March 15, 2000 (Washington) -- Many people who have a heart attack can safely return home after just three days in the hospital, as long as they don't have other serious problems, according to a study in the March 16 issue of TheNew England Journal of Medicine. Serious problems that could preclude such a short stay range from having a stroke or second heart attack to abnormal heart beats.
But hospitals and physicians first must make sure that everything was done right in the hospital and that the patient and his or her family are sufficiently prepared to cope once they leave, the lead author tells WebMD.
"We are not endorsing or saying in this study that we think patients should go home after three days," says L. Kristin Newby, MD. "What we are saying is, here is an opportunity. Almost 60% of heart attacks are uncomplicated. [But] most hospitals and physicians can't provide all the high-quality, evidence-based care in that shortened time frame. While it does look like an exciting opportunity, we are probably not there yet in terms of delivery." Newby is an assistant professor in the division of cardiology at Duke University School of Medicine in Durham, N.C.
"I don't think this is dramatic news and I don't think there will be much of a fight over this, " says cardiologist Allen J. Solomon, MD, an associate professor of medicine at Georgetown University in Washington. "It doesn't necessarily apply to all other patients. Now, if the evening news says you only need to stay three days for a heart attack, and it is not presented as [being] appropriate for a subset of patients who are doing extraordinarily well, then there could be a fight." Solomon reviewed the study for WebMD.
The findings are based on a study of more than 22,300 patients who were enrolled in another study that was trying to determine the effectiveness of clot-busting medications. None of the patients in that study had complications for 72 hours after being given the medication. Complications that can occur include a second heart attack, stroke, congestive heart failure, irregular heartbeats, and the need for emergency surgery to unclog arteries. Sixteen patients of the more than 22,300 had irregular heartbeats during the next 24-hour period. Three of them died.
Applying these findings to clinical practice will take some work, Newby admits. "We need to ensure that everybody goes home on aspirin, gets their [cholesterol] medications. ... That is going to take a certain amount of knowledge and testing, and coordination and communication between the inpatient and outpatient [settings] to make sure medications that are started in the hospital are continued at the right doses."
In addition, the patient and his or her family need to be psychologically prepared to cope with the impact of a heart attack, which for many people is a life-altering event. "The patient is the main reason we are doing this, and we need to make sure there aren't any issues regarding the patient that need to be factored into the equation," Newby says.
An accompanying editorial, co-written by Elliot Antman, MD, an associate professor of medicine at Harvard University School of Medicine, warns that the findings "must not be used by insurance companies as the rationale for refusing to pay for hospital stays beyond 72 hours for patients with uncomplicated [heart attacks]." Instead, the study should instead serve as "the impetus for further research," which should center on developing better ways to determine which patients might develop complications following a heart attack, according to the editorial.
Antman and his co-author also note that discussions of shortened stays, specifically for mastectomies and births, were met with a huge public backlash and ultimately legislation that mandated certain inpatient lengths of stay.
The primary value of the study is that it provides cost estimates for hospital stays over three days. "I think it is reasonable and not surprising," says Solomon. "I think [a three-day stay] is the standard of care in some places and is becoming more of a national trend."
"We used to keep patients a few months, then a few weeks, now a few days. We see lots of patients come in the throes of an acute [heart attack], they have angioplasty, which immediately resolves the clot and their symptoms," he says. "By the time they reach the hospital bed two hours later, they are already doing well and saying, 'When can I go home?' I say, 'You can't go home; you just had a heart attack three hours ago!' Patients are anxious to go home. Doctors are anxious to let them go home."
Solomon says that there are a small number of patients, perhaps 2% of those who have a heart attack, who could go home after just two days. "You see a guy sitting on his bed banging away on his laptop. ... If you've ever been in a hospital, you don't have to be a doctor to know who looks like they are doing well."
- Nearly 60% of heart attack patients have no other serious complications, and a new study shows that these patients may be able to leave the hospital after just three days, instead of the usual five.
- One catch, according to a researcher, is that the hospital has to have all the resources to provide high-quality care within such a short time period, and most of them don't yet.
- Before leaving the hospital, patients need to be taking aspirin and cholesterol-lowering medications, and patients and family members need to be psychologically prepared to cope with the impact of a heart attack.