Same day percutaneous coronary intervention discharge: From exception to expectation

Abstract

Same day discharge after elective percutaneous coronary intervention (PCI) is increasingly adopted, particularly with transradial access, however longterm safety evidence has been limited. Klocek et al recently published a study in the World Journal of Cardiology provide timely real-world data from a single ambulatory surgical center: 787 consecutive PCIs (2018-2023) with a median discharge time of 150 minutes. Early outcomes were reassuring: Within 24 hours there were no deaths, strokes, emergent coronary artery bypass grafting, transfers for overnight care, or hospitalizations; by 30 days, unplanned cardiovascular hospitalizations occurred in 0.7% and there were no deaths or strokes. Two-year events remained low: Death 1.93%, myocardial infarction 0.85%, target vessel revascularization 7.62%, and stroke 0.17%. Subgroup outcomes in higher-risk anatomy - 25 left main and 332 left anterior descending (115 proximal) procedures - were reassuring but based on small numbers and remain hypothesis-generating rather than confirmatory, particularly for left main disease. Femoral cases showed higher two-year target vessel revascularization (21.84% vs 5.85%; P < 0.001) without differences in death or myocardial infarction, reflecting greater baseline comorbidity rather than access site alone. Interpreted alongside the randomized and consensus evidence that preceded it, including the 2018 Society for Cardiovascular Angiography and Interventions shift from anatomy-based exclusions to milestone-based discharge readiness, this hypothesis-generating study supports the feasibility of very early discharge after PCI in experienced centers with structured follow-up and standardized protocols. Nevertheless, its retrospective, single-center design, absence of an inpatient comparator, and capture of unplanned hospitalizations only to 30 days temper conclusions. Future multicenter randomized trials and standardized post-discharge pathways are warranted.

Key Words: Same-day discharge; Elective percutaneous coronary intervention; Major adverse cardiac and cerebrovascular events; Ambulatory surgical center; Discharge timing; Length of stay

Core Tip: Same-day discharge after elective percutaneous coronary intervention appears safe and efficient in experienced centers using predominantly radial access and structured follow-up. Early outcomes were excellent and two-year event rates remained low; findings in left main and proximal left anterior descending disease were reassuring but, given small numbers, are hypothesis-generating. Early discharge should pair with careful selection, robust secondary prevention, and rapid re-entry pathways; multicenter randomized trials are warranted.

This editorial refers to “Safety and feasibility of outpatient percutaneous coronary interventions with short- and long-term outcomes” by Klocek et al, 2026; https://doi.org/10.4330/wjc.v18.i4.115113.

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INTRODUCTION

Coronary artery disease (CAD) remains the leading cause of death worldwide and a dominant driver of healthcare burden[1]. In the United States, CAD accounts for hundreds of thousands of deaths annually, with substantial morbidity from myocardial infarction (MI), chronic angina, heart failure, and repeat revascularization[2]. Percutaneous coronary intervention (PCI) has transformed the management of obstructive CAD, offering rapid symptom relief and improved ischemia control in appropriately selected patients. Procedural volumes continue to increase substantially[3]. Large registries and national databases demonstrate that elective PCI outcomes have improved over time, reflecting advances in stent technology and strategies, understanding of interventional physiology, pharmacotherapy, vascular access, intraprocedural imaging, and interventionist expertise[4,5]. Contemporary mortality after elective PCI is low, and major procedural complications such as emergency coronary artery bypass grafting (CABG), disabling stroke, and major bleeding are uncommon in well-selected patients treated at experienced centers. Radial access is the current standard approach based on the latest guidelines from the American Heart Association and Society for Cardiovascular Angiography and Interventions (SCAI). This approach has been proven to reduce access-site complications, cardiac mortality, and general clinical adverse events, and facilitates early mobilization and shortens observation needs relative to femoral access[6-9].

