Mahek Shah

Thirty-Day Readmissions After Left Ventricular Assist Device Implantation in the United States: Insights From the Nationwide Readmissions Database

Background: Early readmissions contribute significantly to heart failure–related morbidity and negatively affect quality of life. Data on left ventricular assist device (LVAD)–related 30-day readmissions are scarce and limited to small studies. Methods and Results: Patients undergoing LVAD implantation between January 2013 and November 2014 who survived the index hospitalization were identified in the Nationwide Readmissions Database. We analyzed the incidence, predictors, causes, and costs of 30-day readmissions. Of 2510 LVAD recipients, 788 (31%) were readmitted within 30 days. Length of index hospitalization ≥31 days (hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.07–1.50) and female sex (HR, 1.19; 95% CI, 1.01–1.42) were associated with a higher risk of 30-day readmission, whereas private insurance (HR, 0.83; 95% CI, 0.70–0.99), pre-LVAD use of short-term mechanical circulatory support (HR, 0.53; 95% CI, 0.29–0.98), and discharge to a short-term hospital facility (HR, 0.41; CI, 0.21–0.78) were associated with a lower risk. Cardiac causes accounted for 23.8% of readmissions: heart failure (13.4%) and arrhythmias (8.1%). Noncardiovascular causes accounted for 76.2% of readmissions: infection (30.2%), bleeding (17.6%), and device-related causes (8.2%). Mean length of stay for readmission was 10.7 days (median, 6 days), and average hospital cost per readmission was

Spontaneous coronary artery dissection following a preeclampsia pregnancy

34 948±2457. Conclusions: Early readmissions are frequent after LVAD implantation even in contemporary times. Preimplant identification of high-risk patients, and a protocol-driven follow-up using a multidisciplinary approach will be needed to reduce readmissions and improve outcomes.

Prognostic significance of abnormal P wave morphology and PR-segment displacement after ST-elevation myocardial infarction

1. IntroductionSpontaneous coronary artery dissection (SCAD) is an uncommoncause of acute myocardial infarction. The dissection of tunica intima ormedia,formingofhematomaunderneatharterialwallandcompressingthe true coronary lumen leads to myocardial infarction of distal cardiactissue. Thehigh suspiciousindexshouldmakein young female withoutany cardiovascular risk, especially in peripartum period. Emergent cor-onaryangiogramfollowedbyintravascularultrasoundisrecommendedfor diagnosis; however optimal treatment is still inconclusive [1].

Ivc filters—trends in placement and indications, a study of 2 populations

INTRODUCTION Atrial infarction is uncommonly diagnosed and data on its significance are limited. Its incidence in ST-elevation myocardial infarction (STEMI) reportedly ranges from 0.7-42%. Certain atrial ECG changes, such as abnormal P wave morphology suggestive of atrial involvement have been associated with 90-day mortality after STEMI. However, whether atrial ECG changes are associated with short (30-day) or long-term (1-year) mortality have not been studied. METHODS We examined index ECG in 224 consecutive STEMI. Demographics, clinical variables, peak troponin I, ejection fraction, and angiographic data were collected. Atrial ECG patterns were examined and correlated with mortality. RESULTS Length of stay was longer with abnormal P waves (p=0.008) or PR displacement in any lead (p=0.003). Left main coronary disease was more prevalent with abnormal P wave (p=0.045). Abnormal P wave morphology in any lead was associated with higher 30-day (OR 3.09 (1.35-7.05)) and 1-year mortality (OR 5.33 (2.74-10.36)). PR displacement in any lead was also associated with increased 30-day (OR 2.33 (1.03-5.28)) and 1-year mortality (OR 6.56 (3.34-12.86)). Abnormal P wave, PR depression in II, III and AVF, and elevation in AVR or AVL were associated with increased 1-year mortality (OR 12.49 (5.2-30.0)) as was PR depression in the precordial leads (OR 21.65 (6.82-68.66)). After adjusting for age, ejection fraction, peak troponin I, and left main disease, PR displacement in any lead was associated with increased 1-year mortality (adjusted OR 6.22 (2.33-18.64)). CONCLUSION PR segment displacement in any lead, found in 31% of patients with STEMI, independently predicted 1-year mortality.

