Zwolle Risk Score for Safety Assessment of Same-Day Discharge after Primary Percutaneous Coronary Intervention

Abstract

Objectives The Zwolle risk score (ZRS) has been considered to be a useful tool for the systematic evaluation of patients for early discharge after primary percutaneous coronary intervention (PCI). Therefore, aim of this study was to evaluate the clinical utility of ZRS for the same-day discharge strategy after primary PCI at a tertiary care cardiac center of Karachi, Pakistan. Methods This study was conducted at a tertiary care cardiac center between August 2019 and July 2020. Patients discharged within 24 h (same-day) of the primary PCI procedure were included. Patients were stratified as high- and low-risk based on ZRS score; low-risk (≤3) and high-risk (≥4). All patients were followed during 30-days post-procedure period for major adverse cardiac events (MACE). Results Out of 487 patients, 83.2% (405) were male and mean age was 54.6 ± 10.87 years. Mean ZRS was 2.34 ± 1.64 with 16.0% (78) patients in high-risk (≥4) group. 30-days MACE rate was observed to be 5.3% (26) with significantly higher rate among high-risk patients as compared to low-risk patients 12.8% (10) vs. 3.9% (16); p = 0.004 respectively with OR of 3.61 [1.57–8.29]. The area under the curve (AUC) of ZRS for prediction of 30-day MACE was 0.67 [95% CI: 0.58–0.77], ZRS ≥4 had sensitivity of 38.5% and specificity of 85.2% with AUC of 0.62 [95% CI: 0.50–0.74] for prediction of 30-day MACE. Conclusion ZRS showed moderate discriminating potential in identifying patients with high-risk of MACE at 30-day after same-day discharge after primary PCI.

Factors Limiting Same-Day Discharge After Primary Percutaneous Coronary Intervention in Low-Risk Patients

“…In this study ZRS was used retrospectively to 967 individuals who undergone primary PCI and risk-guided triage and discharge was found associated with optimal utilization of healthcare resources and lowering of expenses without impacting quality or patient outcomes. In a recent study by Shah JA et al 21 reported moderate discriminating potential of ZRS for the safety assessment of same-day discharge after primary PCI. A more accurate and reliable risk assessment mode not only based on the clinical factors but also on diseases and procedure related factors is need of the hour for the implementation of SDD strategy to optimize the utilization of healthcare resources in systems with limited resources.…”

“…the Zwolle risk score (ZRS), PAMI II method, Cadillac risk along with other factors, might be used to identify individuals for early discharge following STEMI. 3,21 The application of proper risk classification for the triage of patients having STEMI is necessitated by the rapidly changing healthcare structure and desire for prompt, advanced cardiovascular treatment. A study by Ebinger JE et al 22 described the implementation of a risk-guided triage and early discharge of STEMI patients result in reduction in cost while keeping acceptable patient outcomes.…”

One-year major adverse cardiovascular events among same-day discharged patients after primary percutaneous coronary intervention at a tertiary care cardiac centre in Karachi, Pakistan: a prospective observational study

“…The only available data in this regard is from a recent study by Shah et al ,2 who reported safety of SDD strategy with a minimal rate of 7-day (3.5%) and 30-day (4.9%) MACE. Further, ZRS has been reported to have a moderate discriminating potential for identifying low-risk patients and the need to calibrate ZRS has been suggested for the recognition of ideal patients for SDD following primary PCI 9. Adequate risk assessment and a more scientific and systematic approach to patient identification for SDD are crucial to improve the efficacy and effectiveness of SDD strategy for primary PCI patients.…”

“…Details regarding in-hospital and discharge management and collection of demographic, clinical and procedural data are mentioned in details elsewhere 2 9. The ZRS was calculated as per the scoring criteria defined by De Luca et al 10 based on age, Killip class at presentation, total ischaemic time (defined as symptom onset to device activation time), anterior wall myocardial infarction, postprocedure thrombolysis in myocardial infarction flow grade, and the number of diseased vessels.…”

“…6 A series of risk assessment tools, including the Zwolle Risk Score (ZRS), the CADILLAC Risk Score, and the second Primary Angioplasty in Myocardial Infarction II criteria have been described for assessment of the risk of adverse events post PCI to identify potential candidates for SDD. [7][8][9] The use of such postdischarge risk stratification systems is limited, especially in public sector high-volume PCI centres; a systematic post-PCI risk stratification for early discharge can be of good use in these centres.…”