From the Guidelines
It is generally not safe to discharge STEMI patients the next day after presentation. Most STEMI patients should remain hospitalized for at least 2-3 days following successful reperfusion therapy, with some requiring longer stays depending on their clinical status, as suggested by the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. Early discharge (within 48-72 hours) may be considered only for very low-risk patients who have undergone successful primary PCI, have preserved left ventricular function, have no significant arrhythmias, and demonstrate hemodynamic stability.
- Key considerations for early discharge include:
- Successful reperfusion therapy
- Preserved left ventricular function (ejection fraction >40%)
- No significant arrhythmias
- Hemodynamic stability
- No complications such as heart failure, recurrent ischemia, or mechanical complications
- Before discharge, patients need to be started on appropriate secondary prevention medications, including:
- Dual antiplatelet therapy
- A statin (high-intensity)
- A beta-blocker
- An ACE inhibitor or ARB for those with reduced ejection fraction or diabetes, as recommended by the guideline 1. Early discharge increases the risk of missing potentially life-threatening complications that typically develop within the first few days after STEMI, including arrhythmias, heart failure, mechanical complications, and recurrent ischemia, highlighting the importance of careful patient selection and monitoring 1.
From the Research
Safety of Early Discharge for STEMI Patients
- The safety of discharging STEMI patients the next day after presentation has been evaluated in several studies 2, 3, 4, 5.
- A novel protocol for very early hospital discharge after STEMI has been developed and implemented, allowing for discharge between 20 and 36 hours after successful primary percutaneous coronary intervention 2.
- Early discharge after primary PCI is welcomed by patients and increases efficiency of healthcare, with a study showing that selected low-risk patients can be discharged safely following successful primary PCI using a pathway supported by a structured, multidisciplinary virtual follow-up schedule 3.
- Another study found that very early discharge is safe and feasible and does not increase the mortality rate, with uncomplicated STEMI patients with single vessel disease potentially being discharged after 24 hours 4.
- A systematic review and meta-analysis compared outcomes with early discharge (≤3 days) versus late discharge (>3 days) and found that early discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and has the potential to improve cost of care 5.
Factors Influencing Discharge Timing
- The decision to discharge STEMI patients early should be based on individual patient characteristics and risk assessment, with factors such as Killip class, left ventricular ejection fraction, multi-vessel disease, and diabetes influencing length of stay in hospital 4.
- Statin therapy is also an important consideration, with studies showing that absence of a discharge statin prescription after STEMI is an independent predictor of ischemic events, including death 6.
Outcomes of Early Discharge
- Studies have shown that early discharge is associated with low rates of major adverse cardiac events (MACE) and mortality, with one study reporting a MACE rate of 1.2% and no cardiovascular mortality 3.
- Another study found that early discharge strategy was associated with a reduction in all-cause mortality and MACE, although this was based on observational study data 5.
- Overall, the evidence suggests that early discharge can be safe and effective for selected low-risk STEMI patients, with appropriate follow-up and care 2, 3, 4, 5.