Post-Percutaneous Coronary Intervention Hospitalization, Length of Stay, and Discharge Planning

Physician-to-Patient Communication

The results of the procedure, including any complications and/or unexpected findings, should be explained clearly to the patient and his or her family. The type of intervention, if any, and the duration of DAPT should also be introduced and reinforced repeatedly by the team of care providers throughout the patient stay.

Access Site Management

Typically, manual compression, a compression device, and/or a vascular closure device (VCD) is used in patients following transfemoral access, whereas a wristband compression device is used most frequently among patients undergoing transradial (TR) access. For patients undergoing transfemoral access and anticoagulated with heparin, the access sheaths can generally be removed once the activated clotting time (ACT) falls below 175 seconds if a closure device is not used. The use of bivalirudin typically does not necessitate checking an ACT unless there is significant renal impairment (i.e., creatinine clearance <30 mL/min or hemodialysis); in that situation, sheaths may be removed once the ACT falls below 180 seconds. In patients without significant renal dysfunction, the femoral arterial sheath can be removed 2 hours after the discontinuation of the bivalirudin infusion if a closure device is not used.

Postprocedure Ambulation

The access site, method of hemostasis, intensity of procedure sedation, and anticoagulation strategy drive recommendations for activity immediately postprocedure. Patients undergoing TR catheterization may ambulate as soon as sedation wanes. For patients undergoing transfemoral catheterization and PCI, strict bed rest is typically recommended for 4 to 8 hours if manual compression is used or 1 to 4 hours if a VCD is used; prior to ambulation, a care provider must ensure that hemostasis is achieved and there is no diminution of downstream peripheral pulses.

Postprocedure Monitoring

Patients are generally monitored in a telemetry setting postprocedure, with monitoring of vital signs every 15 minutes for the first 2 hours by trained nursing personnel. Although most patients go home on the same day within 2 to 6 hours following diagnostic cardiac catheterization, there are varying lengths of monitoring following PCI, which will be discussed in greater detail below. Additionally, the role of laboratory testing post-PCI will be discussed below.

Discharge Physical Examination

Although a full physical examination is generally performed prior to discharge, additional focus should be directed to the patient’s access site to ensure adequate hemostasis and perfusion. The access site should be auscultated to ensure no bruit, which may be concerning for a pseudoaneurysm or arteriovenous fistula, each of which requires additional testing to confirm, typically via ultrasound. Distal pulses should be palpated to ensure no decrease in downstream perfusion. Patients should also be able to demonstrate their baseline level of ambulation without difficulty and ensure pain is well controlled prior to consideration of discharge postprocedure.

Discharge Instructions

Patients should be provided with clear instructions regarding physical activity, follow-up, and the need for additional laboratory testing postprocedure. Discharge instructions should also have clear contact information for the recovery unit or the physician in case of complications following discharge. Additionally, discharge instructions should address the following concerns:

• Site management : Patients should be advised that there may be minor bruising and/or pain at the access site, which should resolve within 1 month postprocedure. Patients undergoing transfemoral access should not strain or lift anything greater than 5 pounds for 48 hours postprocedure and should apply pressure to the access site when sneezing or coughing. Clear instructions for an action plan for access site complications, including active arterial bleeding, hematoma, erythema or purulence at the access site, or downstream neurologic symptoms such as numbness/tingling or paresthesia, should be provided.

• Activity levels: Although important to maintain preprocedure activity levels, most patients are advised to refrain from physical exercise for at least 48 hours postprocedure. Patients undergoing PCI should be enrolled in a cardiac rehabilitation program postprocedure to develop a plan of graded exercise.

• Driving and return to work : Most patients are advised to refrain from driving for at least 48 hours, if not 1 week, postprocedure. The decision to return to work is individualized and often is related to job satisfaction, financial stabilities, and/or company policies. Recommendations regarding return to work also depend on the type of work the patient performs, including physical demands, mental stress, and safety considerations.

• Sexual activity : Most patients are advised to refrain from sexual activity for 1 week postcardiac catheterization to allow for access site healing. Other recommendations are based on the patient’s level of fitness. According to an American Heart Association (AHA) consensus statement, sexual activity is reasonable for patients at low risk for cardiovascular complications or who can exercise for 3 to 5 metabolic equivalents (METs) without symptoms or electrocardiogram (ECG) changes. In previous studies of sudden cardiac death related to sexual activity, most patients who died during intercourse were men (82% to 93%) who participated in extramarital sexual activity (75%), typically with a younger partner, after excessive food and alcohol consumption. A recent analysis of 536 patients with incident MI reported that only 3 patients (0.7%) reported sexual activity in the hour prior to the MI and 1.5% in the 3 to 6 hours prior.

Medication Reconciliation

Medication reconciliation is a critical aspect of postprocedure discharge planning and major changes are typically reinforced at multiple instances during the patient stay by trained personnel, which may include physicians, nurses, trainees, or pharmacists. Barring specific contraindications, many patients undergoing PCI will be on dual antiplatelet therapy (DAPT) with aspirin and an additional platelet inhibitor (currently available agents are P2Y ₁₂ antagonists), a β-blocker, an angiotensin converting enzyme (ACE) inhibitor, and a high-intensity statin. Patients should be provided with clear instructions regarding which medications should be stopped, which medications have changed in dosage, and which medications they should begin to take postprocedure. Recommendations for postprocedure DAPT should be clearly stated on the discharge paperwork, and given the critical nature of uninterrupted therapy, a clear plan should be outlined for the patient to obtain the antiplatelet as an outpatient. SCAI has recommended that diabetic patients should withhold their metformin for 48 hours postprocedure. Patients previously on warfarin who have stopped it for the procedure should be restarted on their regimen and have an international normalized ratio (INR) value checked within 1 week postprocedure to ensure a therapeutic range. No consensus guidelines have been provided for the novel oral anticoagulants (NOACs), but they are generally started postprocedure as hemostasis is achieved and do not require close monitoring.

Communication to Referring Physician

An appropriate transition of care from the invasive cardiologist to the primary cardiologist or referring physician is also an integral component of postprocedure care. This communication is typically performed verbally as well as in the form of a procedure note clearly identifying the indications for the procedure, the diagnostic findings, interventions performed, and plan for postprocedure management.