Navdeep Gupta

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

Importance Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery. Objective To evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants Patients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample. Main Outcomes and Measures Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results Among 10 581 621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5 975 798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317 479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150 000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86). Conclusions and Relevance Perioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.

Trend in the use of drug eluting stents in the United States: Insight from over 8.1 million coronary interventions

BACKGROUND Drug eluting stents (DES) reduce the risk of restenosis but are associated with increase in the risk of very late stent thrombosis, especially when antiplatelet therapy is held. The trend in DES use across the US is not fully defined. METHODS Data from the 2001-2011 Nationwide Inpatient Sample for patients undergoing PCI were used. The trend in DES use was analyzed overall and in subgroups at risk of restenosis (those with diabetes, chronic kidney disease or prior PCI), stent thrombosis (those with acute coronary syndrome) or bleeding (those with history of bleeding peptic ulcer or atrial fibrillation). RESULTS Among the 8,150,763 PCI procedures performed, DES use peaked in 2005 at 89% in all patients including groups with a low risk of restenosis, high risk of stent thrombosis or bleeding. A steep drop to 66% was noted in 2007 followed by a progressive rise to 73% in 2011 (P<0.0001). The 2011 DES use patterns indicate increased DES use in subgroups at risk of restenosis, decreased use in subgroups at risk of thrombosis or bleeding but also lower use in groups at risk for discriminant care such as African Americans, the elderly and patients with Medicaid/self-pay. CONCLUSIONS DES trends indicate rapid and broad initial use followed by a sharp decline in 2007 and a progressive rise in 2011. DES use in 2011 seemed based on risk category, but was lower in groups at risk for discriminant care.

Rates of Invasive Management of Cardiogenic Shock in New York Before and After Exclusion From Public Reporting.

IMPORTANCE Reduced rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) are an unintended consequence of public reporting of cardiogenic shock outcomes in New York. OBJECTIVES To evaluate whether the referral rates for cardiac catheterization, PCI, or CABG have improved in New York since cardiogenic shock was excluded from public reporting in 2008 and compare them with corresponding rates in Michigan, New Jersey, and California. DESIGN, SETTING, AND PARTICIPANTS Patients with cardiogenic shock complicating acute myocardial infarction from 2002 to 2011 were identified using the National Inpatient Sample. Propensity score matching was used to assemble a cohort of patients with cardiogenic shock with similar baseline characteristics in New York and Michigan. MAIN OUTCOMES AND MEASURES Percutaneous coronary intervention (primary outcome), invasive management (cardiac catheterization, PCI, or CABG), revascularization (PCI or CABG), and CABG were evaluated with reference to 3 calendar year periods: 2002-2005 (time 1: cardiogenic shock included in publicly reported outcomes), 2006-2007 (time 2: cardiogenic shock excluded on a trial basis), and 2008 and thereafter (time 3: cardiogenic shock excluded permanently) in New York and compared with Michigan. RESULTS Among 2126 propensity score-matched patients representing 10 795 (weighted) patients with myocardial infarction complicated by cardiogenic shock in New York and Michigan, 905 (42.6%) were women and mean (SE) age was 69.5 (0.3) years. A significantly higher proportion of the patients underwent PCI (time 1 vs 2 vs 3: 31.1% vs 39.8% vs 40.7% [OR, 1.50; 95% CI, 1.12-2.01; P = .005 for time 3 vs 1]), invasive management (time 1 vs 2 vs 3: 59.7% vs 70.9% vs 73.8% [OR, 1.84; 95% CI, 1.37-2.47; P < .001 for time 3 vs 1]), or revascularization (43.1% vs 55.9% vs 56.3% [OR, 1.66; 95% CI, 1.26-2.20; P < .001 for time 3 vs 1]) after the exclusion of cardiogenic shock from public reporting in New York. However, during the same periods, a greater proportion of patients underwent PCI (time 1 vs 2 vs 3: 41.2% vs 52.6% vs 57.8% [OR, 1.93; 95% CI, 1.45-2.56; P < .001 for time 3 vs 1]), invasive management (time 1 vs 2 vs 3: 64.4% vs 80.5% vs 78.6% [OR, 2.01; 95% CI, 1.47-2.74; P < .001 for time 3 vs 1]), or revascularization (51.2% vs 65.8% vs 68.0% [OR, 2.00; 95% CI, 1.50-2.66; P < .001 for times 3 vs 1]) in Michigan. Results were largely similar in several sensitivity analyses comparing New York with New Jersey or California. CONCLUSIONS AND RELEVANCE Although the rates of PCI, invasive management, and revascularization have increased substantially after the exclusion of cardiogenic shock from public reporting in New York, these rates remain consistently lower than those observed in other states without public reporting.