Within this context, the timing of discharge after PCI has become an important clinical question. Historically, overnight observation was routine, driven by concerns about access-site bleeding, periprocedural complications such as MI, stent thrombosis, and contrast-related adverse events. Over the past decade, however, same-day discharge (SDD), defined as post-PCI stay without supervised overnight observation in a hospital (usually less than 12 hours after arrival)[10], has gained traction, with an increasing proportion from 4.5% in 2009 to 28.6% in 2017, particularly with radial access, refined periprocedural antithrombotic strategies, and improved postprocedural care[11]. SDD improves patient experience, reduces nosocomial infection risk, lowers costs, and increases catheterization laboratory throughput without compromising safety or conferring a higher risk of death, bleeding, acute kidney injury, or MI at short- and long-term follow-up[12]. However, critics raise concerns about missing silent complications, inadequate monitoring, inadequate patient education and inequities in post-discharge support, and the potential for underdetection and delayed care for nonfatal events that present after the first day.

Despite these concerns, early discharge is safe when patients are appropriately selected, current recommendations are followed, and reliable follow-up and standardized protocols are in place[13-15]. Notably, the 2018 SCAI consensus update replaced the 2009 anatomic and patient-level exclusions - which had formally disqualified proximal left anterior descending (LAD), bifurcation, and multivessel lesions from SDD - with readiness milestones organized around the “three P’s” (procedure, patient, program), on the principle that overnight observation does not modify baseline comorbidity risk[16]. This editorial argues that SDD should therefore be regarded not as an exception reserved for the lowest-risk patients, but as the default pathway for elective PCI - determined by how the procedure concludes rather than by anatomy assumed beforehand - with overnight observation reframed as the exception that must be justified by a defined procedural or clinical trigger, and with the field’s priority shifting from further proof of safety to building the systems that make early discharge dependable.

SDD STRATEGIES: WHAT THE NEW STUDY ADDS

Klocek et al[17] recently published a study in the World Journal of Cardiology provided timely real-world evidence from an ambulatory surgical center that has performed outpatient PCI since 2008. In a retrospective single-center analysis from 2018 to 2023, they reported outcomes from 787 consecutive PCIs in 444 patients, with a median discharge time of 150 minutes measured from the start of the procedure. The study is notable for its inclusion of higher-risk coronary anatomy (left main and proximal LAD artery lesions), structured post-procedural follow-up, and long follow-up duration (up to 720 days post-PCI).

Early outcomes were reassuring. Within 24 hours of PCI, there were no deaths, strokes, emergent CABG, transfers for overnight care, or hospitalizations. Over the first 30 days, unplanned cardiovascular hospitalizations were rare (0.7%), and there were no deaths or strokes. Long-term outcomes up to 24 months remained favorable: Death 1.93%, MI 0.85%, target vessel revascularization (TVR) 7.62%, and stroke 0.17%. Procedural success was high (97.59%), and complications within 24 hours were limited to minor access-site events (hematomas, pseudoaneurysms, minor bruising/swelling, and one radial/ulnar occlusion).

Importantly, the study interrogates subgroups relevant to clinical decision-making around discharge timing. Among 25 left main coronary artery PCIs (10 ostial, 15 mid/distal), median discharge times were between 175 minutes and 180 minutes, and there were no serious short- or long-term complications; TVR rates did not differ between ostial and mid/distal lesions. In 332 LAD PCIs (115 proximal), long-term major adverse cardiac and cerebrovascular events did not differ significantly compared with the general cohort, and proximal vs mid/distal LAD outcomes were similar. These observations indicate that anatomic complexity alone does not automatically preclude SDD, as long as the procedure is uncomplicated and post-procedural milestones are met - consistent with contemporary left main PCI cohorts and the 2018 SCAI recommendations, which list proximal LAD, bifurcation, and multivessel PCI among the cases compatible with expedited discharge[16,18]. Left main disease, however, was not included in that framework; the present 25 left main procedures, while reassuring, are too few to establish safety and should be regarded as hypothesis-generating rather than as justification for routine SDD in this subgroup.

