Heart, Lung and Circulation (2015) 24, 368–376 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.11.011 ORIGINAL ARTICLE Safety and Efficacy of Same-Day Discharge Following Elective Percutaneous Coronary Intervention, Including Evaluation of Next Day Troponin T Levels Yousef Saad, MBChB a,b, Ibrahim M. Shugman, PhD a,b, Manish Kumar, MBBS b, Iwona Pauk, RN b, Christian Mussap, PhD a,b, Andrew P. Hopkins, MBBS a,b, Rohan Rajaratnam, MBBS a,b, Sidney Lo, MBBS a,b, Craig P. Juergens, DMedSc a,b, John K. French, PhD. a,b* a South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia b Received 20 December 2013; received in revised form 6 November 2014; accepted 11 November 2014; online published-ahead-of-print 26 November 2014 Background As patients are increasingly undergoing elective percutaneous coronary intervention (PCI) with same-day discharge (SDD), and as post-PCI troponin T (TnT) elevations are associated with increased rates of death/ myocardial infarction (MI) following elective PCI, we examined late outcomes with respect to post-PCI TnT elevations in patients undergoing SDD. Methods and Results We studied 303 patients (mean age 62 9years, 89% male) who underwent elective-PCI between October 2007 and September 2012, of whom 149 had SDD and 154 stayed overnight (ON) who were age-and sexmatched. Eligibility for SDD excluded patients with: multi-vessel PCI, proximal LAD lesions, chronic total occlusions, side branch occlusions, or access site complications. Femoral access rates were 72% and 96% among SDD and ON patients respectively. Post-PCI, SDD patients left at 4.40[4.13-5.30]hours, and ON patients left at 23.44[21.50-25.41]hours (p < 0.001). Overall 8.45% met the 2012 universal MI definition. No patients were re-hospitalised within 48 hours. At 30-days, unplanned cardiac re-hospitalisation rates were 3.4% and 0.7% among SDD and ON patients (p = 0.118); the only event was MI in an SDD patient. At 16[9-32] months, rates of death, MI, target vessel revascularisation, stroke, were 1.3%,1.3%,2.7% and 1% respectively; the composite rate was 6%(6.1% SDD; 6% ON; p = 0.965). Late death/MI rates among patients with, and without, post-PCI TnT levels5xURL were 3.4% and 2.8% respectively (p = 0.588). Conclusion SDD following elective PCI among low risk patients appears to be safe and 5 fold post-PCI TnT elevations did not appear to confer incremental short and long term risk. A larger cohort is required to confirm this observation. Keywords Elective percutaneous coronary intervention Same-day discharge TroponinT. *Corresponding author at: Cardiology Department, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia. Tel.: +61287383069; fax: +61287383341, Email: firstname.lastname@example.org © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. 369 Same-Day Discharge Following PCI Introduction There is increasing evidence that it is feasible and safe, in the short term, for patients with stable coronary heart disease (CHD) who undergo elective percutaneous coronary intervention (PCI) to be discharged on the same day of the procedure [1–9]. Same-day discharge (SDD) has occurred because of increased safety and reduced complications associated with PCI [10,11]. In addition to its safety in the short term, SDD following PCI in comparison with overnight (ON) stay, can lead to increased hospital bed availability and cost saving [7,8,12]. Associations between post-PCI biomarker, including troponin T (TnT), elevations and late outcomes including death and recurrent myocardial infarction (MI) have been reported [13–17]. Whether such biomarker elevations were associated with cardiovascular adverse events after elective PCI with SDD is not known. To assess the safety and efficacy of SDD strategy and examine the significance of TnT elevations post-elective PCI, we studied patients who underwent elective PCI with SDD, who were age-and-sex matched with patients who stayed in the hospital overnight. Methods Study population The clinical, angiographic and procedural data of all patients undergoing PCI are recorded prospectively in the cardiology database at the Liverpool Hospital cardiac catheterisation laboratory in Sydney, Australia . Institutional criteria were initiated in October 2007 to select patients with stable-CHD who are suitable for SDD after elective PCI. Patients were eligible for SDD if they met all of the inclusion criteria and none of the exclusion criteria (Table 1); they were compared to 154 age-and sex-matched patients with similar characteristics who underwent PCI for stable-CHD and stayed overnight. South Western Sydney Local Health Table 1 Criteria for Same-day Discharge. Inclusion criteria Be a non inpatient undergoing a planned, non emergency procedure on Monday – Thursday. Be willing to be discharged on the day of their PCI Be considered suitable by the proceduralist Procedures required completion and a > 4 hours observation period prior to 18:30 (latest time for discharge) Have a 6F or 7F sheath used Have an uncomplicated procedure (does not meet any angiographic exclusion criteria below) Have a suitable social environment (does not meet any social exclusion criteria below) Have no acute changes on post PCI ECG Have adequate puncture site haemostasis (successfully deployed femoral closure device or radial approach preferred but not essential) Exclusion criteria Angiographic Exclusions Be able to ambulate 4 hours post sheath removal without problems Temporary vessel closure during PCI Suboptimal angiographic result Dissection type C to E Residual dissection after successful stent implantation Occlusion of major side branch Angiographic thrombus No reflow/slow flow phenomenon Clinical Exclusion Perforation with guide wire Age 80 years or greater Severe renal failure (GFR < 30ml/min) Severe bleeding risk (eg on warfarin/LMWH etc) Severe LV dysfunction (EF <30%) or symptomatic heart failure Severe visual or hearing impairment Multi-vessel stenting # Use of GP IIb/IIIa inhibitors Social Exclusions Lives alone or has no telephone Staying 30 minutes or more, by car, from Liverpool hospital on first night Patient or co-habiting relative/friend cannot communicate with nursing/medical staff without the need for an interpreter # Multi-vessel disease was stenosis 50% in 2 major coronary arteries or a left main stenosis of 50%. Patients with MVD not undergoing multi-vessel PCI, were not excluded. 370 District human research ethics committee provided approval for PCI follow-up for quality assurance (QA2008/034). All post-PCI patients (including those with SDD) returned the next day to CCL and underwent clinical assessment, an electrocardiogram (ECG), measurement of levels of: creatinine, TnT, platelets, haemoglobin, and estimated glomerular filtration rate (eGFR). Patients stayed for overnight observation for the following reasons: 1) logistical issues, largely residence 30 minutes drive from the hospital; 2) no overnight or English-speaking carer; 3) patients who were scheduled for elective PCI on Fridays; and/or 4) clinical concerns such as mild chest pain post-PCI without ECG changes. Percutaneous Coronary Intervention Procedures Patients, except those with allergies, received pre-PCI aspirin 100–150 mg daily, and clopidogrel loading 300-600 mg and 75 mg daily. A bolus of unfractionated heparin (60-100 U/ Kg) was given at the start of PCI procedures (performed via either femoral or radial access). The use of stents, either bare metal stents (BMS) or drug eluting stents (DES), was according to the institutional DES use criteria . Angiographically successful procedures were defined as <20% residual stenosis in cases post-stenting or to <50% stenosis following balloon angioplasty in the presence of grade 3 Thrombolysis In Myocardial Infarction (TIMI) flow . Troponin T Measurements Venous blood samples that were obtained post-PCI were assayed for TnT (4th generation from October 2007 to June 2011 [upper reference limit (URL) = 0.03 mg/L] and high sensitivity from June 2011 to September 2012 [URL = 14ng/L]; both Roche Diagnostics, Mannheim, Germany). The primary end point was the association between post-elective PCI TnT levels and major adverse cardiac and cerebral events (MACE) during follow up. Definitions and Clinical Follow-up Definitions used in this study were as follows: 1) Elective PCI was any coronary revascularisation performed in a patient with stable-CHD undergoing planned or ad-hoc PCI; 2) Multi-vessel disease by convention in our CCL has been reported as 50% stenosis in 2 major coronary arteries or a left main stenosis of 50%; 3) Stroke was defined as any neurological deficit occurring after PCI and CT-scan or MRI findings of cerebral or cerebellar infarction and/or haemorrhage; 4) Target vessel revascularisation (TVR) was ischaemia-driven repeat revascularisation (either PCI or coronary artery bypass graft surgery); 5) MACE included cardiac death, MI, stroke, or TVR; 6) Re-hospitalisation was defined as any unplanned re-admission potentially related to the PCI procedure. Clinical follow-up was performed by research staff (nurses and/or doctors), either by reviewing the medical records, or contacting the patients and/or their doctors by telephone. Patients, their next of kin, primary physicians or specialists Y. Saad et al. were asked about recurrent cardiac symptoms requiring hospitalisation, the need for further coronary revascularisation (including for stent thrombosis [ST]), MI, or stroke. Data regarding mortality was obtained from department or hospital records, physicians, next of kin and the state death registry. Data Analysis All statistical analyses were performed