PAMI-II
Source: Grines CL, et al. J Am Coll Cardiol 1998;31: 967-972.
The second primary angioplasty in myocardial Infarction trial (PAMI-II) evaluated the feasibility of discharge at three days after acute MI in low-risk patients treated by primary angioplasty. Low-risk patients were defined as: younger than 70 years of age, left ventricular ejection fraction greater than 45%, 1-2 vessel disease, no arrhythmias, and successful primary angioplasty. They were randomized to traditional care vs. admission to a nonintensive care unit and discharge at three days without noninvasive testing. Traditional care included coronary care unit admission, heparin for 72 hours, and discharge more than five days after noninvasive testing. Accelerated patients received heparin for 48 hours with a 12-hour taper and were discharged at an average of four days. Traditional patients were discharged at an average of seven days (P < 0.001). There was no difference in hospital outcomes between the two groups, but the accelerated group had a lower hospital bill by $2000 (P = 0.002). Clinical outcomes at six months were similar in the two groups. Grines et al conclude that identification of a low-risk group after successful primary angioplasty for acute MI permits avoidance of the intensive care unit and noninvasive testing and permits discharge as early as day 3 post MI.
The $2000 savings may be eaten up by the cost of the catheterization in these patients. Unfortunately, total costs were not estimated in the study. Also, less intensive care and reduced hospital stays are a trend nationwide in MI care whether primary angioplasty is used. At our two teaching hospitals, most MI patients are admitted to a sub-acute monitored unit and our average length-of-stay is about five days for uncomplicated patients. The intensive care unit is only used for patients intubated, on a balloon pump, or requiring an indwelling right heart catheter. The traditional coronary care unit is an anachronism today. -mhc
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