Trend in percutaneous coronary intervention volume following the COURAGE and BARI-2D trials: insight from over 8.1 million percutaneous coronary interventions.

BACKGROUND COURAGE and BARI-2D have questioned the utility of routine revascularization for the prevention of cardiovascular events in patients with stable ischemic heart disease (SIHD). On the other end of the spectrum, a routine invasive strategy in patients with acute coronary syndrome (ACS) is superior to a conservative strategy. The impact of the above trials on the trend in percutaneous coronary intervention (PCI) volume for SIHD and ACS is not known. METHODS Data from the 2001-2011 Nationwide Inpatient Sample for discharges with PCI were used. The trend in PCI volume over time was analyzed, especially in relation to the COURAGE (2007) and the BARI-2D (2009) trials. Age and gender adjusted PCI rates were calculated using direct standardization method. RESULTS Among the 8,150,764 PCI procedures, there was a steady increase in PCI volumes until the publication of the COURAGE/BARI-2D trials after which the volume decreased. Compared to the peak volume of 909,331 in 2006, PCI volume declined by 38% to 562,036 in 2011 (P<0.0001); driven by a 60% decrease in PCI for SIHD from 409,199 in 2006 to 160,707 in 2011 (P<0.0001). Moreover, there was a 20% decrease in PCI for ACS from 500,132 in 2006 to 401,330 in 2011 (P<0.0001) driven by a significant decrease in PCI for unstable angina. Results were similar in diabetics with a decline in the volume after BARI-2D trial, although the decline was less dramatic. CONCLUSION The 11-year trend indicates a substantial impact of COURAGE/BARI-2D on SIHD PCI volumes with an unintended consequence of lower PCI volumes for ACS.

Characteristics and Outcomes in Patients Undergoing Percutaneous Coronary Intervention Following Cardiac Arrest (from the NCDR)

Outcomes in patients with out-of-hospital cardiac arrest (CA) who undergo percutaneous coronary intervention (PCI) have been limited to small, mostly single-center studies. We compared patients who underwent PCI after CA included in the CathPCI Registry with those without CA. Patients with ST elevation were classified as ST-elevation myocardial infarction (STEMI); all other patients having PCI were classified as without STEMI. Patients with CA in each group were compared with the corresponding non-CA groups for baseline characteristics, angiographic findings, and outcomes. A total of 594,734 patients underwent PCI, of whom 114,768 had STEMI, including 9,375 (8.2%) had CA, and 479,966 had without STEMI, including 2,775 (0.6%) had CA. Patients with CA were similar in age to patients with non-CA, with a lower frequency of coronary disease risk factors and known coronary disease. On angiography, patients with CA were significantly more likely to have more complex lesions with worse baseline thrombolysis in myocardial infarction flow. Patients with CA were significantly more likely to have cardiogenic shock, both for patients with STEMI (51% vs 7.2%, respectively) and for patients without STEMI (38% vs 0.8%, respectively, both p<0.001). In-hospital mortality was substantially worse in patients with CA, for both patients with STEMI (24.9% vs 3.1%, respectively) and patients without STEMI (18.7% vs 0.4%, respectively). In conclusion, patients who underwent PCI after CA had more complex anatomy, more shock, and higher mortality. The substantially increased mortality in patients with CA has important implications for the development and regionalization of centers for CA.