using SPSS (Inc, Chicago) version 17.0. Categorical variables are expressed as numbers and percentages, and continuous variables as mean standard deviations (SD) or medians and [25th75th centiles]. For groups comparisons Pearson’s chi square (x2) test or Fisher’s exact test were used as appropriate for unpaired categorical variables. The student’s t tests or the Mann-Whitney U tests (for skewed distribution) were used for continuous variables. Kaplan-Meier clinical outcomes were compared using Log Rank test. All p-values<0.05 (2 sided) were considered statistically significant. Results Among 303 patients with stable-CHD who underwent PCI between October 2007 and September 2012, 149 patients underwent SDD post-PCI after median of 4.40[4.13-5.30] hours of observation; the comparator group, who stayed overnight were 154 age-and sex-matched patients who stayed 23.44[21.50-25.41] hours after PCI (Figure 1). Table 2 shows the baseline clinical characteristics of the patients according to their hospital stay, either SDD or ON, and also whether their post-PCI TnT levels, were normal (<URL) or elevated (>URL). Ad-hoc PCI was performed in 36(24.2%) patients among SDD group compared with 9(5.8%) patients among the ON stay group, p < 0.0001. There were no significant differences between the SDD and ON stay groups with respect to most clinical characteristics though SDD patients were more likely to have prior PCI (50.3% vs 35.7%, p = 0.010). PCI was performed via femoral access in 84%(72% in SDD group vs. 96% in ON group, p = <0.0001), and via the radial artery in 15.5% (and one underwent brachial access). In 83% of patients, 6-French guiding catheters were used. The median PCI duration for the SDD and ON patients were 50[40-65] minutes and 50[39-73.5] minutes respectively (p = 0.615). In 18 patients (7.4% of SDD patients and 4.5% of ON patients, p = 0.296) balloon angioplasty only was used. SDD patients compared with ON patients were less likely to have lesions in the left anterior descending (LAD) artery (28.2% vs. 41.6%, p = 0.015). Angiographic and procedural characteristics are shown in Table 3. Among 284 patients with post-PCI TnT measurements, 167 (58.8%) patients (47.9% SDD) had normal post-PCI TnT levels, and 117(41.1%) patients (43.6% SDD) had elevated post-PCI TnT levels. Patients with elevated post-PCI TnT levels, compared with those with levels <URL were less likely to have diabetes mellitus (25.6% vs. 38.3%, p = 0.025), to have a family 371 Same-Day Discharge Following PCI Total PCIs (October 2007 to September 2012) n=4470 2863 PCIs are excluded for the following reasons: - PCIs for ACS. - PCI with complications. - Failed PCI. - Miscellaneous (CHD with severe heart Failure or renal failure). Elective PCIs n=1607 Patients underwent elective PCIs and stayed overnight n=1458 528 Procedural reasons b: - Proximal LAD lesion = 378 - Extensive dissection = 10 - Multivessel intervention = 69 - CTO = 5 - Bifurcation = 59 -Glycoprotein IIb/IIIa inhibitor use = 7 568 Personal/Social reasons: - Non English speaker = 343 - Lived ≥30 minutes drive from the hospital = 210 - Age >80 = 15 70 PCI performed late in the day 292 not specified Discharged on the same day of PCI a n=149 Age- and Sex- matched patients stayed overnight c n=154 Figure 1 Study Population. ACS = acute coronary syndrome; CHD = coronary heart disease; CTO = chronic total occlusions; LAD = left anterior descending; PCI = percutaneous coronary intervention. a Based on criteria (see Table 1). b Procedural reasons for overnight stay are listed in hierarchical order. c Age- and Sex- matched group who stayed overnight for further observation included those with one or more of the following reasons; 1) logistical reasons such as those who live 30 minutes driving or more from the hospital, those who did not have a person to look after them after hospital discharge, those who could not speak English, or patients who were scheduled for elective PCI on Friday; and/or 2) clinical events such as mild atypical chest pain after procedure without ECG changes. history of CHD (11.1% vs. 24.6%, p = 0.004), to have a lower body mass index (median 27.8 vs. 28.9, p = 0.048), and a lower platelet count (median 218 vs. 244, p = 0.011). Patients with elevated post-PCI TnT levels were less likely to have right coronary artery stenosis (28.2% vs. 43.7%, p = 0.008), and more likely to have class B2/C lesions (61.5% vs. 49.1%, p = 0.038) and lesions at a bifurcation (20.5% vs. 11.4%, p = 0.035). Among the study population, an elevation in post-PCI TnT levels to >3 URL occurred in 53(18.7%) patients (14.5% among SDD and 22.2% among ON, p = 0.096). Overall 30 (10.6%) patients (7.6% among SDD and 13.1% among ON, p = 0.137) had elevation in post-PCI TnT levels to >5 URL, of whom 24 patients met the 2012 universal MI