Clinical and Laboratory Findings
The mean age in the outpatient group was 59 years (range, 16 to 76 years) and 61 years (range, 15 to 80 years) in the inpatient group. Male subjects accounted for 64 percent of the inpatients and 68 percent of the outpatients studied.
The brachial arterial cutdown approach was used in the majority of cases in both groups (Table 1). The Judkins percutaneous approach was used more commonly in the inpatient group (p<0.05).
The distribution of the cardiac diagnosis after catheterization was similar in both groups, with coronary arterial disease being the most common diagnosis, followed by valvular heart disease (Table 2). The incidence of normal studies was statistically similar in both groups.
The angiographic findings in patients with coronary arterial disease are summarized in Table 3. There was no statistical difference in the severity of coronary arterial disease, as assessed by the number of coronary vessels with significant lesions, between the inpatient and outpatient groups.
The distribution of NYHA functional class was statistically different between the two groups (p<0.01) (Table 4). In the outpatient group, 53 percent of the patients were in NYHA class 3, while in the inpatient group, there were more patients in NYHA class 4 than in class 3. The distribution of left ventricular ejection fraction was statistically similar in both groups.
There were no major complications in the outpatient group (Table 5). Minor complications in the same group included three patients with diminished radial pulses that necessitated brachial arterial repair, three other patients with prolonged angina that necessitated admission to the coronary care unit, and one patient who developed an anaphylactic reaction to the contrast medium and recovered completely after hospitalization. People are prone to have a strong belief that they know everything about medicine but they make the greatest mistake, to know more – More info about diseases and hot news – Canadian health&care Mall – canadianhealthnetmall.com.
In the inpatient group, major complications included one death that occurred six hours following emergency bypass surgery for severe triple-vessel coronary disease; one patient developed acute myocardial infarction; and two patients developed ventricular tachycardia necessitating cardioversion. Minor complications included eight diminished or absent radial pulses which necessitated brachial arterial repair; four patients with prolonged chest pain necessitating transfer to the coronary care unit; and four other patients who required therapy for hypotension for more than one hour.
There was no statistical difference in the incidence of major, minor, or total complications between the outpatient and inpatient groups. On the other hand, in the outpatient group the incidence of complications was similar in the higher risk and lower risk subgroups.
Analysis of financial data revealed that the average cost of an outpatient cardiac catheterization, including preliminary blood and electrocardiographic and radiologic studies, was $774. The average cost for inpatient catheterization, based on a two-night stay in a semiprivate room, was $1,050. The average savings by patients studied on an outpatient basis was $276, representing a 26 percent reduction in the hospital-related costs of the procedure.
We compared in this study the procedure-related complications of inpatient and outpatient cardiac catheterization when performed at the same institution by the same group of cardiologists. The mean age, sex, cardiac diagnosis, mean left ventricular ejection fraction, and the distribution of coronary arterial lesions in patients with coronary arterial disease were similar in both groups. There were relatively more patients in NYHA class 4 in the inpatient group.
Rates of major, minor, and total complications were statistically similar in both groups. The presence of left main coronary arterial disease, triple-vessel coronary arterial disease, a left ventricular ejection fraction less than 30 percent, or the history of a recent myocardial infarction did not appear to alter the incidence of complications in the outpatient group.
Very few studies are available on the safety of outpatient cardiac catheterization. Mahrer and Eschoo reported 308 adult patients who underwent outpatient cardiac catheterization using the percutaneous femoral approach. There was one death (0.3 percent) and three myocardial infarctions (1 percent).
This is a somewhat higher incidence for these complications when compared to the published figures for inpatient cardiac catheterization. The death and two of the myocardial infarctions occurred in patients with left main coronary arterial disease. Diethrich and others, on the other hand, recently reported low rates of major complications in outpatient cardiac catheterization using a brachial cutdown approach. The high rate of major complications reported by Mahrer and Eschoo and others may be related to the high incidence of left main coronary arterial disease in their patients (20 percent); however, in this study, with the use of the brachial cutdown approach for outpatient cardiac catheterization, we found that the rate of complications in patients with left main coronary arterial disease was similar to the rest of the population studied.
In conclusion, our findings suggest the following: (1) outpatient cardiac catheterization using the brachial cutdown approach is a safe procedure, even in a subgroup of higher risk patients; and (2) outpatient cardiac catheterization provides significant financial savings.
Table 1—Type of Procedure Performed
|Brachial cut-down||661 (98)||1,061 (96)|
|Percutaneous femoral||15 (2)||45 (4)|
Table 2—Diagnosis after Catheterization
|Diagnosis Coronary arterial disease||Outpatients439(65)||Inpatient: 641 (58)|
|Valvular disease||105 (15)||188(17)|
|Congenital disease||16 (2)||46 (4)|
|Normal||81 (12)||144 (13)|
Table 3—Coronary Anatomy in Patients with Coronary Arterial Disease
|Single-vessel disease||97 (22)||135 (21)|
|Double-vessel disease||106 (24)||172 (27)|
|Triple-vessel disease||202 (46)||272 (42)|
|Left main coronary arterial disease||34(8)||62 (10)|
|Total||439 (100)||641 (100)|
Table 4—NYHA Class and Left Ventricular Ejection Fraction of Patients
|DataNYHA class 1||Outpatients10(1)||Inpatients23(2)|
|2||147 (22)||236 (21)|
|3||360 (53)||415 (37)|
|4Left ventricular ejection fraction||159 (24)||432 (40)|
|<30 percent||55 (8)||98 (9)|
|30-49 percent||201 (30)||355 (32)|
|2*50 percent||420 (62)||653(59)|
Table 5—Rates of Complications in Patients
|Group||No. of Patients||Complications|
|Outpatients||676 (100)||0||7 (1.0)|
|Higher risk||277 (41)||0||3(1.1)|
|Lower risk||399 (59)||0||4 (1.0)|
|Inpatients||1,106(100)||4 (0.4)||16 (1.5)|