LAUSR

In this issue of Catheterization and Cardiovascular Interventions, Tripathi et al analyze data from an administrative database on 22,257 hemodynamically stable ST-elevation myocardial infarction (STEMI) patients who underwent multivessel percutaneous coronary intervention (PCI) between 2010 and 2014. Readmission within 30 days of discharge occurred in 10.3%. Using multivariate analysis, the authors identified 11 baseline characteristics associated with readmission and found that use of mechanical circulatory support devices and discharge to a facility were both associated with higher readmission rates. The use of multivessel PCI as a marker of a high-risk subgroup is a particularly timely topic as there is a trend toward multivessel and nonculprit vessel PCI in the setting of STEMI. The authors call for exploration of strategies to reduce 30-day readmission rates in their high-risk population, although they do not propose any such potential strategies. Multivessel coronary artery disease correlates with a higher risk of STEMI adverse outcomes. There is potentially more ischemic myocardium, perhaps a higher propensity for associated cardiogenic shock, and perhaps an older population with more comorbidities. Longer procedure time with more technical complexity and more contrast may lead to other cardiac or non-cardiac complications that increase 30-day readmission rates. However, in this presumably higher risk group of multivessel PCI patients, the authors found that the readmission rate was not markedly different than rates reported in other studies (Table 1). Why are readmission rates not higher in these patients with more coronary disease and more PCI? Another analysis of the same database over the same period as reported in Tripathi's study found an 11.0% readmission rate for all STEMI PCI patients, most of whom were single vessel PCI. Thus, the report from Tripathi of a lower readmission rate (10.3%) for the multivessel PCI subset supports the hypothesis that more PCI, yielding better revascularization, may reduce readmissions. This is congruent with other recent studies suggesting that more complete revascularization of multivessel coronary disease after STEMI decreases adverse outcomes, including unscheduled readmissions. Perhaps the biggest limitation of this analysis is the inability to compare multivessel PCI readmission rates for STEMI directly with culprit-only single vessel PCI. Nor does the data distinguish patients who underwent multivessel PCI at the time of the initial procedure from those who underwent PCI at a separate session during the initial hospitalization. In addition, the data collected here are likely not representative of current practice since it reflects practice patterns of 5–9 years ago. During the period of the study, guideline recommendations changed for this set of patients. The 2011 American College of Cardiology (ACC)/Society for Cardiovascular Angiography and Interventions (SCAI) PCI guidelines and the 2013 ACC/SCAI STEMI guidelines, both published during the study, stated that PCI should not be performed in a non-infarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (Class III: harm: Level of Evidence: B). Since the study, practice patterns have changed reflecting the 2015 ACC/SCAI focused STEMI guideline update, which upgraded non-culprit PCI during STEMI PCI to a Class IIb recommendation. Finally, most of the correlates of readmission identified in this study offer little room for quality improvement efforts since they are nonmodifiable: age, gender, chronic kidney disease, heart failure, anemia, diabetes, weekday versus weekend admission, length of stay, disposition to a facility, insurance carrier. Although the authors call for exploration of strategies to reduce 30-day readmission rates, their data do not identify any potential approaches. In the quest to reduce readmissions, what other strategies have been suggested? Tanguturi et al reported a multipronged quality improvement initiative that reduced 30-day readmission by 50% compared to historical averages. Minges et al identified several strategies associated with lower readmission rates including regular meetings with cardiac rehabilitation staff and involvement of hospital leadership with quality metrics. Both authors highlight the importance scheduling close cardiology follow-up appointments before the patient left the hospital. Wasfy et al concluded that only a small fraction (10%) of readmissions were due to PCI complications or bleeding. This metric is quite consistent across studies of PCI readmission in all-comers and is likely to decline in the United States with increased adoption of transradial access for PCI and other bleeding avoidance strategies. Finally, Wasfy et al claimed that 43% of readmissions were Received: 13 November 2019 Accepted: 13 November 2019