definition angiographic criteria (Figure 2); one ON patient with a postPCI TnT level of 3.1 mg/L(>70 URL) met the new post-PCI MI definition of the Society for Cardiovascular Angiography and Interventions (SCAI) . Clinical Outcomes and Troponin after Percutaneous Coronary Intervention Aside from peri-procedural MI, no major events were reported during the in-hospital observation periods, or in the two-days post-PCI (including rehospitalisation). By 30 days there were no deaths, ST, urgent TVR, stroke, or bleeding. Overall 16 patients (5.4%) had been rehospitalised for various reasons (6.8% among SDD group vs 4% among ON group, p = 0.285). Among six patients (2%) who had unplanned re-hospitalisation post-PCI because of cardiac causes one patient had a non-culprit coronary artery MI on day 5, one patient had a left common femoral artery pseudo-aneurysm at day 9, one patient had an arrhythmia on day 28 post PCI, and three patients were readmitted at median of 21 days post-PCI due to recurrent chest pain (all had TnT levels <URL and no interventions were performed). 372 Y. Saad et al. Table 2 Baseline Clinical Characteristics. All n = 303 Same day Overnight TnT discharge stay Normal elevated n = 149 n = 154 n = 167 n = 117 p-value (49.2%) (50.8%) p-value TnT Same day discharge - - - - 80(47.9%) 51(43.6%) 0.473 Age (mean SD) years 62.4 (9.3) 62.5(9.3) 62.3(9.3) 0.810 62.3(9.3) 62.8(9) 0.647 - Age 75 years 30(9.9%) 15(10.1%) 15(9.7%) 0.924 20(12.0%) 9(7.7%) 0.241 -Age 65 years 108(35.6%) 53(35.6%) 55(35.7%) 0.979 61(36.5%) 40(34.2%) 0.685 271(89.4%) 134(89.9%) 137(89.0%) 0.783 148(88.6%) 104(88.9%) 0.944 28.4 [25.7-32.1] 28.7 [25.7-32.1] 28.4 [25.4-32.3] 0.946 28.9 [26.1-32.4] 27.8 [24.9-31.4] 0.048 Male gender BMI (kg/m2) a Diabetes mellitus 98(32.3%) 51(34.2%) 47(30.5%) 0.490 64(38.3%) 30(25.6%) 0.025 Smoking 39(13.0%) 20(13.4%) 19(12.5%) 0.812 21(12.7%) 14(12.1%) 0.884 Hypertension 242(79.9%) 113(75.8%) 129(83.8%) 0.085 139(83.2%) 89(76.1%) 0.135 Family history of CHD 56(18.5%) 34(22.8%) 22(14.3%) 0.056 41(24.6%) 13(11.1%) 0.004 248(81.8%) 114(76.5%) 134(87.0%) 0.018 136(81.4%) 99(84.6%) 0.485 Prior Aspirin 277(91.4%) 139(93.3%) 138(89.6%) 0.253 155(92.8%) 104(88.9%) 0.250 Previous PCI Previous CABG 130(42.9%) 34(11.2%) 75(50.3%) 12(8.1%) 55(35.7%) 22(14.3%) 0.010 0.086 69(41.3%) 19(11.4%) 54(46.2%) 13(11.1%) 0.418 0.944 228(87.7%) 117(85.4%) 111(90.2%) 127(88.8%) 85(85.9%) 32(12.3%) 20(14.6%) 12(9.8%) 16(11.2%) 14(14.1%) 144[134-151] 143.5[134-152] 146[133-151] 0.569 146 [135-151] 140[130-151] 0.107 7.5[6.2-9] 7.5[6.1-9.2] 7.5[6.2-8.9] 0.877 7.5[6.2-9.2] 7.5[6.1-8.9] 0.675 235[201-283] 227[198-280] 241[204-289] 0.235 244[209-283] 218[183-278] 0.011 30(9.9%) 45(14.9%) 19(12.8%) 36(24.2%) 11(7.1%) 9(5.8%) 17(10.2%) 26(15.6%) 9(7.7%) 16(13.7%) 0.474 0.658 Hyperlipidaemia b Pre-PCI eGFR - eGFR >60 0.235 c - eGFR 30-<60 Pre Hb WBC a a Platelet a Staged PCI Ad hoc c 0.102 <0.0001 0.493 BMI = body mass index; CABG = coronary artery bypass grafting; CHD = coronary heart disease; PCI = Percutaneous coronary intervention; TnT = troponin T. a Median [25 percentile-75 percentile]. b Hyperlipidaemia defined as previous diagnosis of hypercholesterolaemia, including treatment with lipid-lowering agents or fasting low-density lipoprotein cholesterol of 130 mg/dl or total cholesterol of 200 mg/dl. c eGFR = estimated glomerular filtration rate ml/min/1.73 m2. Calculated by the abbreviated MDRD equation. Among the remainder of re-hospitalisations, four patients underwent planned staged PCI, one patient had a chest infection, one patient had a urinary tract infection, one patient had haematuria and two patients had gastrointestinal bleeding at a median of 24 days post-PCI, and one had musculoskeletal chest pain. Late outcomes at 16[9-32] months were obtained in 299 (98.7%) patients (Table 4). The respective rates of cardiac death, MI, TVR, and stroke, comparing SDD with ON groups, were: 1.4% vs. 1.3%, p = 0.999; 2.7% vs. 0%, p = 0.059; 2%vs. 3.3%, p = 0.723 and 0.7% vs. 1.3%, p = 0.999. Overall MACE occurred in 6% (6.1% among SDD vs. 6% among ON, p = 0.965). Among SDD patients, cardiac death or MI occurred in six patients only and none of these had post-PCI TnT levels>X5 URL. The rates of the composite of cardiac death/MI among patients who had post-PCI TnT levels>5xURL (34.5% SDD and 65.5% ON) compared with patients without these elevations (47.8% SDD and 52.2% ON) were 3.4% versus 2.8% (p = 0.588). Three patients developed stroke; none of them had post-PCI TnT levels>X5 URL. Discussion This study assessed the safety of a SDD strategy at 4-5 h following elective PCI. We also examined an outcome surrogate of post-PCI TnT levels >5XURL among SDD patients and those who stayed ON, as we and others have previously reported elevated post-PCI cardiac marker levels are associated with higher rates of adverse clinical outcomes (death and/or MI) among these patients [13–17,21]. There were no significant differences in cardiac death/MI reported among patients who had post-PCI TnT levels >5XURL, compared with those without such post-PCI TnT levels, though this relatively small study was likely underpowered to examine associations with ‘hard’ clinical outcomes. The study found that among low risk patients, SDD is safe after elective PCI, 373 Same-Day Discharge Following PCI Table 3 Angiographic and Procedural Characteristics. All Same day discharge Overnight stay TnT TnT elevated n = 303 n = 149 n = 154 Normal n = 117 49.2% 50.8% n = 167 P value P value Site of Culprit lesion - Left Main 6(2.0%) 1(0.7%) 5(3.2%) 0.214 2(1.2%) 4(3.4%) 0.234 - LAD 106(35.0%) 42(28.2%) 64(41.6%) 0.015 53(31.7%) 48(41.0%) 0.108 - RCA 112(37.0%) 58(38.9%) 54(35.1%) 0.486 73(43.7%) 33(28.2%) 0.008 - LCX 72(23.8%) 46(30.9%) 26(16.9%) 0.004 35(21.0%) 30(25.6%) 0.355 - Graft 7(2.3%) 2(1.3%) 5(3.2%) 0.448 4(2.4%) 2(1.7%) 0.999 Number of diseased vessels - 1-Vessel disease 0.603 0.971 160(52.8%) 81(54.4%) 79(51.3%) 88(52.7%) 60(51.3%) - 2-Vessel disease 109(36.0%) 54(36.2%) 55(35.7%) 60(35.9%) 43(36.8%) - 3-Vessel disease 34(11.2%) 14(9.4%) 20(13.0%) 19(11.4%) 14(12.0%) 143(47.2%) 68(45.6%) 75(48.7%) 0.646 79(47.3%) 57(48.7%) 0.904 82[70-91] 90[74.5-90] 80[70-95] 0.730 88[70-95] 80[70-90] 0.402 255(84.2%) 107(71.8%) 148(96.1%) <0.0001 140(83.8%) 99(84.6%) 0.859 47(15.5%) 42(28.2%) 5(3.2%) <0.0001 <0.001 26(15.6%) 18(15.4%) 0.966 0.623 6-F 250(82.5%) 143(96.0%) 107(69.5%) 138(82.6%) 94(80.3%) 7-F 53(17.5%) 6(4.0%) 47(30.5%) 29(17.4%) 23(19.7%) - Multi-vessel disease Stenosis Before PCI Access site a b c Femoral Radial Guiding catheter size Lesion class (ACC/ AHA) 0.752 0.179 -A 46(15.2%) 25(16.8%) 21(13.6%) 24(14.4%) 14(12.0%) - B1 97(32.0%) 44(29.5%) 53(34.4%) 61(36.5%) 31(26.5%) - B2 68(22.4%) 35(23.5%) 33(21.4%) 33(19.8%) 33(28.2%) -C - B2&C 92(30.4%) 160(52.8%) 45(30.2%) 80(53.7%) 47(30.5%) 80(51.9%) 0.761 49(29.3%) 82(49.1%) 39(33.3%) 72(61.5%) TIMI flow grad 3 after PCI 303(100%) 149(100%) 154(100%) - 167(100%) 117(100%) - Ostial lesions 15(5.0%) 3(2.0%) 12(7.8%) 0.020 9(5.4%) 5(4.3%) 0.669 Culprit lesion at bifurcation 44(14.5%) 20(13.4%) 24(15.6%) 0.593 19(11.4%) 24(20.5%) 0.035 Lesion calcification 42(13.9%) 14(9.4%) 28(18.2%) 0.027 27(16.2%) 14(12.0%) 0.321 18[12-25] 16[12-24] 18[12-28] 0.290 18[12-24] 18[12-28] 0.187 - Lesion >20mm 104(34.6%) 46(31.3%) 58(37.7%) 0.245 53(31.9%) 48(41.4%) 0.103 DES BMS 134(47.0%) 147(51.6%) 57(41.3%) 79(57.2%) 77(52.4%) 68(46.3%) 0.061 0.064 73(45.6%) 85(53.1%) 55(50.9%) 51(47.2%) 0.394 0.343 Ballon angioplasty 18(5.9%) 11(7.4%) 7(4.5%) 0.296 7(4.2%) 9(7.7%) 0.208 > 1 stent 71(24.9%) 30(21.7%) 41(27.9%) 0.230 41(25.6%) 30(27.8%) 0.695 2.75[2.5-3] 3[2.5-3] 2.75[2.5-3] 0.154 2.75[2.5-3] 2.75[2.5-3] 0.696 18[16-20] 18[16-20] 18[16-20] 0.093 18[16-19] 18[16-20] 0.013 22[15-30] 24[17-30] 20[15-30] 0.161 20[16-30] 24[15-30] 0.900 0.009 0.009 0.009 0.026 0.009 0.08 [0.009-0.03] [0.009-0.01] [0.009-0.048] [0.009-0.009] [0.045-0.12] 20[9-50] 18[10-46] 28.5[9-51] 0.440 8[4.9-11] 38[23-76] 117(41.2%) 51(38.9%) 66(43.1%) 0.473 - - Culprit Lesion length (mm) Stent diameter (mm) b b Inflation pressure max (atm) b Maximal duration of deployed pressure (sec) Post- PCI Troponin-T - Conventional assay 0.038 b b - High Sensitivity assay b Elevated above URL <0.0001 <0.0001 - ACC/AHA = American College of Cardiology/American Heart Association; BMS = Bare metal stent; DES = Drug eluting stent; 6-F = 6 French; 7-F = 7 French; LAD = Left anterior descending; LCX = Left circumflex; PCI = Percutaneous coronary intervention; RCA = Right coronary artery; TIMI = Thrombolysis in myocardial infarction; TnT = Troponin T. a Multi vessels disease defined as 50% stenosis in 2 major epicardial vessels (left anterior descending, left circumflex and right coronary arteries) or 50% stenosis of left main coronary artery (which is defined as 2 vessel disease). b c Median [25 percentile-75 percentile]. There was only one patient who had PCI through brachial access among ON group. 