Perioperative acute myocardial infarction associated with non-cardiac surgery

Aims Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We sought to evaluate national trends in perioperative AMI, its management, and outcomes. Methods and results Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the United States National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile a cohort of AMI patients managed invasively (defined as cardiac catheterization or coronary revascularization) vs. conservatively. The primary outcome was in-hospital all-cause mortality. Among 9 566 277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84 093 (0.88%). Over time, the rate of perioperative AMI per 100 000 surgeries declined by 170 [95% confidence intervals (95% CI) 158-181], from 898 in 2005 to 729 in 2013 (P for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI [18.0% vs. 1.5%, P < 0.0001; adjusted odds ratio (OR) 5.76, 95% CI 5.65-5.88]. Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84-0.88). In a propensity-matched cohort of 34 650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, P < 0.001; OR 0.44, 95% CI 0.41-0.47). Conclusion In an observational cohort study from the USA, perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk, and further research on the management of perioperative AMI is warranted.

Management and outcomes of acute myocardial infarction in patients with chronic kidney disease

BACKGROUND Chronic kidney disease (CKD) is associated with cardiovascular disease and acute myocardial infarction (AMI). Contemporary management and outcomes of AMI in patients with CKD have not been reported. METHODS We analyzed United States National Inpatient Sample data for patients admitted with AMI with or without CKD from 2007 to 2012. Propensity score matching was used to identify patients with AMI and CKD with similar baseline characteristics who were managed invasively (cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) or conservatively. The primary outcome was in-hospital all-cause mortality. RESULTS Among 753,782 patients admitted with AMI, 17.8% had a diagnosis of CKD. Patients with CKD had lower odds of invasive management (49.9% vs. 73.1%; adjusted OR 0.57, 95% CI 0.57-0.58), were less likely to undergo revascularization (adjusted OR 0.60, 95% CI 0.59-0.61), and had higher in-hospital mortality (8.4% vs. 5.0%; adjusted OR 1.55, 95% CI 1.51-1.59) than those without CKD. In a propensity-matched cohort of 89,630 CKD patients treated for AMI with invasive vs. conservative management, invasive management was associated with lower in-hospital mortality overall (5.9% vs. 10.9%, p<0.001; OR=0.51 (0.49-0.54)) as well as in subgroups by MI type and severity of CKD. CONCLUSIONS Patients with AMI and CKD are less likely to receive invasive management, coronary revascularization, and have higher in-hospital mortality than patients without CKD. Invasive management of AMI was associated with lower in-hospital mortality versus conservative management in all patients, regardless of CKD severity.

Comparison of Outcomes of Patients With Sepsis With Versus Without Acute Myocardial Infarction and Comparison of Invasive Versus Noninvasive Management of the Patients With Infarction.

Patients hospitalized with sepsis may be predisposed to acute myocardial infarction (AMI). The incidence, treatment, and outcomes of AMI in sepsis have not been studied. We analyzed data from the National Inpatient Sample from 2002 to 2011 for patients with a diagnosis of sepsis. The incidence of AMI as a nonprimary diagnosis was evaluated. Propensity score matching was used to identify a cohort of patients with secondary AMI and sepsis with similar baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft [CABG] surgery) or conservatively. The primary outcome was in-hospital all-cause mortality. A total of 2,602,854 patients had a diagnosis of sepsis. AMI was diagnosed in 118,183 patients (4.5%), the majority with non-ST elevation AMI (71.4%). In-hospital mortality was higher in patients with AMI and sepsis than those with sepsis alone (35.8% vs 16.8%, p <0.0001; adjusted odds ratio 1.24, 95% CI 1.22 to 1.26). In patients with AMI, 11,899 patients (10.1%) underwent an invasive management strategy, in which 4,668 patients (39.2%) underwent revascularization. PCI was performed in 3,413 patients (73.1%), CABG in 1,165 (25.0%), and both CABG and PCI in 90 patients (1.9%). In a propensity-matched cohort of 23,708 patients with AMI, invasive management was associated with a lower mortality than conservative management (19.0% vs 33.4%, p <0.001; odds ratio 0.47, 95% CI 0.44 to 0.50). In subgroups that underwent revascularization, the odds of mortality were consistently lower than corresponding matched subjects from the conservative group. In conclusion, myocardial infarction not infrequently complicates sepsis and is associated with a significant increase in in-hospital mortality. Patients managed invasively had a lower mortality than those managed conservatively.

