Early discharge in the thrombolytic era: an analysis of criteria for uncomplicated infarction from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial.
OBJECTIVE
This study sought to readdress the definition of uncomplicated myocardial infarction and to apply clinical criteria for early discharge of such patients in the thrombolytic era.


BACKGROUND
Previous studies proposed early hospital discharge at day 7 to 10 after acute myocardial infarction. The potential for earlier discharge of patients with uncomplicated infarction after thrombolysis remains undemonstrated.


METHODS
We defined "uncomplicated infarction" a priori as the absence of death, reinfarction, ischemia, stroke, shock, heart failure (Killip class > 1), bypass surgery, balloon pumping, emergency catheterization or cardioversion or defibrillation in the first 4 hospital days. We applied this definition to 41,021 patients in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial. We examined death at 30 days and 1 year and rates of in-hospital reinfarction, heart failure, recurrent ischemia, shock and stroke in the uncomplicated and complicated groups created by application of our definition. We also assessed lengths of hospital and cardiac care unit stay.


RESULTS
Application of our clinical criteria yielded 23,497 (57.3%) patients in the uncomplicated group at day 4 with a very low risk of death and in-hospital complications: 30-day mortality 1%, reinfarction 1.7%, heart failure 2.6%, recurrent ischemia 6.7%, shock 0.4% and stroke 0.2%. One-year mortality was 3.6%. The median hospital stay was 9 days (7, 12 [25th, 75th percentiles, respectively]), and the median cardiac care unit stay 3 days (3, 5).


CONCLUSIONS
Simple clinical characteristics can identify a very low risk post-myocardial infarction population by hospital day 4. Use of these criteria for early discharge planning could substantially reduce length of stay for patients with uncomplicated acute myocardial infarction.
Newby
L K
LK
Department of Medicine (Cardiology), Duke University Medical Center, Durham, North Carolina 27710, USA.
Califf
R M
RM
Guerci
A
A
Weaver
W D
WD
Col
J
J
Horgan
J H
JH
Mark
D B
DB
Stebbins
A
A
Van de Werf
F
F
Gore
J M
JM
Topol
E J
EJ
D000368:Aged; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D010351:Patient Discharge; D018579:Patient Selection; D011379:Prognosis; D012008:Recurrence; D012720:Severity of Illness Index; D013300:Streptokinase / Q000627:therapeutic use; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator