Brijesh Patel

Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States

BackgroundRecent trends on outcomes in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) suggest improvements in early survival. However, with the ever-changing landscape in management of CS, we sought to identify age-based trends in these outcomes and mechanical circulatory support (MCS) use among patients with both AMI and non-AMI associated shock.MethodsWe queried the 2005–2014 Nationwide Inpatient Sample databases to identify patients with a diagnosis of cardiogenic shock. Trends in the incidence of hospital-mortality, and use of MCS such as intra-aortic balloon pump (IABP), Impella/TandemHeart (IMP), and extra corporeal membrane oxygenation (ECMO) were analyzed within the overall population and among different age-categories (50 and under, 51–65, 66–80 and 81–99 years). We also made comparisons between patient groups admitted with CS complicating AMI and those with non-AMI associated CS.ResultsWe studied 144,254 cases of CS, of which 55.4% cases were associated with an AMI. Between 2005 and 2014, an overall decline in IABP use (29.8–17.7%; ptrend < 0.01), and an uptrend in IMP use (0.1–2.6%; ptrend < 0.01), ECMO use (0.3–1.8%; ptrend < 0.01) and in-hospital mortality (44.1–52.5% AMI related, 49.6–53.5% non-AMI related; ptrend < 0.01) was seen. Patients aged 81–99 years had the lowest rate of MCS use (14.8%), whereas those aged 51–65 years had highest rate of MCS use (32.3%). Multivariable analysis revealed that patients aged 51-65 years (aOR 1.46, 95% CI 1.40–1.52; p<0.001), 66–80 years (aOR 2.51, 95% CI 2.39–2.63; p<0.01) and 81–99 years (aOR 5.04, 95% CI 4.78–5.32; p<0.01) had significantly higher hospital mortality compared to patients aged ≤ 50 years. Patients admitted with CS complicating AMI were older and had more comorbidities, but lower hospital mortality (45.0 vs. 48.2%; p < 0.001) when compared to non-AMI related CS. We also noted that the proportion of patients admitted with CS complicating AMI significantly decreased from 2005 to 2014 (65.3–45.6%; ptrend < 0.01) whereas those admitted without an associated AMI increased.ConclusionsIABP use has declined whereas IMP and ECMO use has increased over time among CS admissions. Older age was associated with an incrementally higher independent risk for hospital mortality. Recent trends indicate an increase in both proportion of patients admitted with CS without associated AMI and in-hospital mortality across all CS admissions irrespective of AMI status.

The day of the week and acute heart failure admissions: Relationship with acute myocardial infarction, 30-day readmission rate and in-hospital mortality.

BACKGROUND In-hospital care may be constrained during the weekend due to lesser resources. Impact on outcomes of weekend versus weekday care in congestive heart failure (HF) needs further study. METHODS Admissions with a primary diagnosis of HF using ICD-9CM codes were studied. 22,287 HF-admissions from Einstein Medical Center (2003-2013) and 2,248,482 HF-admissions from the 2002-2012 Nationwide Inpatient Sample (NIS) were analyzed separately. Primary outcomes were 30-day HF-readmission and in-hospital mortality. Logistic regression models were used to evaluate outcomes. RESULTS Weekends experienced lower rates of admission and discharge. Mondays experienced the highest admission rate and Fridays experienced the highest discharge rate. Friday was independently associated with highest 30-day HF-readmission rates (Adjusted OR 1.12, CI 1.01-1.23; p=0.02) in addition to risk factors such as African-American race, hypertension, diabetes, hyperlipidemia, end-stage renal disease and coronary artery disease. Within the NIS sample, 85,479 in-hospital deaths (3.8%) were recorded. Compared to weekdays, patients admitted over the weekend had greater comorbidities, higher incidence of acute myocardial infarction (AMI) (15.8% vs. 16.8%; p<0.01), higher Charlson-comorbidity index and underwent less procedures such as echocardiography, right heart catheterization, coronary angiography, coronary revascularization or mechanical circulatory support. Weekend HF admission predicted higher in-hospital mortality (aOR 1.07, 95%CI 1.05-1.08; p<0.01) on multivariate analysis. This relationship was applicable for teaching and non-teaching hospitals. CONCLUSION Friday was associated with the highest discharge and 30-day HF-readmission rate. Weekend HF admissions experienced more AMI, had greater comorbidities, received less cardiac procedures and predicted higher in-hospital mortality. Higher weekend mortality may be related to the greater degree of severity of illness among admitted patients.

Trends in hospitalization for hypertensive emergency, and relationship of end-organ damage with in-hospital mortality

BACKGROUND There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality. METHODS We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality. RESULTS Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms. CONCLUSION A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

Use of therapeutic hypothermia among patients with coagulation disorders - A Nationwide analysis.

