Early ambulation after percutaneous coronary intervention does not increase bleeding risk compared with late ambulation
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia and South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Correspondence to: Associate Professor Craig Juergens
Department of Cardiology, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia;
Commentary on: Tongsai S, Thamlikitkul V. The safety of early versus late ambulation in the management of patients after percutaneous coronary interventions: a meta-analysis. Int J Nurs Stud 2012;49:1084–90.
Implications for practice and research
Early ambulation after percutaneous coronary intervention (PCI) may facilitate earlier hospital discharge and improve patient comfort.
There are a limited number of randomised clinical trials assessing the safety of this strategy.
This meta-analysis suggests that earlier ambulation was not associated with an increased risk of adverse bleeding events.
The number of PCIs performed around the world continues to increase due to a rising incidence of patients with symptomatic coronary artery disease. Despite an increased interest in performing the procedure via the radial approach, with large-scale clinical trials demonstrating reductions in vascular complications and time to ambulation, the majority of cases involve femoral arterial access. While vascular closure devices (VCDs) facilitate sheath removal at the end of the procedure, these devices are costly, have not convincingly been shown to reduce vascular complications and cannot be used in all patients. The default strategy is a period of bed rest to allow intraprocedural anticoagulation to wear off, sheath removal using either manual or device compression, followed by a further period of bed rest. The duration of each of these steps varies markedly in individual centres with little evidence-based support. The current meta-analysis by Tongsai and Thamlikitkul is an attempt to examine the existing literature particularly around the safety of a strategy of earlier ambulation.
After a comprehensive literature search using appropriate search words, the authors chose to focus on studies where patients were either randomised or ‘quasi-randomised’ to either 6–10 h of bed rest in one group or 2–4 h in the early ambulation group. They excluded studies where the duration of bed rest was greater than 4 h in both groups or the main endpoints did not contain major vascular complications including bleeding. At the end, only five studies including 1854 patients were found to be suitable for meta-analysis. The authors used statistical methods to try and control for publication bias and found no evidence of heterogeneity of relative risk across the studies for haematoma, or bleeding events, which was the primary safety endpoint.
Of the identified studies, three were randomised and two were non-randomised comparative studies. The authors found no evidence that early ambulation, within 2–4 h of sheath removal, was harmful with respect to adverse bleeding events when compared with a longer period of bed rest. They suggest that early ambulation should be considered as routine given the additional benefits of improved patient comfort and potential earlier hospital discharge.
This study tries to address an important area of clinical care which has not been well studied in the past. Owing to the lack of definitive large-scale randomised clinical trials, the authors have performed a meta-analysis to try and overcome the shortfalls of previous underpowered studies. Unfortunately, they were only able to identify a small number of randomised studies that specifically addressed the issue of early versus delayed ambulation after sheath removal. In addition, one study,1 unlike the others, randomised patients to immediate sheath removal at the end of the procedure with manual compression followed by ambulation within 3 h versus a more traditional approach. The endpoints of vascular complications and bleeding were different in each study making firm conclusions problematic and no studies included bivilarudin which is associated with reduced bleeding complications when compared with unfractionated heparin and glycoprotein IIb/IIIa antagonists.2 The use of VCDs was allowed in one study3 but not others. While there have been no large-scale randomised clinical trials conclusively demonstrating a reduction in vascular complications with VCDs, their use has been shown to reduce time to ambulation and reduce hospital length of stay and therefore including such patients in this study potentially impacts the conclusions. The authors are to be congratulated for highlighting a neglected area of clinical research; however, given the limitations of this study, I cannot agree with their conclusion that ‘the practice of early ambulation after percutaneous coronary intervention should be implemented without conducting more primary study on this issue’. This meta-analysis may be used as the basis for a large-scale, multicentre trial with standardised bleeding and vascular endpoints to more definitively answer this important clinical question.