Prospective study of early discharge after acute myocardial infarction (SHORT)

AIMS: To identify, without additional investigation, a large group of myocardial infarction patients at low risk who would qualify for early discharge. METHODS: The decision rule was developed in 647 unselected patients with consecutively admitted myocardial infarction, and validated in 825 others. Daily event-rates were calculated for major (death, ventricular fibrillation, recurrent infarction, heart failure, advanced AV-block) and minor (unstable angina and rhythm-abnormalities) cardiac complications. RESULTS: Patients free from major complications until day 7 (44% of all patients) were found to constitute a very low risk group and thus would qualify for discharge at day 7. Of the 39% of patients with an uncomplicated infarction (low risk) in the validation group, 31% were discharged at day 7, while 8% stayed longer because of non-cardiac co-morbidity, for social reasons or logistic problems. No major adverse event occurred within 7 days after hospital discharge and only 1.8% developed complications within 1 month. The median duration of hospital stay for all in-hospital survivors was 7 days compared to 10 days in the control group. CONCLUSION: Prospective application of the early discharge decision rule, based upon simple clinical variables and without the need for additional non-invasive and/or invasive tests, resulted in a significant reduction of hospital stay. The decision rule correctly classified patients into high and low risk groups and appeared feasible and safe. Its efficacy was demonstrated by its ability to identify a large group of post infarction survivors at low risk for complications during follow-up.

Variation in the use of coronary angiography in patients with unstable angina is related to differences in patient population and availability of angiography facilities, without affecting prognosis.

OBJECTIVES: Examination of the difference in management strategies with respect to coronary angiography in patients with unstable angina pectoris, and the consequences of this difference on prognosis. DESIGN: Prospective registration of consecutive patients admitted to two different hospitals. SETTING: University and a large community hospital in Rotterdam, the Netherlands. SUBJECTS: Patients under 80 years, without recent (< 4 weeks) infarction or recent (< 6 months) coronary revascularization procedure, admitted for chest pain suspected to indicate unstable angina pectoris. MAIN OUTCOME MEASURES: Decision to initiate coronary angiography or to continue on medical treatment. At 6 months the occurrence of death and myocardial infarction was measured. RESULTS: Clinical variables associated with the decision to initiate angiography were young age, male gender, progression of angina, multiple pain episodes and use of beta-blocker or calcium antagonists before admission, abnormal ST-T segment on baseline ECG, recurrent pain in hospital, and ECG changes during pain. These associations did not differ between hospitals. Nevertheless, angiography was performed more often in the presence of angiography facilities (university hospital), independent of the variable case-mix. Survival and infarct-free survival were similar in both hospitals, 96% and 90% respectively. CONCLUSION: The difference in angiography rate for unstable angina can be explained in part by differences in patient population and hospital facilities, but no difference was observed in physicians' assessment of patient characteristics. The observed practice variation did not affect prognosis.