Access site findings were also important. Wrist (radial/ulnar) access accounted for 700 procedures (88.95%), with favorable two-year outcomes: TVR 5.85%, death 1.14%, MI 0.57%, and no strokes. Femoral access, used in 87 procedures (11.05%), was associated with higher two-year TVR (21.84% vs 5.85%; P < 0.001) but no significant differences in death or MI. The femoral cohort, however, carried a heavier comorbidity burden: More diabetes mellitus, chronic kidney disease, prior MI, prior PCI, and prior CABG - suggesting these worse outcomes might be linked to higher baseline risk and lesion complexity rather than an intrinsic hazard of the access site alone.

Beyond anatomy and access, the study explores risk modifiers. Repeat revascularization was more common in patients with diabetes or pre-diabetes (P = 0.046), and among those who underwent revascularization, hyperlipidemia and prior stroke were overrepresented (P = 0.03 and P = 0.007, respectively) - findings consistent with known predictors of TVR in contemporary PCI cohorts[19,20]. Patients who later underwent TVR had a slightly longer initial discharge time (median 168 minutes vs 150 minutes; P = 0.025). Multivessel procedures had higher two-year TVR (11.7%) than single-vessel interventions (6.34%; P = 0.015), a finding consistent with more extensive disease biology and treatment complexity[20].

Finally, among 30 chronic total occlusion (CTO) procedures, only 21 were successful, and the favorable outcomes apply to that completed subset; failed or complicated CTO attempts - precisely the scenario carrying the greatest post-procedural risk - warrant continued observation rather than SDD.

HOW DO THESE FINDINGS FIT INTO THE BROADER LITERATURE?

The authors’ results align with and extend a growing body of evidence supporting safe SDD for elective PCI. Randomized trials and large registries have repeatedly shown that, in appropriately selected patients - particularly those treated via radial access - SDD does not increase short-term adverse events, with low rates of major bleeding and ischemic events within 72 hours, and offers favorable cost-effectiveness compared with overnight observation[14,15,21-23]. Observational studies and pragmatic trials in diverse settings (regional hospitals, rural populations) corroborate its safety and feasibility, with consistent themes: Careful selection, standardized antithrombotic protocols, clear discharge instructions, and rapid re-entry pathways[24].

The Klocek et al’s study[17] contributes three meaningful findings. First, it confirmed the current literature regarding the safety of SDD in elective PCI in terms of short-term and long-term outcomes and complications. Second, it extends the boundaries of the “very early” aspect - median 150 minutes from procedure start - demonstrating that observation windows can be short in well-structured settings. Lastly, it includes higher-risk anatomical subgroups (left main, proximal LAD, CTO) and shows acceptable outcomes, encouraging a shift away from anatomy-based exclusion toward a milestone-based assessment of discharge readiness, while preserving clinical judgment in the highest-risk subgroups.

Nevertheless, several limitations should be considered when interpreting the findings of this study. First, the results derive from a single, freestanding ambulatory center performing outpatient PCI since 2008, with experienced operators, established protocols, and structured follow-up; the intervention tested is therefore not “shorter observation” in isolation but an entire mature outpatient care pathway, and the favorable outcomes may reflect this infrastructure, patient selection, radial access, and procedural success as much as discharge timing itself. Whether comparable results are achievable in lower-volume centers, femoral-predominant practices, or systems lacking a dedicated ambulatory pathway cannot be inferred from these data. Second, the absence of an overnight-observation comparator, which the authors acknowledge, prevents any causal inference regarding whether very early discharge is noninferior to longer observation. Third, subgroup findings in left main, proximal LAD, multivessel, and CTO PCI are clinically valuable but underpowered for definitive conclusions. Finally, unplanned cardiovascular hospitalizations were captured only up to 30 days, so later nonfatal events and non-cardiac hospitalizations may be underestimated. These limitations do not negate the study's value but define its proper interpretation: It is a strong feasibility study of an experienced outpatient PCI program, not definitive evidence for universal very early discharge.

