Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty - Implications for early discharge

Background - The aim of this study was to create a practical score for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty and to assess the feasibility of early discharge in low-risk patients. Methods and Results - A prognostic score was built according to 30-day mortality rates in 1791 patients undergoing primary angioplasty for STEMI. For the identified low-risk patients without any contraindication to early discharge, we estimated and compared the costs of conventional care ( prolonged 24-hour hospitalization) with the costs of shifting the care from inpatient to outpatient setting ( early discharge) between 48 and 72 hours. Independent predictors of 30-day mortality included in the score were age, anterior infarction, Killip class, ischemic time, postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow, and multivessel disease. This score was able to identify a large cohort (73.4%) of low-risk ( score less than or equal to3) patients, with a good discriminatory capacity ( c statistic = 0.907). The mortality rate was 0.1% at 2 days and 0.2% between 2 and 10 days in patients with a score less than or equal to 3. The incremental cost-effectiveness ratio for late discharge in low-risk patients was estimated at E1949.33. Therefore, this policy would save 1 life per 1097 low-risk patients, at additional costs of E194 933.33, in comparison with an early discharge policy. Conclusions - This score is a practical and useful index for risk stratification after primary angioplasty for STEMI, with a significant impact on clinical decision-making and the related costs. It reliably identifies a large group of patients at very low risk, who may safely be discharged early after primary angioplasty.