374 Y. Saad et al. Figure 2 Comparing TnT Criteria for Myocardial Infarction Using 2007 and Third Universal Definition of Myocardial Infarction. MI = myocardial infarction; ON = overnight; SDD = same day discharge; TnT = troponin T; URL = upper reference limit. a 2007 periprocedural MI definition b 2012 periprocedural MI definition c 24 patients met the universal MI definition angiographic criteria. and that short and long term clinical outcomes were comparable between those who were discharged on the same day and those who stayed ON. The first study demonstrating the safety of a SDD strategy was performed by Kiemeneij et al, in 1997 . The feasibility and safety of this strategy after elective PCI with a femoral or radial access has also been established among low risk patients [1–8,23–28]. Our study confirms that low risk patients who undergo an elective PCI using mainly a femoral approach can be safely discharged on the same day of the procedure. An average observation time of 4.5 hours post-PCI appeared sufficient for effective triage of low risk patients for the SDD. Although other studies show that some events occur over the following day [23,25], none occurred in our study; very late events were rare. Indeed in our study of 300 patients, no events were reported during the first 48 hrs after PCI, the period when the majority of post-PCI complications, such as abrupt vessel closure, bleeding, acute ST, and acute renal failure, have been reported . Despite 250 patients in this study undergoing PCI via the femoral route, no major bleeding complications occurred, which probably explains the low 30 days re-hospitalisation rate compared to other studies [5,28]. Importantly SDD did not contribute to an increased hospital burden due to more un-planned re-admissions. The relatively strict selection criteria implemented in our study may explain the lower incidence of these adverse events; these were somewhat different to selection criteria used elsewhere for SDD [1,28,30]. Our study did not involve patients receiving a glycoprotein IIb/IIIa inhibitors, patients who lived >30 minutes drive from the hospital, and >7Fr guiding catheter(s). The outpatient (SDD) PCI criteria from SCAI and endorsed by the American College of Cardiology Foundation (ACC) , are stricter as exclusions include patients >70 years old, those with eGFR<60, and/or those receiving multiple stents; none of these were exclusions from our study. Gilchrist et al.  have assessed these SCAI criteria by evaluating the SDD strategy on 100 patients undergoing elective trans-radial PCI and were all discharged safely on the same day of PCI. These authors (and others ) reported that following successful elective PCI without angiographic complications, age and other pre-existing Table 4 Clinical Outcomes. 30 days All re-hospitalisation, n (%) a Unplanned cardiac re-hospitalisation, n(%) b All Same day Overnight TnT TnT n = 299 discharge stay Normal elevated n = 148 n = 151 n = 164 n = 116 16(5.4%) 10(6.8%) 6(4%) 0.285 9(5.5%) 6(5.2%) 0.908 6(2%) 5(3.4%) 1(0.7%) 0.118 3(1.8%) 2(1.7%) 0.999 P value P value Late outcomes at 16[9-32] months Cardiac death, n (%) 4(1.3%) 2(1.4%) 2(1.3%) 0.999 2(1.2%) 2(1.7%) 0.999 MI, n (%) 4(1.3%) 4(2.7%) 0(0%) 0.059 3(1.8%) 1(0.9%) 0.644 TVR, n (%) 8(2.7%) 3(2.0%) 5(3.3%) 0.723 5(3.0%) 3(2.6%) 0.999 Stroke, n (%) 3(1.0%) 1(0.7%) 2(1.3%) 0.999 2(1.2%) 1(0.9%) 0.999 18(6.0%) 8(2.7%) 9(6.1%) 6(4.1%) 9(6.0%) 2(1.3%) 0.965 0.170 11(6.7%) 5(3.0%) 7(6.0%) 3(2.6%) 0.821 0.999 Composite: cardiac death, MI, stroke, TVR, n (%) Cardiac death /MI, n (%) MI = myocardial infarction; TnT = troponin T; TVR = target vessel revascularisation. a n = 6 cardiac, n = 4 staged PCIs, n = 6 Non-cardiac (1 chest infection / 1 urinary tract infection / 1 haematuria / 2 GIT bleeding/ 1 musculoskeletal chest pain). b cardiac causes (n = 1 arrhythmia, n = 1 myocardial infarction,n = 1 left femoral pseudo aneurysm, n = 3 chest pain). 375 Same-Day Discharge Following PCI conditions should not preclude SDD unless there is clinical instability. Patients with ad-hoc PCI are included in our analysis unlike those in a randomised trial ; this trial included patients living up to 60 min distance but excluded 7Fr guiding catheter use. While none of our patients received glycoprotein IIb-IIIa inhibitors, Bertrand et al. reported that some SDD patients received an abciximab bolus . Though some studies have shown that a SDD PCI is a safe and feasible practice even among non-low risk patients [12,22,33], this approach needs to be studied in larger randomised trials. Troponin is the preferable cardiac biomarker to detect myocardial injury/necrosis post-PCI, [34–38]. To our knowledge ours is the first report of the SDD patients who underwent measurement of post-PCI TnT levels. Prasad et al  examined peri-procedural MI as a predictor of late mortality among patients with, and without pre-PCI TnT elevations, and pre-procedural TnT elevations have a greater prognostic significance than post-procedural TnT levels. Post-PCI TnT >5XURL occurred in 30 patients (10.6%) of whom 24 (8.45%) had the additional criteria necessary for the 2012 PMI definition in our study; there was no significant difference in the SDD and ON groups. The prognostic significance of hsTnT elevations meeting PMI criteria, after elective PCI among low risk patients including with SDD, would need clarification in a larger study. Our study has other limitations. The TnT data were retrospectively analysed