Aortic Atherosclerosis: A Common Source of Cerebral Emboli, Often Overlooked!

Aortic atherosclerotic plaques are usually seen in males older than 55 years who are known to have risk factors of atherosclerosis. Recent large series of consecutive stroke patients reported that the prevalence of aortic atheromatous plaques in patients with stroke is about 21%–27%, which is in the same magnitude when compared with the prevalence of carotid disease (10%–13%) and atrial fibrillation (18%–30%). Atheromatous plaques are composed of a lipid pool, a fibrous cap, smooth muscle cells, and mononuclear cell infiltration with calcification. Aortic plaques can cause embolization to brain, extremities, or visceral organs. Atheroembolization can occur spontaneously or as a result of manipulation during cardiac or vascular surgery. Only few cases of cerebral embolization from an aortic plaque in the absence of any manipulation have been described. Although few atherosclerotic plaques can be visualized on the aortogram, transesophageal echocardiogram remains a preferred modality for diagnosis in such cases. We present a case of cerebral embolism arising from a mobile noncalcified complex aortic arch plaque diagnosed on a transesophageal echocardiogram and review the literature on its diagnosis, clinical implications, and management.

Trends in cardiovascular risk factor and disease prevalence in patients undergoing non-cardiac surgery

Objectives Cardiovascular risk factors are prevalent in the population undergoing non-cardiac surgery. Changes in perioperative cardiovascular risk factor profiles over time are unknown. The objective of this study was to evaluate national trends in cardiovascular risk factors and atherosclerotic cardiovascular disease (ASCVD) among patients undergoing non-cardiac surgery. Methods Adults aged ≥45 years old who underwent non-cardiac surgery were identified using the US National Inpatient Sample from 2004 to 2013. The prevalence of traditional cardiovascular risk factors (hypertension, dyslipidaemia, diabetes mellitus, obesity and chronic kidney disease) and ASCVD (coronary artery disease, peripheral artery disease and prior stroke] were evaluated over time. Results A total of 10 581 621 hospitalisations for major non-cardiac surgery were identified. Between 2008 and 2013, ≥2 cardiovascular risk factors and ASCVD were present in 44.5% and 24.3% of cases, respectively. Over time, the prevalence of multiple (≥2) cardiovascular risk factors increased from 40.5% in 2008–2009 to 48.2% in 2012–2013, P<0.001. The proportion of patients with coronary artery disease (17.2% in 2004–2005 vs 18.2% in 2012–2013, P<0.001), peripheral artery disease (6.3% in 2004–2005 vs 7.4% in 2012–2013, P<0.001) and prior stroke (3.5% in 2008–2009 vs 4.7% 2012–2013, P<0.001) also increased over time. The proportion of patients with a modified Revised Cardiac Risk Index score ≥3 increased from 6.6% in 2008–2009 to 7.7% in 2012–2013 (P<0.001). Conclusions Among patients undergoing major non-cardiac surgery, the burden of cardiovascular risk factors and the prevalence of ASCVD increased over time. Adverse trends in risk profiles require continued attention to improve perioperative cardiovascular outcomes.