OBJECTIVES The study aimed to assess the impact of therapeutic hypothermia (TH) on bleeding and in-hospital mortality among patients with coagulation disorders (CD). BACKGROUND TH affects coagulation factors and platelets putting patients at risk for bleeding and worse outcomes. Effect of TH among patients with CD remains understudied. METHODS Between 2009 and 2014, a total of 6469 cases of TH were identified using the National Inpatient Sample out of which 1036 (16.02%) had a CD. The incidence of bleeding events, blood product transfusion and in-hospital mortality was compared between patients with and without CD using one to one propensity score matching. RESULTS Proportion of patients with CD increased during study duration from 13.0% to 17.4% from 2009 to 2014. Propensity matching was performed to adjust for baseline differences with 799 patients in both groups depending on presence or absence of CD. Patients with CD had a higher rate of bleeding events (13% vs. 8.5%; adjusted odds ratio 1.60; 95% confidence interval 1.16-2.23; P = 0.004), and blood product transfusion (25.0% vs. 14.1%; aOR 2.03; 95% CI 1.56-2.63; p < 0.001) compared to those without CD. There was no difference in rate of intracranial bleeding or hemorrhagic strokes between those with and without CD (3.3% vs. 3.2%; p = 0.88). There was no difference in mortality between patients with CD and those without (74.5% vs. 74.8%, aOR 0.98, 95% CI 0.78-1.23; P = 0.86). CONCLUSIONS Use of TH with CD resulted in more bleeding events and blood product transfusion but there was no difference in hospital mortality.

Etiologies, predictors, and economic impact of readmission within 1 month among patients with takotsubo cardiomyopathy

Limited data exist on readmission among patients with takotsubo cardiomyopathy (TC), a commonly reversible cause of heart failure.

Etiologies, Predictors and Economic Impact of 30 Day Readmissions among Patients with Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a pregnancy-associated cause of heart failure. Given the significant impact of heart failure on healthcare, we sought to identify etiologies and predictive factors for readmission in PPCM. We queried the 2013 to 2014 National Readmissions Database to identify patients admitted with a diagnosis of PPCM. Patients who were readmitted within 30 days were evaluated to identify etiologies and predictors of readmission. We identified 6,977 index admissions with PPCM. Of the 6,880 (98.6%) patients who survived the index hospitalization, 30-day readmission rate was 13%. Seventy-six percent of readmitted patients were admitted once, and the other 24% were readmitted at least twice within 30 days of discharge. Length of stay was ≥8 days (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 2.08 to 3.77), multiparity (aOR 2.07, 95% CI 1.09 to 3.92), coronary artery disease (aOR 2.28, 95% CI 1.42 to 3.67), and long-term anticoagulation use (aOR 2.51, 95% CI 1.73 to 3.64) were independently associated with increased risk of 30-day readmission. Among the readmissions, 48% were due to cardiac causes, where PPCM and related complications (24%) were the most common cardiac cause followed by heart failure (16%). The annual cost of stay for index admissions was

A complete heart block in a young male: a case report and review of literature of cardiac sarcoidosis

64.2 million (average cost for index admission was

Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study

16,892). The annual charges attributed to readmission within 30 days were ≈

Left ventricular thrombosis in acute anterior myocardial infarction: Evaluation of hospital mortality, thromboembolism, and bleeding

9 million. Cardiac etiologies were the most common cause for 30-day readmissions in PPCM patients, with a readmission rate of 13%. Long-term anticoagulation use, multiparity, coronary disease and length of stay predicted higher 30-day readmission.

Mortality in sepsis: Comparison of outcomes between patients with demand ischemia, acute myocardial infarction, and neither demand ischemia nor acute myocardial infarction

Cardiac sarcoidosis is one of the uncommon causes of heart failure. Generally, it presents in the form of varying clinical manifestations ranging from asymptomatic to fatal arrhythmias such as ventricular tachycardia and complete heart block. It is difficult to make a diagnosis strictly based on clinical grounds. However, in the setting of extracardiac sarcoidosis and patients presenting with advanced heart block or ventricular arrhythmia, direct cardiac involvement should be suspected. The definitive diagnosis of cardiac sarcoidosis can be made from endomyocardial biopsy, but it is falling out of favor due to patchy myocardial involvement, considerable procedure-related risks, and advancement in additional imaging modalities. Once cardiac sarcoidosis has been diagnosed, management of the disease remains challenging. Steroids are considered the mainstay of therapy, and implantable cardioverter defibrillator therapy can be considered in a selected group of patients at greater risk for malignant ventricular arrhythmias.