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Therapeutics

Abbreviated heparin therapy reduced hospital stay and charges

ACP J Club. 1995 May-June;122:59 doi:10.7326/ACPJC-1995-122-3-059


Source Citation

Friedman HZ, Cragg DR, Glazier SM, et al. Randomized prospective evaluation of prolonged versus abbreviated intravenous heparin therapy after coronary angioplasty. J Am Coll Cardiol. Nov


Abstract

Objective

To evaluate the effectiveness of abbreviated heparin therapy compared with that of continuous prolonged heparin therapy in patients who have had coronary angioplasty.

Design

Randomized controlled trial with 2-day follow-up.

Setting

Cardiac unit established for intermediate level nursing care after angioplasty.

Patients

284 patients (mean age, 60.5 y; 217 men) had stable angina and were scheduled for elective percutaneous transluminal coronary angioplasty. Exclusion criteria were recent myocardial infarction (MI), uncompensated left ventricular dysfunction, valvular heart disease, coagulopathy, renal dysfunction, unstable angina, planned atherectomy, totally occluded target vessels, vessels associated with thrombus, ostial stenosis, excessive angulation, and residing > 1 hour from the hospital. 46 patients were excluded after angioplasty for complications occurring in the catheterization laboratory. Follow-up was complete for the 238 patients who entered the study.

Intervention

Patients were allocated to abbreviated (n = 118) or prolonged (n = 120) heparin infusion. All patients received an initial bolus of heparin and further infusion every hour during the procedure. Patients receiving abbreviated treatment received no heparin after the angioplasty unless required by clinical events and had the vascular sheath removed after 3 to 4 hours. Patients receiving prolonged treatment had heparin initiated at 10 U/kg per hour immediately after the procedure and titrated to an activated clotting time of 160 to 190 seconds for 24 hours. Ambulation was encouraged in all patients after sheath removal and 6 hours of bed rest. Patients were contacted by a nurse clinician 1 to 2 days after discharge for complication and symptom status.

Main Outcome Measures

Complications (death, acute MI, need for emergency bypass surgery, acute coronary occlusion syndrome, and unstable angina), length of hospital stay, and hospital charge.

Main Results

The groups did not differ for major complications. 1 patient in the abbreviated heparin therapy group developed acute coronary occlusion syndrome and then had an MI 3 hours after the procedure. None of the patients reported delayed complications after discharge. Patients in the abbreviated heparin therapy group had a shorter mean hospital stay (23 vs. 42 h; P < 0.001) and a lower hospital charge ($6093 vs $7463; P < 0.001) than did those in the prolonged heparin therapy group.

Conclusion

Abbreviated heparin therapy placed patients at no additional risk for major complications after coronary angioplasty compared with continuous prolonged heparin therapy and resulted in shorter hospital stays and lower hospital charges.

Source of funding: Not stated.

For article reprint: Dr. H.Z. Friedman, Division of Cardiology, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073. FAX 810-551-4199.


Commentary

The results of coronary angioplasty can be very much operator-dependent. As such, the conclusions of angioplasty studies must be viewed in the context of the operators' skills. This is an article from a high-volume, high-quality institution, and it describes the experience of the investigators in shortening the duration of heparin therapy after angioplasty. Of interest is that the data reflect the investigators' experience from 1989 to 1991.

The paper describes a well-organized trial, which included consecutive patients who were screened before hospitalization. The decision to randomize a patient was made in the catheterization laboratory. 46 patients were excluded from randomization at the time of angioplasty because of substantial adverse outcomes. Only 1 patient had an "acute closure"; this occurred 2 hours after the procedure in a patient not receiving heparin after the procedure. This was still within the time period in which heparin was active. As such, the adverse result cannot be ascribed to cessation of anticoagulation. The group not treated with heparin after angioplasty was discharged with fewer bleeding complications and almost 20 hours sooner, saving nearly $1400 per patient. Still, as the authors point out, a procedural complication rate of 7% means that they would need to treat 800 patients to see a 50% change in cardiac events. Thus, the study is only a beginning for validation of the hypothesis that early cessation of heparin and early discharge are safe.

It is already the practice in many institutions, including my own, not to give heparin to patients after angioplasty unless the operator notes a complication, such as a thrombus or a major dissection of the artery. If a complication is noted, heparin is continued afterward. Again, although the article is a useful addition to the literature, it reflects what is becoming common practice. For those cardiologists who still routinely give heparin to all patients after angioplasty, it should be a wake-up call. We look forward to larger studies with current patient populations.

Michael N. Sills, MD
Texas Cardiology Consultants Dallas, Texas