THE FUTURE OF PCI AND SDD: OPERATIONALIZING SAFETY AND VALUE

Where do we go from here? SDD after PCI is best understood not as a binary “yes/no” decision made at scheduling, but as a milestone-based judgment made at the conclusion of the procedure, structured around the three domains articulated by SCAI - procedure, patient, and program (Table 1). The first two tiers both represent SDD; overnight observation, the third tier, is the deviation that a defined procedural, clinical, or system factor must justify. Within this framework, anatomic complexity informs planning but does not by itself determine disposition. A stable, uncomplicated radial-access case that concludes with an optimal angiographic result and secure hemostasis may reasonably proceed to very early discharge, whereas any case - however straightforward the anatomy - complicated by no-reflow, dissection, a large contrast load in a patient with reduced renal function, or unstable access-site hemostasis warrants extended observation or an overnight stay. Left main disease remains the exception in which caution should dominate until larger data are published. Critically, the program domain is not optional infrastructure but a precondition: Where a reliable re-entry pathway and structured follow-up are absent, the limiting factor is the system rather than the patient.

Table 1 A milestone-based framework for discharge timing after elective percutaneous coronary intervention.

Discharge strategy	Reasonable clinical scenario	Factors favoring this category
Very early discharge (≤ 2-3 hours)	Stable elective PCI with an uncomplicated course	Procedure: Radial/ulnar access, secure hemostasis, no dissection, perforation, no-reflow, or side-branch loss, acceptable contrast load. Patient: No persistent chest pain, ischemic ECG change, arrhythmia, or hemodynamic instability. Program: Confirmed antiplatelet plan, reliable patient understanding, adult support at home, telephone access and a defined rapid re-entry pathway
Extended same-day observation	Moderate-risk patient or procedure with reassuring recovery	Procedure: Selected proximal LAD, uncomplicated multivessel or successful CTO PCI, femoral access with secure closure, longer procedure or higher contrast without instability. Patient: Older age, diabetes, mild-to-moderate CKD, stable recovery. Program: Adequate support with early callback
Overnight observation preferred	High-risk anatomy, complicated procedure, unstable recovery, or inadequate outpatient support	Procedure: Unprotected left main bifurcation, last remaining vessel, atherectomy or lithotripsy, unsuccessful or complicated CTO, periprocedural MI, difficult femoral hemostasis, high contrast with advanced CKD. Patient: Persistent symptoms, ECG changes, arrhythmia, hypotension, bleeding or expanding hematoma. Program: Uncertain antiplatelet adherence, poor health literacy, no transport, caregiver, or rapid access to emergency care

PCI: Percutaneous coronary intervention; ECG: Electrocardiogram; LAD: Left artery descending; CTO: Chronic total occlusion; CKD: Chronic kidney disease; MI: Myocardial infarction.

The advantages of early discharge are compelling: Patient-centered care, reduced risk of nosocomial infection, operational efficiency, and cost savings. In systems stressed by bed capacity limits and workforce constraints, the ability to safely “right-size” observation can be transformative. However, the disadvantages and risks must be explicitly managed: Access-site bleeding, late-onset chest pain or arrhythmias, and patient-level barriers to understanding instructions or accessing rapid re-entry in case of complications. The solution is not simply shorter stays but building reliable safety nets.

From an evidence perspective, we need multicenter randomized controlled trials comparing very short observation (e.g., two to four hours) vs standard same-day or overnight stays in well-defined patient strata. Trials should evaluate not only major adverse cardiac and cerebrovascular events but also access-site complications, unplanned care utilization, patient-reported outcomes (satisfaction, anxiety, confidence), and cost-effectiveness.

CONCLUSION

Klocek et al[17] deliver encouraging real-world evidence that very early discharge after elective PCI can be safe and practical in experienced centers with standardized protocols, predominantly wrist access, and structured follow-up. Early outcomes were excellent and two-year event rates remained low; subgroup results in left main and proximal LAD disease were reassuring but, given small numbers, remain hypothesis-generating. The next phase should prioritize multicenter randomized trials with longer follow-up and the development of practical discharge timing tools that integrate clinical and procedural variables.