Significance of QRS duration in non-ST elevation myocardial infarction

Abstract Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence. Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population. At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend < 0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075–11,655; Ptrend < 0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio—aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis. Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.

Tumor-like pyogenic liver abscess caused by Klebsiella pneumoniae in diabetes

Part of the Cardiology Commons This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson Universitys Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship.Significance of QRS duration in non-ST elevation myocardial infarction.

Clinical utility of the HEART score in patients admitted with chest pain to an inner-city hospital in the USA

We have read a very interesting case reported by Williams et al. [1] ‘‘Occult pyogenic liver abscess in an adolescent with type 2 diabetes’’ which described a case of Klebsiella liver abscess (KLA) in a poorly controlled diabetic with an initial presentation of fever of unknown origin. In this letter, we would like to highlight another atypical presentation of KLA in a diabetic patient that presented as a tumor-like liver mass. A 63-year-old Vietnamese male with diabetes had a kidney biopsy 1 month prior to admission for evaluation of nephrotic syndrome that was complicated by the development of a kidney hematoma. Computed tomography (CT) of abdomen was performed to reassess the kidney hematoma when an ill-defined multicystic liver mass was incidentally discovered (Fig. 1, panel a–c). The patient had stable vital signs and was afebrile without any evidence of abdominal pain or leukocytosis. Since his blood cultures remained negative, a necrotizing tumor mass was the most likely diagnosis at that point. Additionally, the pathologic report of the kidney biopsy showed nodular diabetic glomerulosclerosis. The patient was discharged home to be followed up with tumor marker tests and further evaluation as an outpatient. A month after discharge, the patient returned with significant fatigue and anemia (hemoglobin drop from 7 to 5 g/dl) accompanied by mild right-sided upper abdominal pain. On exam, his vital signs were stable, he was afebrile, and well-oriented but looked pale and chronically ill. An abdominal exam revealed hepatomegaly with mild tenderness localized in the right upper quadrant. Tumor marker levels from the previous admission were within normal range (alpha fetoprotein level: 1.4 ng/ml and CA19-9: 32 U/ml). Laboratory results were as follows: white blood cell count 10 9 10/mm (N 80 %, L 9 %), alkaline phosphatase 169 IU/l, total bilirubin 0.2 mg/dl, direct bilirubin 0.2 mg/dl, albumin 1.4 g/dl, globulin 4.7 g/dl, aspartate transaminase 27 IU/l, alanine transaminase 16 IU/l, international normalized ratio 1.1, blood glucose 130 mg/dl, and serum creatinine 2.6 mg/dl. Due to chronic kidney disease, a CT scan of the abdomen was performed without use of intravenous contrast that demonstrated an increase in the size of the liver mass (Fig. 1 panel d–f). The liver mass was growing gradually for over a month without any signs and symptoms of infection, which was again attributed to likely being a necrotizing tumor mass. There was a serious concern for chronic bleeding from the site of the tumor and the patient received a right-sided hepatic lobectomy for bleeding control and tissue diagnosis. Surprisingly, the pathology report revealed a liver abscess with chronic inflammation and the tissue cultures grew pansensitive Klebsiella pneumoniae. KLA is an emerging disease in North America, frequently found in the Asian population, diabetics, and patients with chronic kidney disease [2]. K. pneumonia was isolated in 7–27 % of pyogenic liver abscess in USA but only a few cases of metastatic infection have been reported such as endophthalmitis, lung abscess, and meningitis. The incidence is higher in Taiwan, Japan, and south-east Asia. Common presentations are fever, abdominal pain, and leukocytosis which were initially absent in our case and misled us to pursue for liver malignancy. The findings suggestive of KLA on CT or ultrasonography are the formation of gas within the abscesses, pneumatosis in the biliary tree, an irregular abscess border, and an overall solid appearance with internal necrotic debris. Since several hepatic neoplasms or metastatic liver diseases S. Buppajarntham (&) M. Shah P. Junpaparp Internal Medicine Department, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA e-mail: BuppajaS@einstein.edu

