This document discusses same day discharge after elective percutaneous coronary intervention (PCI). It reviews the literature on criteria for selecting low-risk patients suitable for same day discharge. Studies show same day discharge is safe and feasible in properly selected patients and can provide significant cost savings compared to overnight admission. The document outlines one institution's protocol for same day discharge following radial PCI, including clinical, procedural, and socio-demographic criteria for patient selection. It emphasizes focusing on low risk patients, procedures, and clinical scenarios to safely implement a same day discharge program.

1. Same Day Discharge after
Elective PCI
Adhir Shroff, MD, MPH
Associate Professor of Medicine
University of Illinois-Chicago
Jesse Brown VA Medical Center

2. Disclosure Statement of Financial Interest
Within the past 12 months, I have had a financial
interest/arrangement or affiliation with the organization(s) listed
below.
Adhir Shroff, MD, MPH
Associate Professor of Medicine
Grant Support/Research Contract:
• Terumo
• Cordis
• Abiomed
Consulting Fees/Honoraria/Speakers Bureau:
• Terumo
• Cordis
• St Jude
• Medicines Company
• Abiomed
Equity Interests: None
Royalty Income/Intellectual Property Rights: None
Salary/Salary Support/Employee: None
2

3. Adhir Shroff, MD, MPH
Associate Professor of Medicine
Agenda
• Review the published literature for
inclusion/exclusion criteria for SD-DC
• Review current guidelines
• How to develop a program

4. Why do we observe patients overnight ?
Adhir Shroff, MD, MPH
Associate Professor of Medicine
• Inefficient care-processes
• Acute vessel closure
• Bleeding and vascular complications
• Post-procedure pain, difficulty with
ambulation
• Traditional practice…reimbursement

5. Adhir Shroff, MD, MPH
What has changed with PCI?
Associate Professor of Medicine
Better pharmacology
Better PCI technology
Access site management
Choice of access site
• Less bleeding
• Less acute vessel closure
• Smaller access catheters
• Improved ability to deliver
devices and document
deployment
• Less time to ambulation
• Less discomfort
• Transradial approach

6. Adhir Shroff, MD, MPH
Associate Professor of Medicine
Adverse Events p PCI
• 450 consecutive PCI
pts at Emory
• All TR
• Elective, N/STEMI,
CTO’s
Am Heart J 2008;156:1141-6

7. Adhir Shroff, MD, MPH
Associate Professor of Medicine
• Dutch study
• 800 elective patients
• Randomized prior to
PCI: Overnight vs SD-DC
▫ TF access
▫ UFH alone
▫ No VCD
• SD-DC is safe and
feasible in selected pts
Circulation. 2007;115:2299-2306

8. Admit
4hrs Obs DC
Post-PCI, exclusion criteria:
▫ Suboptimal PCI
 Dissection/occlusion/perforation
 Thrombus/TIMI<3
 Side-branch occlusion
▫ Chest pain, CHF
▫ ECG changes
▫ Complicated hemostasis
Adhir Shroff, MD, MPH
Associate Professor of Medicine
EPOS – Patient Selection
Exclusion criteria:
▫Ad hoc PCI
▫>6Fr catheters
▫Oral anticoagulants
▫Scheduled use of
abciximab
▫ Difficult follow-up
 Residence > 60 mi
 No caregiver at home
 No transportation
All
Cases
R
Overnight
SD-DC
PCI
PCI
Eligible
Cases
Circulation. 2007;115:2299-2306

9. Prevalence and Outcomes of SD-DC: NCDR
Adhir Shroff, MD, MPH
Associate Professor of Medicine
• Cohort of elective PCI pts
>65 from NCDR (11/04-
12/08)
• 1339 patients from over
100K were DC on SD p
elective PCI
• Rates of death or re-hospitalization
at 2 d:
<0.2%, at 30d: 9.7%
(p=ns)
• For patients with adverse
events, mean duration
was 13days
JAMA, October 5, 2011—Vol 306, No. 13

10. Adhir Shroff, MD, MPH
Associate Professor of Medicine
EASY Trial
• Randomized trial of prolonged Exclusion Criteria
GPI infusion vs. bolus GPI + SD-DC
(~1000pts)
• Successful TR-PCI
• In brief,
▫ Primary end point was 20.4%
in SD-DC group and 18.2% in
overnight
▫ Outcomes similar at 1, 6, 12
mos
• Conclusion, SD-DC non-inferior
to overnight admission
• Clinical/Patient Features
▫ Recent ST-elevation MI
▫ Allergy/intolerance to
aspirin or thienopyridines
▫ INR > 2.0
▫ Ejection fraction≤ 30%;
• Procedural
▫ Transient vessel closure
▫ Hemodynamic collapse
▫ Femoral artery sheath
Circulation. 2006;114:2636-2643
Am Heart J 2008;156:135-40

11. Adhir Shroff, MD, MPH
Associate Professor of Medicine
• MA of 13 studies involving
111,830 pts
• Lots of limitations
• SD-DC had OR=1.2 in RCT
and 0.67 in obs trials
• Low event rate, an adequately
powered trial require >17K pts

12. Economics of TR: Same Day Discharge (SD-DC)
12
Adhir Shroff, MD, MPH
Associate Professor of Medicine
• 370 elective PCI patients
• 3 high-volume PCI centers in
France
▫ 52.3% patients with
multivessel coronary artery
disease
▫ 22.7% patients with
multilesion procedures
▫ 21.5% bifurcation lesions
• At 24hrs, no MACCE
• At 1 month, 4 (1.9%)
readmitted
Catheterization and Cardiovascular Interventions 81:15–23 (2013)

