Anupama Shivaraju

Temporal Trends in Gastrointestinal Bleeding Associated with Percutaneous Coronary Intervention: Analysis of the 1998–2006 Nationwide Inpatient Sample (NIS) Database

BACKGROUND Gastrointestinal bleeding (GIB) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) and coronary artery disease (CAD) is associated with high morbidity and mortality. METHODS The NIS database from 1998 to 2006 was used to identify 1,216,759 PCIs performed for ACS and CAD. We sought to analyze temporal trends in the incidence and in-hospital outcomes of GIB associated with PCI along with its predictors. RESULTS The overall incidence of GIB was 1.04% (95% confidence interval (CI), 1.02%-1.06%). The incidence of GIB decreased over the study period (P for trend <.0001). The overall mortality in the GIB group was 6.0% (95% CI, 5.6%-6.4%). The adjusted OR for in-hospital mortality and GIB was 4.70 (95% CI, 4.23-5.23; P < .0001); this remained high and essentially unchanged over the study period. Independent predictors of GIB included rectum/anal cancer (OR, 4.64; 95% CI, 3.20-6.73; P < .0001), stomach cancer (OR, 2.74; 95% CI, 1.62-4.66; P = .0002), esophageal cancer (OR, 1.99; 95% CI, 1.08-3.69; P = .0288), colon cancer (OR, 1.69; 95% CI, 1.43-2.02; P < .0001), congestive heart failure (OR, 1.43; 95% CI, 1.35-1.52; P < .0001), and acute myocardial infarction (OR, 1.23; 95% CI, 1.13-1.35; P < .0001). CONCLUSIONS Although the incidence of GIB associated with PCI decreased from 1998 to 2006 in the face of aggressive therapies for ACS and CAD, the risk of GIB-associated death remained high. Underlying GI malignancy is a significant independent predictor of GIB associated with PCI; identifying these patients may reduce the rate of GIB.

Temporal trends in the use of intraaortic balloon pump associated with percutaneous coronary intervention in the United States, 1998-2008

BACKGROUND With conflicting evidence regarding the usefulness of intraaortic balloon pump (IABP), reports of IABP use in the United States have been inconsistent. Our objective was to examine trends in IABP usage in percutaneous coronary intervention (PCI) in the United States and to evaluate the association of IABP use with mortality. METHODS This is a retrospective, observational study using patient data obtained from the Nationwide Inpatient Sample database from 1998 to 2008. Patients undergoing any PCI (1,552,602 procedures) for a primary diagnosis of symptomatic coronary artery disease and acute coronary syndrome, including non-ST-elevation myocardial infarction and ST-elevation myocardial infarction, were evaluated. RESULTS The overall use of IABP significantly decreased during the study period from 0.99% in 1998 to 0.36% in 2008 (univariate and multivariate P for trend < .0001). Patients who received IABP had substantially higher rates of shock compared with those who did not receive IABP (38.09% vs 0.70%; P < .0001), which was associated with markedly higher inhospital mortality rates (20.31% vs 0.72%; P < .0001). However, IABP use significantly decreased in patients with shock (36.5%-13.4%) and acute myocardial infarction (2.23%-0.84%) (univariate and multivariate P for trend for both < .0001). A temporal reduction in all-cause PCI-associated mortality from 1.1% in 1998 to 0.86% in 2008 (univariate and multivariate P for trend < .0001) was also observed. CONCLUSIONS The utilization of IABP associated with PCI significantly decreased between 1998 and 2008 in the United States, even among patients with acute myocardial infarction and shock.

Temporal Trends in Percutaneous Coronary Intervention–Associated Acute Cerebrovascular Accident (from the 1998 to 2008 Nationwide Inpatient Sample Database)

Acute cerebrovascular accident (CVA) after percutaneous coronary intervention (PCI) for acute coronary syndrome and coronary artery disease is associated with high rates of morbidity and mortality. Nationwide Inpatient Sample from 1998 to 2008 was used to identify 1,552,602 PCIs performed for acute coronary syndrome and coronary artery disease. We assessed temporal trends in the incidence, predictors, and prognostic impact of CVA in a broad range of patients undergoing PCI. The overall incidence of CVA was 0.56% (95% confidence interval [CI] 0.55 to 0.57). The incidence of CVA remained unchanged over the study period (adjusted p for trend=0.2271). The overall mortality rate in the CVA group was 10.76% (95% CI 10.1 to 11.4). The adjusted odds ratio (OR) of CVA for in-hospital mortality was 7.74 (95% CI 7.00 to 8.57, p<0.0001); this remained high but decreased over the study period (adjusted p for trend<0.0001). Independent predictors of CVA included older age (OR 1.03, 95% CI 1.02 to 1.03, p<0.0001), disorder of lipid metabolism (OR 1.31, 95% CI 1.24 to 1.38, p<0.001), history of tobacco use (OR 1.21, 95% CI 1.10 to 1.34, p=0.0002), coronary atherosclerosis (OR 1.56, 95% CI 1.43 to 1.71, p<0.0001), and intra-aortic balloon pump use (OR 1.39, 95% CI 1.09 to 1.77, p=0.0073). A nomogram for predicting the probability of CVA achieved a concordance index of 0.73 and was well calibrated. In conclusion, the incidence of CVA associated with PCI has remained unchanged from 1998 to 2008 in face of improved equipment, techniques, and adjunctive pharmacology. The risk of CVA-associated in-hospital mortality is high; however, this risk has decreased over the study period.