CARDIAC THROMBOSIS IN ACUTE ANTERIOR MYOCARDIAL INFARCTION: EVALUATION OF HOSPITAL MORTALITY, THROMBOEMBOLISM AND BLEEDING

Background Chest pain is one of the most common presentations to a hospital, and appropriate triaging of these patients can be challenging. The HEART score has been used for such purposes in some countries and only a few validation studies from the USA are available. We aim to determine the utility of the HEART score in patients presenting with chest pain to an inner-city hospital in the USA. Patients and methods We retrospectively screened 417 consecutive patients admitted with chest pain to the observation/telemetry units at Einstein Medical Center Philadelphia. After applying inclusion and exclusion criteria, 299 patients were included in the analysis. Patients were divided into low-risk (0–3) and intermediate-high (≥4)-risk HEART score groups. Baseline characteristics, thrombolysis in myocardial infarction score, need for revascularization during index hospitalization, and major adverse cardiovascular events (MACE) at 6 weeks and 12 months were recorded. Results There were 98 and 201 patients in the low-score group and intermediate-high-score group, respectively. Compared with the low-score group, patients in the intermediate-high-risk group had a higher incidence of revascularization during the index hospital stay (16.4 vs. 0%; P=0.001), longer hospital stay, higher MACE at 6 weeks (9.5 vs. 0%) and 12 months (20.4 vs. 3.1%), and higher cardiac readmissions. HEART score of at least 4 independently predicted MACE at 12 months (odds ratio 7.456, 95% confidence interval: 2.175–25.56; P=0.001) after adjusting for other risk factors in regression analysis. Conclusion HEART score of at least 4 was predictive of worse outcomes in patients with chest pain in an inner-city USA hospital. If validated in multicenter prospective studies, the HEART score could potentially be useful in risk-stratifying patients presenting with chest pain in the USA and could impact clinical decision-making.

Death during exercise testing in a patient with asymptomatic severe aortic stenosis

Left ventricular thrombus (LVT) is a well-known complication of acute myocardial infarction, most commonly seen in anterior wall ST-segment elevation myocardial infarction (STEMI). It is associated with systemic thromboembolism. The aim of this study is to evaluate the impact of LVT on in-hospital

An unusual cause for syncope: Pericardial paraganglioma causing right ventricular outflow obstruction

Introduction: Patients with symptomatic severe aortic valve stenosis (As) experience short and long-term survival benefit with aortic valve replacement (AVr). Among patients with asymptomatic severe As (AsAs) current guidelines recommend exercise stress testing (Ett) as a safe and effective method to risk stratify patients and to assist with the timing of AVr. We discuss the course of disease in As, review the role of Ett and express concerns about the safety of performing stress tests in asymptomatic patients with severe As. case report: We describe the case of a 69-year-old male with left bundle branch block and AsAs who underwent Ett with echocardiographic imaging. We describe the details of the patient’s clinical, EcG and echo doppler parameters prior, during and following the test. Patient developed pulseless electrical activity during early recovery with eventual resuscitation and mechanical support. the patient did not survive due to continued deterioration in clinical status. conclusion: Despite being considered safe, Ett can unmask symptoms in AsAs and result in Mahek Shah1, Anuraj Sudhakaran1, Baburaj Aparna3, Muhammad Qasim2, Brijesh Patel2, Lohit Garg1, Bruce Feldman1 Affiliations: 1Division of Cardiology, Department of Medicine, Lehigh Valley Health Network, Allentown PA, USA; 2Department of Medicine, Lehigh Valley Health Network, Allentown PA, USA; 3Amritha Institutes of Medical Science and Research Center, Kochi, Kerala, India. Corresponding Author: Anuraj Sudhakaran, MD, 1250 S Cedar Crest Blvd, Suite 300, Allentown PA 18103 United States; Email: dranurajms@yahoo.com Received: 18 December 2017 Accepted: 13 February 2018 Published: 15 March 2018 caSe rePO Peer reviewed | OPen a ce S hemodynamic instability leading to death. A comprehensive registry of safety data is needed. clinical vigilance and physician supervision during stress testing may minimize the risk of serious adverse events.