Cardiovascular Angiography and Interventions to endorse SDD in 2018.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> In my opinion, the call to action for an increased uptake of SDD in Portugal and how to implement it are the take-home messages from Rodrigues’ paper. Certainly, all Portuguese interventional cardiology laboratories have at some point discharged an elective PTCA on the same day of the intervention - usually a morning surgery patient who underwent a straightforward intervention, on a day where there was a particular shortage of hospital beds. Needless to say, the current COVID-19 pandemic will become an even more likely trigger for SDD. So, what can other laboratories learn from CH Gaia's study?</p><p id="par0020" class="elsevierStylePara elsevierViewall">First, that a nearby recovery room, led by nursing staff with on-demand support from an interventional cardiologist, is necessary. This so-called Radial Lounge,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> with dedicated reclining chairs and commodities such as television or WIFI, allows for a four to six-hour period of observation with telemetry and full equipment for emergencies.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Second, the short four-hour observation after PTCA in the present study was previously described twenty years ago<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> and is safe. The option not to include post-procedure ECG or enzyme assay, unless there is clinical suspicion of complications, is still a matter for discussion. The high cutoffs<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> necessary for clinical impact are unlikely to occur in asymptomatic patients, and as such the strategy of testing only symptomatic patients is an established practice in many centers.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Third, the need for a systematic 24 h and 30-day telephone follow-up that enables safety monitoring and patient education and reassurance.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fourth, the need for local discussion and acceptance of standard criteria for SDD or ONS. It is well known that SDD is more frequently used among male and younger patients with fewer comorbidities. Rodrigues et al. defined ONS criteria, but in routine practice, the interventional cardiologist's immediate post-PTCA assessment and patient willingness to be same-day discharged, if they live within an acceptable hospital distance, are probably more important.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Not discussed by the authors, but also very important, is the issue of reimbursement. This has been suggested as the likely reason for a very limited uptake of SDD in healthcare systems in the United States of America<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> or Australia,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">10</span></a> in contrast with the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">11</span></a> or Canada.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">12</span></a> In Portugal, some hospitals require overnight stay for full reimbursement of PTCA. Since SDD has a well-established economic advantage,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> this issue must be addressed with the hospital and upstream payors (the national healthcare system or the insurance companies).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, we must praise Alberto Rodrigues and colleagues from CH Gaia for challenging the Portuguese cardiology community to embrace same-day discharge after PTCA. It is safe and it is cheaper, so why shouldn’t we offer it to our patients?</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Same day discharge after elective percutaneous coronary intervention – a single center experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 4 | 11 |
| 2024 October | 29 | 40 | 69 |
| 2024 September | 35 | 29 | 64 |
| 2024 August | 36 | 37 | 73 |
| 2024 July | 25 | 32 | 57 |
| 2024 June | 25 | 31 | 56 |
| 2024 May | 26 | 13 | 39 |
| 2024 April | 24 | 30 | 54 |
| 2024 March | 29 | 35 | 64 |
| 2024 February | 20 | 28 | 48 |
| 2024 January | 28 | 18 | 46 |
| 2023 December | 21 | 33 | 54 |
| 2023 November | 32 | 34 | 66 |
| 2023 October | 13 | 15 | 28 |
| 2023 September | 18 | 15 | 33 |
| 2023 August | 20 | 21 | 41 |
| 2023 July | 24 | 8 | 32 |
| 2023 June | 22 | 17 | 39 |
| 2023 May | 35 | 22 | 57 |
| 2023 April | 23 | 4 | 27 |
| 2023 March | 32 | 14 | 46 |
| 2023 February | 25 | 20 | 45 |
| 2023 January | 14 | 13 | 27 |
| 2022 December | 37 | 21 | 58 |
| 2022 November | 27 | 32 | 59 |
| 2022 October | 44 | 18 | 62 |
| 2022 September | 38 | 37 | 75 |
| 2022 August | 29 | 26 | 55 |
| 2022 July | 25 | 37 | 62 |
| 2022 June | 19 | 26 | 45 |
| 2022 May | 19 | 23 | 42 |
| 2022 April | 18 | 33 | 51 |
| 2022 March | 25 | 37 | 62 |
| 2022 February | 30 | 36 | 66 |
| 2022 January | 15 | 21 | 36 |
| 2021 December | 13 | 24 | 37 |
| 2021 November | 27 | 38 | 65 |
| 2021 October | 27 | 42 | 69 |
| 2021 September | 24 | 26 | 50 |
| 2021 August | 13 | 30 | 43 |
| 2021 July | 14 | 28 | 42 |
| 2021 June | 22 | 29 | 51 |
| 2021 May | 26 | 34 | 60 |
| 2021 April | 62 | 29 | 91 |
| 2021 March | 38 | 23 | 61 |
| 2021 February | 23 | 14 | 37 |
| 2021 January | 24 | 23 | 47 |
| 2020 December | 20 | 7 | 27 |
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