Pandemic-Associated Delays in Myocardial Infarction Presentation in Predominantly Rural Counties With Low COVID-19 Prevalence.

Fewer ST-elevation myocardial infarctions (STEMIs) presentations and increased delays in care occurred during the COVID-19 pandemic in urban areas. Whether these associations occurred in a more rural population has not been previously reported. Our objective was to evaluate the impact of COVID-19 on time-to-presentation for STEMI in rural locations. Patients presenting to a large STEMI network spanning 27 facilities and 13 predominantly rural counties between January 1, 2016 and April 30, 2020 were included. Presentation delays, defined as time from symptom onset to arrival at the first medical facility, classified as ≥12 and ≥24 hours from symptom onset were compared among patients in the pre-COVID-19 and the early COVID-19 eras. To account for patient-level differences, 2:1 propensity score matching was performed using binary logistic regression. Among 1,286 patients with STEMI, 1,245 patients presented in the pre-COVID-19 era and 41 presented during the early COVID-19 era. Presentation delays ≥12 hours (19.5% vs 4.0%) and ≥24 hours (14.6% and 0.2%) were more common in COVID-19 than pre-COVID-19 cohorts (p <0.001 for both), despite a low COVID-19 prevalence. Similar results were seen in propensity-matched comparisons (≥12 hours: 19.5% vs 2.4%, p = 0.002; ≥24 hours 14.6% vs 0.0%, p = 0.001). In a predominantly rural STEMI population, delays in seeking medical care after symptom onset were markedly more frequent during the COVID-19 era, despite low COVID-19 prevalence. Considering delays in reperfusion have multiple adverse downstream consequences, these findings may have important implications in rural communities during future pandemic resurgences.

Barriers to Early Discharge after Elective Percutaneous Coronary Intervention (BED PCI): A Single-Center Study.

OBJECTIVE: To identify patient characteristics and procedural factors that may play a role in hindering same-day discharge (SDD) practices. BACKGROUND: Multiple studies have shown the safety and cost effectiveness of SDD following elective percutaneous coronary intervention (PCI), but factors that hinder SDD practices have not been thoroughly studied. MATERIAL AND METHODS: A retrospective comparative analysis of elective PCI patients who had an overnight stay (OS) (n=345) vs. SDD patients (n=222) was conducted to identify significant differences between the two groups in baseline patient characteristics, procedural, and postprocedural factors. RESULTS: Comparing OS to SDD patients, OS patients had a lower prevalence of radial access (20.29% vs. 39.64%, P<0.0001); a higher incidence of suboptimal angiographic results (14.49% vs. 1.80%, P=0.0027); CRCL values lower than 60mL/min (26.38% vs. 15.32%, P=0.0019); and greater femoral vascular site hemostasis with manual compression (69.09% vs. 36.57%, P=0.0027). OS patients received larger sheath sizes (P=0.0209), more bivalirudin (45.80% vs. 36.70%) and glycoprotein IIb/IIIa inhibitors (5.51% vs. 2.25%), but less heparin (51.30% vs. 53.21%). Chest pain (8.12% vs. 0.92%, P=0.0042) and vascular access site concerns (20.58% vs. 0%, P=0.0027) were more common among OS patients. CONCLUSIONS: Pre-, peri-, and post-procedural factors play a role in SDD eligibility. Understanding factors that limit as well as those that facilitate SDD may enable institutions to establish or enhance a SDD program.

Assessment of clinical outcomes related to early discharge after elective percutaneous coronary intervention: COED PCI.

OBJECTIVE: To assess clinical outcomes of same-day discharge (SDD) patients after elective percutaneous coronary intervention (PCI). BACKGROUND: An overnight stay after PCI has been the standard approach in the majority of institutions. Data supporting SDD while maintaining patient safety, based on contemporary United States practice, have not been well established. METHODS: Using institutional pre-, peri-, and post-procedural guidelines, short-term clinical outcomes of 200 consecutive patients discharged on the same day after elective PCI were prospectively studied. Major adverse cardiac events (MACE), access site and vascular complications, readmissions, and emergency room (ER) visits were assessed within 24 hrs and at 7-day post-SDD. MACE included cerebral vascular accidents, death, myocardial infarction, target vessel revascularization, pulmonary embolism, and emergent coronary artery bypass grafting. RESULTS: The mean age of the population was 63.2 years; 75% were males. Of 200 patients, 75.5% were accessed femorally and 24.5% had radial access. Intra-procedural anticoagulation included bivalirudin alone (47%), bivalirudin with glycoprotein (GP) IIb/IIIa inhibitors (3.5%), heparin alone (37%), and heparin with GP IIb/IIIa inhibitors (12.5%). No major bleeding or MACE was reported within 24 hrs or at 7 days. Within 7 days, 8 (4%) patients experienced minor bleeding, 4 (2%) were readmitted, and 3 (1.5%) had ER visits only. Pseudoaneurysm occurred in 1 (0.5%) patient. CONCLUSIONS: Our institution-specific guidelines identify low-risk PCI patients who can be safely considered candidates for SDD with virtually no short-term adverse consequences.