Identifying low-risk patients eligible for early discharge after ST-segment elevation myocardial infarction

Abstract Introduction Early discharge after ST-segment elevation myocardial infarction (STEMI) should be considered in low-risk patients after successful percutaneous coronary intervention (PCI) to reduce healthcare costs and improve resource utilization. The Zwolle criteria is recommended by current guidelines for the identification of low-risk patients but a new score, the FASTEST score, has recently demonstrated to add prognostic value over Zwolle score in small and unicentric studies. Purpose Assess if FASTEST score could better identify low-risk patients compared to Zwolle in a contemporary nationwide cohort of patients with STEMI who underwent primary PCI and complete revascularization. Methods Multicentric observational study of consecutive patients with ACS recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between October 2010 and January 2019. Patients who underwent primary PCI and received complete revascularization were included, and those with missing data for score calculation were excluded. The FASTEST score awards 1 point for each: femoral access, age>65, LVEF<50, TIMI<3; creatinine >1.5 mg/dl; stenosis of the left main coronary artery; and Killip≥2. The Zwolle score was calculated for comparison. The rate of hospital mortality and a composite of serious adverse events (heart failure, cardiogenic shock, re-infarction, mechanical complication, ventricular arrhythmia and major hemorrhage) was compared between low-risk patients as classified by FASTEST (score=0) or Zwolle (score≤3). One-year mortality and cardiovascular rehospitalization was compared between the two groups. Results We included 3322 patients (77.4% male, mean age 62±13 years, 49.5% with anterior STEMI). The FASTEST score identified 855 (25.8%) and Zwolle 2353 (70.7%) low-risk patients. Discrimination by AUC for hospital mortality was 0.92 (95% CI 0.91–0.93) for FASTEST score, significantly higher than Zwolle (0.83 (95% CI 0.82–0.84), p<0.001 for comparison) (Fig.1). Overall hospital mortality was 2.8%. 1 patient died in low-risk FASTEST compared to 24 (1%) in low-risk Zwolle (p=0.01). Low-risk Zwolle patients were more likely to suffer serious hospital adverse events compared with FASTEST score low-risk (19.5% vs 8.5%, p<0.001). At one-year, 1384 patients had follow-up data. Mortality was significantly lower in low-risk FASTEST than Zwolle (1.5% vs 4.6%, p<0.001) and a tendency for less cardiovascular rehospitalization was also noted (5.4% vs 7.5%, p=0.08). Figure 1. ROC-AUC for hospital mortality Conclusion Approximately one in every four patients were classified as low-risk according to FASTEST score, in contrast with 70% for Zwolle score. Low-risk FASTEST score patients exhibited significantly less hospital mortality (1 patient), hospital serious adverse events and 1-year mortality compared with low-risk Zwolle patients. FASTEST score demonstrated better discriminatory capacity for hospital mortality than Zwolle score and its use for risk stratification should be preferred.