and an unappreciated bias could have occurred. As some patients with stable CHD have elevated troponin T levels (including high sensitivity) [40–42], assumption of normality of TnT levels pre-PCI may have lead to an over-estimation of the frequency of elevated levels post-PCI. Furthermore, other causes of TnT elevations  were not evaluated in this study. As the numbers of SDD patients, including those with post-PCI TnT>5xURL were small, and event rates were low, a possible adverse effect of SDD can’t be excluded due to reduced study power. Conclusion In this study the SDD strategy appears to be safe and feasible among low risk patients following an elective PCI and 5fold post-PCI TnT elevations did not appear to confer incremental short and long-term risk. Randomised trials with a larger population are required to further assess this observation. Conflicts of interest There are no conflicts of interest to disclose. Acknowledgments The authors would like to acknowledge the contribution of Karen Lintern (RN) in setting up the same day discharge program. The secretarial assistance of Philomena Kaarma is acknowledged. References  Heyde GS, Koch KT, de Winter RJ, Dijkgraaf MG, Klees MI, Dijksman LM, et al. Randomized trial comparing same-day discharge with overnight hospital stay after percutaneous coronary intervention: results of the Elective PCI in Outpatient Study (EPOS). Circulation 2007;115:2299–306.  Muthusamy P, Busman DK, Davis AT, Wohns DH. Assessment of clinical outcomes related to early discharge after elective percutaneous coronary intervention: COED PCI. Catheter Cardiovasc Interv 2013;81:6–13.  Perret X, Bergerot C, Rioufol G, Bonvini RF, Ovize M, Finet G. Same-daydischarge ad hoc percutaneous coronary intervention: initial single-centre experience. Arch Cardiovasc Dis 2009;102:743–8.  Patel M, Kim M, Karajgikar R, Kodali V, Kaplish D, Lee P, et al. Outcomes of patients discharged the same day following percutaneous coronary intervention. JACC Cardiovasc Interv 2010;3:851–8.  Abdelaal E, Rao SV, Gilchrist IC, Bernat I, Shroff A, Caputo R, et al. Sameday discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention: a systematic review and metaanalysis. JACC Cardiovasc Interv 2013;6:99–112.  Herman BA. Safety of same day discharge following percutaneous coronary intervention. Heart Lung Circ 2011;20:353–6.  Khatri S, Webb JG, Carere RG, Amis A, Woolcott J, Chugh S, et al. Safety and cost benefit of same-day discharge after percutaneous coronary intervention. Am J Cardiol 2002;90:425–7.  Rao SV, Kaltenbach LA, Weintraub WS, Roe MT, Brindis RG, Rumsfeld JS, et al. Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients. JAMA 2011;306:1461–7.  Brayton KM, Patel VG, Stave C, de Lemos JA, Kumbhani DJ. Same-day discharge after percutaneous coronary intervention: a meta-analysis. J Am Coll Cardiol 2013;62:275–85.  Gilchrist IC, Rhodes DA, Zimmerman HE. A single center experience with same-day transradial-PCI patients: a contrast with published guidelines. Catheter Cardiovasc Interv 2012;79:583–7.  Bertrand OF, Larose E, De Larochelliere R, Proulx G, Nguyen CM, Dery JP, et al. Outpatient percutaneous coronary intervention: Ready for prime time? Can J Cardiol 2007;23(Suppl B):58B–66B.  Rinfret S, Kennedy WA, Lachaine J, Lemay A, Rodes-Cabau J, Cohen DJ, et al. Economic impact of same-day home discharge after uncomplicated transradial percutaneous coronary intervention and bolus-only abciximab regimen. JACC Cardiovasc Interv 2010;3:1011–9.  Shugman IM, Diu P, Gohil J, Kadappu KK, Leung M, Lo S, et al. Evaluation of troponin T criteria for periprocedural myocardial infarction in patients with acute coronary syndromes. Am J Cardiol 2011;107:863–70.  Nienhuis MB, Ottervanger JP, Bilo HJ, Dikkeschei BD, Zijlstra F. Prognostic value of troponin after elective percutaneous coronary intervention: A meta-analysis. Catheter Cardiovasc Interv 2008;71:318–24.  Feldman DN, Kim L, Rene AG, Minutello RM, Bergman G, Wong SC. Prognostic value of cardiac troponin-I or troponin-T elevation following nonemergent percutaneous coronary intervention: a meta-analysis. Catheter Cardiovasc Interv 2011;77:1020–30.  Nienhuis MB, Ottervanger JP, Dambrink JH, Dikkeschei LD, Suryapranata H, van ’t Hof AW, et al. Troponin T elevation and prognosis after multivessel compared with single-vessel elective percutaneous coronary intervention. Neth Heart J 2007;15:178–83.  Nienhuis MB, Ottervanger JP, Dikkeschei B, Suryapranata H, de Boer MJ, Dambrink JH, et al. Prognostic importance of troponin T and creatine kinase after elective angioplasty. Int J Cardiol 2007;120:242–7.  Shugman IM, Hsieh V, Cheng S, Parikh D, Tobing D, Wouters N, et al. Safety and efficacy of rescue angioplasty for ST-elevation myocardial infarction with high utilization rates of glycoprotein IIb/IIIa inhibitors. Am Heart J 2012;163:649–56. e641.  Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124: e574–651.  Moussa ID, Klein LW, Shah B, Mehran R, Mack MJ, Brilakis ES, et al. Consideration of a New Definition of Clinically Relevant Myocardial 376             Y. Saad et al. Infarction After Coronary Revascularization: An Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions (SCAI). J Am Coll Cardiol 2013;62:1563–70. Idris H, Lo S, Shugman IM, Saad Y, Hopkins AP, Mussap C, et al. Varying definitions for periprocedural myocardial infarction alter event rates and prognostic implications. J Am Heart Assoc 2014;3 [Online]. Available: http://jaha.ahajournals.org/content/3/6/e001086.long [Accessed 3 November 2014]. Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. Outpatient coronary stent implantation. J Am Coll Cardiol 1997;29:323–7. Koch KT, Piek JJ, Prins MH, de Winter RJ, Mulder K, Lie KI, et al. Triage of patients for short term observation after elective coronary angioplasty. Heart 2000;83:557–63. Slagboom T, Kiemeneij F, Laarman GJ, van der Wieken R, Odekerken D. Actual outpatient PTCA: results of the OUTCLAS pilot study. Catheter Cardiovasc Interv 2001;53:204–8. Slagboom T, Kiemeneij F, Laarman GJ, van der Wieken R. Outpatient coronary angioplasty: feasible and safe. Catheter Cardiovasc Interv 2005;64:421–7. Ziakas AA, Klinke BP, Mildenberger CR, Fretz DE, Williams EM, Kinloch FR, et al. Safety of same-day-discharge radial percutaneous coronary intervention: a retrospective study. Am Heart J 2003;146:699–704. Kumar S, Anantharaman R, Das P, Hobbs J, Densem C, Ansell J, et al. Radial approach to day case intervention in coronary artery lesions (RADICAL): a single centre safety and feasibility study. Heart 2004; 90:1340–1. Bertrand OF, De Larochelliere R, Rodes-Cabau J, Proulx G, Gleeton O, Nguyen CM, et al. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation 2006;114:2636–43. Rao SV, Ohman EM. Anticoagulant therapy for percutaneous coronary intervention. Circ Cardiovasc Interv 2010;3:80–8. Carere RG, Webb JG, Buller CE, Wilson M, Rahman T, Spinelli J, et al. Suture closure of femoral arterial puncture sites after coronary angioplasty followed by same-day discharge. Am Heart J 2000;139:52–8. Chambers CE, Dehmer GJ, Cox DA, Harrington RA, Babb JD, Popma JJ, et al. Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation. Catheter Cardiovasc Interv 2009; 73:847–58. Ranchord AM, Prasad S, Seneviratne SK, Simmonds MB, Matsis P, Aitken A, et al. Same-day discharge is feasible and safe in the majority            of elderly patients undergoing elective percutaneous coronary intervention. J Invasive Cardiol 2010;22:301–5. Small A, Klinke P, Della Siega A, Fretz E, Kinloch D, Mildenberger R, et al. Day procedure intervention is safe and complication free in higher risk patients undergoing transradial angioplasty and stenting. The discharge study. Catheter Cardiovasc Interv 2007;70:907–12. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. J Am Coll Cardiol 2007;50:2173–95. Morrow DA, Cannon CP, Jesse RL, Newby LK, Ravkilde J, Storrow AB, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Circulation 2007;115:e356–75. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/ AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;123:e426–579. Harris BM, Nageh T, Marsden JT, Thomas MR, Sherwood RA. Comparison of cardiac troponin T and I and CK-MB for the detection of minor myocardial damage during interventional cardiac procedures. Ann Clin Biochem 2000;37:764–9. Miller WL, Garratt KN, Burritt MF, Reeder GS, Jaffe AS. Timing of peak troponin T and creatine kinase-MB elevations after percutaneous coronary intervention. Chest 2004;125:275–80. Prasad A, Gersh BJ, Bertrand ME, Lincoff AM, Moses JW, Ohman EM, et al. Prognostic significance of periprocedural versus spontaneously occurring myocardial infarction after percutaneous coronary intervention in patients with acute coronary syndromes: an analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. J Am Coll Cardiol 2009;54:477–86. Beatty AL, Ku IA, Christenson RH, DeFilippi CR, Schiller NB, Whooley MA. High-sensitivity cardiac troponin T levels and secondary events in outpatients with coronary heart disease from the Heart and Soul Study. JAMA Intern Med 2013;173:763–9. Koenig W, Breitling LP, Hahmann H, Wusten B, Brenner H, Rothenbacher D. Cardiac troponin T measured by a high-sensitivity assay predicts recurrent cardiovascular events in stable coronary heart disease patients with 8-year follow-up. Clin Chem 2012;58:1215–24. Omland T, de Lemos JA, Sabatine MS, Christophi CA, Rice MM, Jablonski KA, et al. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med 2009;361:2538–47. French JK, White HD. Clinical implications of the new definition of myocardial infarction. Heart 2004;90:99–106.