Abstract
BackgroundThe Zwolle Risk Score (ZRS) identifies primary percutaneous coronary intervention (PPCI) patients at low mortality risk, eligible for early discharge. Recently, this score was improved by adding baseline NT-proBNP. However, the optimal timepoint for NT-proBNP measurement is unknown.MethodsPPCI patients in the On-Time 2 study were candidates. The ZRS and NT-proBNP levels on admission, at 18–24 h, at 72–96 h, and the change in NT-proBNP from baseline to 18–24 h (delta NT-proBNP) were determined. We investigated whether addition of the different NT-proBNP measurements to the ZRS improves the prediction of 30-day mortality. Based on cut-off values reflecting zero mortality at 30 d, patients who potentially could be discharged early were identified and occurrence of major adverse cardiac events (MACE) and major bleeding until 10 d was registered.Results845 patients were included. On multivariate analyses, NT-proBNP at baseline (HR 2.09, 95% CI 1.59–2.74, p < 0.001), at 18–24 h (HR 6.83, 95% CI 2.94–15.84), and at 72–96 h (HR 3.32, 95% CI 1.22–9.06) independently predicted death at 30 d. Addition of NT-proBNP to the ZRS improved prediction of mortality, particularly at 18–24 h (net reclassification index 29%, p < 0.0001, integrated discrimination improvement 17%, p < 0.0001). Based on ZRS (<2) or NT-proBNP at 18–24 h (<2500 pg/ml) 75% of patients could be targeted for early discharge at 48 h, with expected re-admission rates of 1.2% due to MACE and/or major bleeding.ConclusionsNT-proBNP at different timepoints improves prognostication of the ZRS. Particularly at 18–24 h post PPCI, the largest group of patients that potentially could be discharged early was identified.Electronic supplementary materialThe online version of this article (doi: 10.1007/s12471-016-0935-2) contains supplementary material, which is available to authorized users.
Highlights
Primary percutaneous coronary intervention (PPCI) substantially improved outcome in patients with ST-elevation myocardial infarction (STEMI), which has been paralleled by a decrease in hospital length of stay [1,2,3]
The Zwolle Risk Score (ZRS) is a simple tool designed to identify primary percutaneous coronary intervention (PPCI) patients who can be safely discharged within 72 h, based on their 30-day mortality risk [11]
Patients Our study population consists of patients with the diagnosis of STEMI admitted for PPCI, who were included in the Ongoing Tirofiban in Myocardial Infarction Evaluation (On-TIME) 2 trial [13]
Summary
Primary percutaneous coronary intervention (PPCI) substantially improved outcome in patients with ST-elevation myocardial infarction (STEMI), which has been paralleled by a decrease in hospital length of stay [1,2,3]. In addition several studies have demonstrated that most low-risk PPCI patients are eligible candidates for early discharge [4,5,6,7,8,9,10,11]. The Zwolle Risk Score (ZRS) is a simple tool designed to identify PPCI patients who can be safely discharged within 72 h, based on their 30-day mortality risk [11]. Neth Heart J (2017) 25:243–249 with a score Ä3 (low risk) the mortality rate was 0.1% at 2 d and 0.2% between 2–10 d and early discharge between 48–72 h could be applied in slightly more than 60% of patients (Fig. 1). We demonstrated that the predictive accuracy of the ZRS was improved by adding baseline NT-proBNP [12].
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