Elsevier

American Heart Journal

Volume 201, July 2018, Pages 103-110
American Heart Journal

Clinical Investigation
Discharge timing and outcomes after uncomplicated non–ST-segment elevation acute myocardial infarction

https://doi.org/10.1016/j.ahj.2018.04.010Get rights and content

Abstract

Background

Length of stay after non–ST-segment elevation myocardial infarction (NSTEMI) continues to decrease, but information to guide duration of hospitalization is limited.

Methods

We used landmark analyses, in which the landmark defined potential days of discharge, to estimate complication rates on the first day the patient would have been out of the hospital, and estimated associations between timing of discharge and 30-day and 1-year event-free survival after discharge among NSTEMI patients.

Results

Among 20,410 NSTEMI patients, median length of stay was 7 (4, 12) days; 3,209 (15.7%) experienced a cardiac complication on days 0 to 2 and 1,322 (6.5%) were discharged without complications during hospital days 0 to 2. At the start of day 3, 15,879 patients (77.8%) were still hospitalized without complications. Of these, 1,689 (10.6%) were discharged event-free on day 3. Adjusted event-free survival rates of death or myocardial infarction from day 4 to 30 days after among the 1,689 patients was 99.1% compared with 93.1% for the 14,190 who remained hospitalized at the end of day 3. For 1-year mortality, these rates were 98.1% and 96.4%, respectively. Among 13,334 patients hospitalized without complications at the start of day 4, 1,706 were discharged event-free that day. Adjusted survival rates among these patients, compared with those still hospitalized at the end of day 4, were 98.0% versus 93.7% for 30-day death or myocardial infarction and 97.8% versus 96.1% for 1-year mortality.

Conclusions

Patients with NSTEMI who had no serious complications during the first 2 hospital days were at low risk of subsequent short- and intermediate-term death or ischemic events.

Section snippets

Trial selection

We performed a patient-level pooled analysis of outcomes in 5 acute coronary syndrome clinical trials published from 1996 to 2004 for which we had the complete final database available at the Duke Clinical Research Institute: Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY),8 Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON)-A,9 PARAGON-B,10 Platelet

Baseline patient characteristics

Figure 1 provides a diagram of patients grouped by occurrence or absence of complications by the beginning of hospital day 3. Table III displays baseline characteristics for all NSTEMI patients (n = 20,410), stratified according to occurrence or absence of complications by the beginning of hospital day 3. Compared with patients who were uncomplicated during days 0-2 (n = 15,879), those who experienced complications (n = 3,209) were more frequently female and from North America. They also more

Discussion

In our exploration of timing of discharge and subsequent outcomes among NSTEMI patients, more than three quarters of all NSTEMI patients were complication-free from presentation through hospital day 2, and nearly two thirds overall (or 83% of those without complications through day 2) had no complications through 7 days. We demonstrated that NSTEMI patients who did not have serious complications during days 0 to 2 were at low risk of complications on landmark day 3 and for subsequent short- and

Conclusions

Patients with NSTEMI who had no serious complications during hospital days 0 to 2 seemed to be at low risk for major complications on day 3 and for subsequent short- and intermediate-term death or recurrent ischemic events. Earlier discharge could be reasonable for many NSTEMI patients.

Acknowledgments

This work was supported in part by a Barton F. Haynes Resident Research Award, Department of Medicine, Duke University Medical Center, and from academic discretionary resources of the senior investigator. Dr Rymer was supported by a training grant to Duke University from the National Heart Lung and Blood Institute (5 T32 HL 69749).

Disclosures

Dr Rymer, Dr Templehof, Mr Clare, Ms Pieper, Dr Granger, and Dr Moliterno have no relevant conflicts of interest. Dr Van de Werf reports research grants from Merck, and advisory board membership, DSMB, and lecture fees from Merck. Harrington reports research grants from Merck, Astra, BMS, J&J, and consulting honoraria from CSL, BMS, Daiichi, Gilead, J&J, Merck, and MyoKardia. Dr White reports research grants from Sanofi Aventis, Eli Lilly, Medicines Company, NIH, Roche, Merck Sharpe & Dohme,

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