13. Economics of TR: Same Day Discharge (SD-DC)
Non-Procedural Costs
€ 1,214 € 1,634 € 2,304
p<10-6
SD-DC Prolonged stay Conventional
PCI
Overhead & bed charges Drugs, supplies Personnel
13
Adhir Shroff, MD, MPH
Associate Professor of Medicine
• 370 elective PCI patients
• 3 high-volume PCI centers in
France
▫ 52.3% patients with
multivessel coronary artery
disease
▫ 22.7% patients with
multilesion procedures
▫ 21.5% bifurcation lesions
• At 24hrs, no MACCE
• At 1 month, 4 (1.9%)
readmitted
• Significant cost-saving for SD-DC
€ 2,500
€ 2,000
€ 1,500
€ 1,000
€ 500
€ -
Adapted from: Catheterization and Cardiovascular Interventions 81:15–23 (2013)

14. SD-DC p PCI: Patient Perspective
SD: ± pain at
dc
SD: ± anxiety
Adhir Shroff, MD, MPH
Associate Professor of Medicine
• 50 pts randomized to SD-DC
vs overnight in US
• Successful, elective TF-PCI
with VCD
• Observed for 3 hrs
• At time of dc, pts assessed for:
▫ Pain (p=ns)
▫ Satisfaction (p=ns)
▫ Anxiety (p=ns)
▫ Readiness for discharge
(p=ns)
• NO Difference in cardiac
outcomes or complications Proc (Bayl Univ Med Cent) 2011;24(3):192–194

15. • Reviewed existing evidence and practice for elective PCI
• Definitions:
▫ Outpatient: “patient undergoes PCI and returns home or to a
nonmedical facility (i.e., a hotel) the same working day… seldom
extends beyond 12 hr.”
▫ Observation: “remain in medical facility overnight for monitoring
and nursing care…sent home <24hrs”
▫ Extended observation (>24hr): “Has a peri/procedural
complication that requires stay beyond 24hr”
• Proposed a classification scheme to define appropriate patients
Catheterization and Cardiovascular Interventions 73:847–858 (2009)
Adhir Shroff, MD, MPH
Associate Professor of Medicine

16. SCAI Consensus Statement: OP-PCI
Adhir Shroff, MD, MPH
Associate Professor of Medicine
Inclusions Exclusions
Clinical · Stable angina
· Asymptomatic but abnormal stress test
· Ad-hoc PCI planned
· Normal LVEF
· Pre-loaded with thienopyridine
· Unstable coronary syndrome
· Abnormal renal function (eGFR < 60mL/min)
· Laboratory abnormalities
· Insulin-requiring DM
· Age > 70
· Dialysis patient
Co-morbidities None · Contrast allergy
· PVD
· CHF
· COPD on medications
Anatomic Single-vessel disease · One-vessel PCI in setting of multi-vessel disease
· LM, proximal LAD, SVG, IMA or bifurcation PCI
Procedural · Single-vessel PCI
· Single stent (< 28 mm)
· Radial, brachial cutdown, or femoral access
with successful use of closure device, or
secure manual compression
· Balloon angioplasty alone
· Atherectomy (DCA, Rotablator)
· CTO attempt
· Use of GP IIb/IIIa infusion
· Need for follow-up labs
Catheterization and Cardiovascular Interventions 73:847–858 (2009)

17. Adhir Shroff, MD, MPH
Associate Professor of Medicine
One size does not fit all…
• 100 consecutive pts
• Elective TR-PCI with
same-day dc
• Only 15% satisfied ALL
of the SCAI criteria
• No patients were
readmitted or had post-
PCI complications
Catheterization and Cardiovascular Interventions 00:000–000 (2011)

18. Adhir Shroff, MD, MPH
Associate Professor of Medicine
UIH Program:
Patient Selection
Low-Risk Clinical Criteria
• Not currently an inpatient
• Preserved EF (> 30%)
• Not presenting with an acute coronary
syndrome (N/STEMI)
• Normal mental status (pre and post PCI)
• Controlled blood pressure
< 180/100mm/Hg
• Creatinine <2.5 mg/dl and/or eGFR > 30
ml/min
• INR < 1.8
• Does not require prolonged or systemic
Favorable anticoagulation Procedural/following Angiographic
PCI
• No hemodynamic Criteria
instability during PCI
• Have not received LMWH or
thrombolytic therapy in past 48 hrs
• No allergy/intolerance to aspirin and/or
thienopyridines
Sheath size < 6F
• Successful PCI
< 50% residual stenosis
• TIMI 3 flow
• No coronary dissection
• CP free following procedure
• Native vessel PCI only
• No bifurcation lesion
• No major branches “jailed”
• No rotational atherectomy performed
• No access site complication
Optimal Socio-demographic Criteria
• Has a home
• Lives with a caregiver
• Has a working phone
• Reliable transportation
• Able to obtain/pay for medications
• Reliable for follow-up and/or education
• No contraindication from third-party
payor
• TR only
• Observed for
8hrs p PCI
• All
caregivers/patie
nt/family can
opt out
• Emphasize “low
risk patient and
low risk
procedure”

19. Adhir Shroff, MD, MPH
Our Program:
Workflow
Associate Professor of Medicine
UIH Program:
Patient Selection
• This sheet follows
patient as they move
through the units
• Follow-up
appointments are
made
• DAPT is dispensed to
patient prior to dc
• EKG at 3 hours
• No troponin check
• Phone follow-up the
next day

20. Conclusions
• Same day discharge following elective PCI can be
done safely
• Patient selection is important
• TR access may be preferable due to patient
comfort
• Focusing on low risk interventions, in low risk
clinical scenarios, in low risk patients
• Look for a “Best Practices Statement” later this
year
Adhir Shroff, MD, MPH
Associate Professor of Medicine