Ankit Rathod

Contemporary Trends of Hospitalization for Atrial Fibrillation in the United States, 2000 Through 2010 Implications for Healthcare Planning

Background— Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The associated morbidity and mortality make AF a major public health burden. Hospitalizations account for the majority of the economic cost burden associated with AF. The main objective of this study is to examine the trends of AF-related hospitalizations in the United States and to compare patient characteristics, outcomes, and comorbid diagnoses. Methods and Results— With the use of the Nationwide Inpatient Sample from 2000 through 2010, we identified AF-related hospitalizations using International Classification of Diseases, 9th Revision, Clinical Modification code 427.31 as the principal discharge diagnosis. Overall AF hospitalizations increased by 23% from 2000 to 2010, particularly in patients ≥65 years of age. The most frequent coexisting conditions were hypertension (60.0%), diabetes mellitus (21.5%), and chronic pulmonary disease (20.0%). Overall in-hospital mortality was 1%. The mortality rate was highest in the group of patients ≥80 years of age (1.9%) and in the group of patients with concomitant heart failure (8.2%). In-hospital mortality rate decreased significantly from 1.2% in 2000 to 0.9% in 2010 (29.2% decrease; P<0.001). Although there was no significant change in mean length of stay, mean cost of AF hospitalization increased significantly from

Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes A 5-Year United States Experience (2005–2009)

6410 in 2001 to

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III.

8439 in 2010 (24.0% increase; P<0.001). Conclusions— Hospitalization rates for AF have increased exponentially among US adults from 2000 to 2010. The proportion of comorbid chronic diseases has also increased significantly. The last decade has witnessed an overall decline in hospital mortality; however, the hospitalization cost has significantly increased.

QRS duration on electrocardiography and cardiovascular mortality (from the National Health and Nutrition Examination Survey-III).

Background— The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. Methods and Results— Cross-sectional study based on the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9th Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457 498 PCIs were identified representing a total of 2 243 209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4th [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3rd [45–100; 0.87% and 6.40%], and 2nd quartile [16–44; 1.15% and 7.75%] were significantly less (P<0.001) when compared with those by operators in the 1st quartile [⩽15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001). Conclusions— Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization.

Comparison of mortality and morbidity in patients with atrial fibrillation and heart failure with preserved versus decreased left ventricular ejection fraction

BACKGROUND Neutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model. METHODS We performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998-94) including subjects aged 30-79 years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0-4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification. RESULTS We included 7363 subjects with a mean follow up of 14.1 years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07-6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer-Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%. CONCLUSIONS NLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.

Percutaneous Aortic Balloon Valvotomy in the United States: A 13-Year Perspective

The relation of bundle branch block (BBB) with adverse outcome is controversial. We hypothesized that increased QRS duration is an independent predictor of cardiovascular (CV) mortality in a cross-sectional US population. This is a retrospective cohort study on prospectively collected data to assess the relationship between QRS duration on routine ECG and CV mortality. Participants included 8,527 patients with ECG data available from the National Health and Nutrition Examination Survey data set, representing 74,062,796 individuals in the United States. Mean age was 60.5 ± 13.6 years. Most subjects were white (87%) and women (53%). During the follow-up period of 106,244.6 person-years, 1,433 CV deaths occurred. Multivariate analysis revealed that the highest quartile of QRS duration was associated with higher CV mortality than lowest quartile (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01 to 1.7, p = 0.04) after adjustment for established risk factors. Both left BBB (HR 2.4, 95% CI 1.3 to 4.7, p = 0.009) and right BBB (HR 1.90, 95% CI 1.2 to 3.0, p = 0.008) were significantly associated with increased CV mortality. The addition of the QRS duration in 10-millisecond increments to the Framingham Risk Score model resulted in 4.4% overall net reclassification improvement (95% CI 0.02 to 0.04; p = 0.00006). In conclusion, increased QRS duration was found to be an independent predictor of CV mortality in this cross-sectional US population. A model including QRS duration in addition to traditional risk factors was associated with improved CV risk prediction.

Healthy Eating Index and mortality in a nationally representative elderly cohort.

Almost 50% of patients with congestive heart failure (HF) have preserved ejection fraction (PEF). Data on the effect of HF-PEF on atrial fibrillation outcomes are lacking. We assessed the prognostic significance of HF-PEF in an atrial fibrillation population compared to a systolic heart failure (SHF) population. A post hoc analysis of the National Heart, Lung, and Blood Institute-limited access data set of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was carried out. The patients with a history of congestive HF and a preserved ejection fraction (EF >50%) were classified as having HF-PEF (n = 320). The patients with congestive HF and a qualitatively depressed EF (EF <50%) were classified as having SHF (n = 402). Cox proportional hazards analysis was performed. The mean follow-up duration was 1,181 ± 534 days/patient. The patients with HF-PEF had lower all-cause mortality (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.46 to 0.85, p = 0.003) and cardiovascular mortality (HR 0.56, 95% CI 0.38 to 0.84, p = 0.006), with a possible decreased arrhythmic end point (HR 0.39, 95% CI 0.16 to 1.006, p = 0.052) than did the patients with SHF. No differences were observed for ischemic stroke (HR 1.08, 95% CI 0.48 to 2.39, p = 0.86), rehospitalization (HR 0.89, 95% CI 0.75 to 1.07, p = 0.24), or progression to New York Heart Association class III-IV (odds ratio 0.80, 95% CI 0.42 to 1.54, p = 0.522). In conclusion, although patients with HF-PEF have better mortality outcomes than those with SHF, the morbidity appears to be similar.

