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Aim Primary percutaneous coronary intervention (PPCI) produces more effective coronary reperfusion and allows immediate risk stratification compared with fibrinolysis. We investigated the safety and feasibility of very early discharge at 2 days following PPCI in selected low-risk cases. Methods This was a prospective observational cohort study of 2779 patients who underwent PPCI between 2004 and 2011. Patients meeting the following criteria were deemed suitable for very early discharge; TIMI III flow, left ventricle (LF) ejection fraction >40%, and rhythmic and haemodynamic stability out to 48 h. Higher-risk patients who did not fulfil these criteria were discharged later according to physician preference. All patients were offered outpatient review by a multidisciplinary team. Endpoints included 30 day readmission rates and major adverse cardiac events (MACE) out to a median of 2.8 years (IQR range: 1.3–4.4 years). Results 1309 (49.3%) PPCI patients met very early discharge criteria, of whom 1117 (85.3%) were actually discharged at 2 days. 620 (23.4%) were discharged at 3 days, and 916 (34.5%) >3 days after admission (median 5, IQR: 4–8) days). Patients discharged at 2 days were younger, and had lower rates of diabetes, renal dysfunction, multivessel coronary artery disease, previous myocardial infarction, and previous coronary artery bypass surgery, compared with patients discharged later. 30-day readmission rates for non-MACE events were 4.8%, 4.9% and 4.6% for patients discharged 2 days, 3 days and >3 days after admission, respectively. MACE rates were lowest in patients discharged at 2 days (9.6%, 95% CI 4.7% to 16.6%) compared with patients discharged at 3 days (12.3% 95% CI 6.0% to 19.2%) and >3 days (28.6% 95% CI 22.9% to 34.7%, p Conclusions Our data suggest that discharge of low-risk patients 2 days after successful PPCI is feasible and safe. Over 40% of all patients with ST-elevation myocardial infarction may be suitable for early discharge with important implications for healthcare costs.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting 3–5% of the population aged between 65 and 75 years and increasing to 8% for those over 80 years of age.1–4 The major cause of serious disability and death in patients with AF is embolic stroke. The annual stroke rate varies from 2% to more than 20% depending on the age and comorbidity of the population studied.1 Most ischaemic strokes associated with AF originate in the atria, and transoesophageal echocardiographic (TOE) studies suggest that the vast majority (>90%) of all thrombi related to stroke in patients with AF originate in the left atrial appendage (LAA).5 Current UK National Institute for Health and Clinical Excellence (NICE) guidelines recommend oral anticoagulants as the mainstay of therapy to reduce stroke risk in AF.6 Adjusted-dose warfarin reduces stroke by approximately 60% and death by approximately 25% compared with no antithrombotic treatment.7 However, warfarin therapy is markedly underused in patients with AF for several reasons, including compliance issues, contraindications, the need for regular international normalised ratio (INR) measurements, the narrow therapeutic window and also a fear of bleeding complications.8–13 In practice, the estimated number of patients with AF adequately receiving anticoagulant therapy is less than 50%,14 and may be still lower in developing countries where the management of anticoagulation is often problematical.15 More recently dedicated percutaneous devices designed to occlude the LAA have been introduced. The hypothesis for their use is that occlusion of the LAA may prevent thrombus formation in the appendage and thus reduce the risk of thromboembolic stroke. Initial registry data and randomised studies of these devices have shown encouraging results as an alternative to warfarin therapy for selected patients. In this paper we will review the currently available LAA occlusion devices and the evidence …

Background Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI) provided PPCI is performed in a timely manner. There is conflicting data regarding the outcomes of patients treated in-hours versus out of-hours, we sought to determine whether in-hospital and long-term outcomes are different among in-hours versus out of hours PPCI patients. Methods This was an observational study of 3347 STEMI patients treated with PPCI between 2004 and 2012 at a single centre with follow-up for a median of 3.3 years (IQR range 1.2–4.6 years). The primary end-point was long-term major adverse cardiac events (MACE) with all cause mortality a secondary endpoint. Of these, 1299 patients (38.8%) underwent PPCI during a weekday between 08:00 and 18:00 (routine-hours group) and 2048 (61.2%) underwent PPCI on a weekday between 18:00 and 08:00 or a weekend (out-of-hours group). Results There were no differences in baseline characteristics between the two groups with comparable door to balloon times (IHs 67.8 min vs OOHs 69.6 min, p=0.709) and procedural success (table 1). In hospital mortality rates were comparable between the two groups (IHs 3.6% vs OFHs 3.2%) with timing of presentation not predictive of outcome (HR 1.25 (95% CI 0.74 to 2.11). Over the follow-up period there were no significant differences in rates of mortality (IHs 7.4% vs OFHs 7.2%, p=0.44) or MACE (IHs 15.4% vs OFHs 14.1%, p=0.28) (figure 1) between the two groups. After adjustment for confounding variables using multivariate analysis, timing of presentation was not an independent predictor of mortality (HR 1.04 95% CI 0.78 to 1.39). Conclusions This large registry study demonstrates that in a large volume, well-staffed centre, PPCI outside routine-working hours is safe with no difference in outcome compared with PPCI during routine-working hours.

Background Recent UK epidemiological data suggests that while incidence and mortality of myocardial infarction (MI) is in decline, mortality associated with out of hospital cardiac arrest (OOHCA) in the setting of MI is still a significant problem now constituting 70% of its total fatality. Small studies have shown survival benefit with primary percutaneous coronary intervention (pPCI) in OOHCA in the setting of ST elevation myocardial infarction (STEMI). There is little contemporary outcome data in this population. We sought to identify predictors of survival in STEMI complicated by OOHCA in a large, contemporary cohort in the era of pPCI. Methods Between January 2008 and October 2011, 1836 consecutive STEMI admissions to a high volume pPCI centre were retrospectively analysed. 132 patients were identified as having OOHCA. Clinical and procedural data was collected from the UK Myocardial Ischaemia National Audit Project (MINAP) database and patient notes. Endpoints were all cause mortality to 4 years (mean: 559 days, median: 380 days) and neurological recovery at discharge (Cerebral Performance Score/CPS 1). Mortality data was collected using the Office of National Statistics mortality database. Results 132 out of 1836 consecutive STEMI patients were identified with OOHCA (7.2%). The mean age of patients was 59.4±14years, 78.8% were male and 55% were directly conveyed to the pPCI centre; the remaining were transferred from district hospitals. Survival to discharge was 76.5% (101/132 patients). 86 patients had full neurological recovery (65% of the whole cohort). Long term follow-up revealed only one further death making the overall survival rate 75.8%. Survivors had significantly higher incidence of witnessed arrest (p Conclusions To our knowledge, this is the first reported series of STEMI complicated by OOHCA of this size in UK contemporary practice. This data shows a 76% survival rate, 65% rate of full neurological recovery and supports the emergent transfer of this patient group to a cardiac centre for pPCI.