Comparative prognostic utility of conventional and novel lipid parameters for cardiovascular disease risk prediction: Do novel lipid parameters offer an advantage?

BACKGROUND We determined the contemporary trends of percutaneous aortic balloon valvotomy and its outcomes using the nations largest hospitalization database. There has been a resurgence in the use of percutaneous aortic balloon valvotomy in patients at high surgical risk because of the development of less-invasive endovascular therapies. METHODS This is a cross-sectional study with time trends using the Nationwide Inpatient Sample database between the years 1998 and 2010. We identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for valvotomy. Only patients aged more than 60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications and length of hospital stay. RESULTS A total of 2127 percutaneous aortic balloon valvotomies (weighted n = 10,640) were analyzed. The use rate of percutaneous aortic balloon valvotomy increased by 158% from 12 percutaneous aortic balloon valvotomies per million elderly patients in 1998-1999 to 31 percutaneous aortic balloon valvotomies per million elderly patients in 2009-2010 in the United States (P < .001). The hospital mortality decreased by 23% from 11.5% in 1998-1999 to 8.8% in 2009-2010 (P < .001). Significant predictors of in-hospital mortality were the presence of increasing comorbidities (P = .03), unstable patient (P < .001), any complication (P < .001), and weekend admission (P = .008), whereas increasing operator volume was associated with significantly reduced mortality (P = .03). Patients who were admitted to hospitals with the highest procedure volume and the highest volume operators had a 51% reduced likelihood (P = .05) of in-hospital mortality when compared with those in hospitals with the lowest procedure volume and lowest volume operators. CONCLUSION This study comprehensively evaluates trends for percutaneous aortic balloon valvotomy in the United States and demonstrates the significance of operator and hospital volume on outcomes.

Utilization and Adverse Outcomes of Percutaneous Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation in the United States

was associated with a 28% lower risk of death even after these factors, as well as depression and health behaviors, had been taken into account. Other factors may be responsible for the remaining association between enjoyment and survival. It may be caused by unmeasured confounding factors such as other pre-existing illnesses. Only 3 health behaviors were assessed, and other aspects such as diet may be relevant. In addition, direct links with health outcomes are plausible, since biological responses such as reduced cortisol output in everyday life and attenuated cardiovascular and inflammatory responses to stress are related to positive well-being. The results of this study do not establish that enjoyment of life is causally related to survival. Enjoyment may be a marker of underlying health-related biological, behavioral, or dispositional factors that are responsible for the association. Nonetheless, our findings show that the link between enjoyment and survival at older ages is not fully accounted for by demographic factors or major preexisting illnesses. These results highlight the importance of positive well-being in older adults and suggest that efforts to improve enjoyment of life, as well to manage and prevent disease, could have beneficial effects on life expectancy.

Prevalence, Determinants, and Clinical Significance of Cardiac Troponin‐I Elevation in Individuals Admitted for a Hypertensive Emergency

BACKGROUND Comparative data on the prognostic utility of novel lipid parameters vs. conventional lipid parameters in predicting coronary events are scant. OBJECTIVE We sought to compare the predictive value of various lipid measures for coronary events and to further examine the incremental value of novel lipid parameters over traditional cardiovascular risk factors in estimating cardiac risk. METHODS We performed a post-hoc analysis of the National Heart Lung and Blood Institute limited access dataset of Multi-Ethnic Study of Atherosclerosis subjects (n = 6693). The lipid measures considered in the estimation of coronary risk were conventional and novel lipid parameters, the latter included total low-density lipoprotein (LDL), high-density lipoprotein (HDL) and very low-density lipoprotein (VLDL)-particle concentrations (LDL-p, HDL-p and VLDL-p), LDL-p/HDL-p ratio, and LDL-p subfractions. The outcome measured was occurrence of any coronary event (CE) that included myocardial infarction, resuscitated cardiac arrest, cardiac death, and angina. RESULTS During an average follow up of 4.5 years, 228 patients developed coronary events. In the multivariate Cox proportional hazards model, TC/HDL-c (HR: 3.27; 95% CI: 1.95 to 5.47, P < .0001) was a stronger predictor of CE. Among the novel lipid parameters, LDL-p/HDL-p (hazard ratio 2.84; 95% confidence interval 1.89 to 4.26; P < .0001) was a powerful independent predictor of CE. The c-statistics were similar for both LDL-p/HDL-p and TC/HDL-c ratios (0.60). The addition of LDL-p/HDL-p ratio to the Framingham risk score components resulted in a very small increase in the overall C statistic. CONCLUSION In our large study cohort, a predictive model for future coronary events incorporating the best-available novel lipid parameter (LDL-p/HDL-p ratio) was comparable with the same model that incorporated conventional lipid ratios such as the TC/HDL-c ratio . The use of LDL-p/HDL-p ratio did not appear to offer incremental value over more traditional risk prediction models.