Nileshkumar J. Patel

In-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United States Between 2000 and 2010 Analysis of 93 801 Procedures

Background— Atrial fibrillation ablation has made tremendous progress with respect to innovation, efficacy, and safety. However, limited data exist regarding the burden and trends in adverse outcomes arising from this procedure. The aim of our study was to examine the frequency of adverse events attributable to atrial fibrillation (AF) ablation and the influence of operator and hospital volume on outcomes. Methods and Results— With the use of the Nationwide Inpatient Sample, we identified AF patients treated with catheter ablation. We investigated common complications including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, vascular access complications (hemorrhage/hematoma, vascular complications requiring surgical repair, and accidental arterial puncture), and in-hospital death described with AF ablation, and we defined these complications by using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. An estimated 93 801 AF ablations were performed from 2000 to 2010. The overall frequency of complications was 6.29% with combined cardiac complications (2.54%) being the most frequent. Cardiac complications were followed by vascular complications (1.53%), respiratory complications (1.3%), and neurological complications (1.02%). The in-hospital mortality was 0.46%. Annual operator (<25 procedures) and hospital volume (<50 procedures) were significantly associated with adverse outcomes. There was a small (nonsignificant) rise in overall complication rates. Conclusions— The overall complication rate was 6.29% in patients undergoing AF ablation. There was a significant association between operator and hospital volume and adverse outcomes. This suggests a need for future research into identifying the safety measures in AF ablations and instituting appropriate interventions to improve overall AF ablation outcomes.

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

Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011

6410 in 2001 to

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

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.

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.

BACKGROUND In accordance with the 2007 American College of Cardiology and American Heart Association infective endocarditis (IE) guideline update, antibiotic prophylaxis is now being restricted to a smaller number of cardiac conditions with very high risk for adverse outcomes from IE. However, there is scant data on IE trends since this major practice change in the United States. OBJECTIVES The aim of this study was to compare temporal trends in IE incidence, microbiology, and outcomes before and after the change in the 2007 IE prophylaxis guideline in the United States. METHODS The NIS (Nationwide Inpatient Sample) database was used to investigate IE hospitalization rates in the United States from 2000 through 2011. The mean annual rates of IE before and after the 2007 guideline change were compared using segmented regression analysis. RESULTS There were 457,052 IE-related hospitalizations in the United States from 2000 to 2011, with a steady increase in incidence (p < 0.001). The trend in IE hospitalization rates from 2000 to 2007 and from 2008 to 2011 was not significantly different (p = 0.74). The increases in the number of Staphylococcus IE cases per million population during the study periods 2000 to 2007 and 2008 to 2011 were similar (p = 0.13), but Streptococcus IE hospitalization rates were significantly higher after the release of new guidelines (p = 0.002). Finally, valve replacement rates for IE steadily increased from 2000 to 2007 (p = 0.03) but showed a plateau from 2007 to 2011. Overall, there was no significant difference in the rates of valve replacement for IE before and after the release of new guideline (p = 0.23). CONCLUSIONS These results show that IE incidence has increased in the United States over the past decade. With regard to the microbiology of IE, there has been a significant rise in the incidence of Streptococcus IE since the 2007 guideline revisions. However, the rates of hospitalization and valve surgery for IE have not increased since the change in IE prophylaxis guideline in 2007.

Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome)

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.

Trends in Hospitalization for Atrial Fibrillation: Epidemiology, Cost, and Implications for the Future

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.

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

INTRODUCTION The objective of our study was to assess the burden of arrhythmias, the gender differences in occurrence of arrhythmias and the impact of these arrhythmias on hospitalization outcomes in patients with Takotsubo Cardiomyopathy (TTC). METHODS TTC and various arrhythmias were identified using appropriate ICD-9-CM codes from Nationwide Inpatient Sample (NIS) discharge records 2006-2010. Length of hospital stay (LOS), in-hospital mortality and total charges were used to assess the impact of the arrhythmias on TTC hospitalization. All analyses were performed using SASv9.2 (Cary Institute Inc., Cary, NC). RESULTS A total of 16,450 patients were included in the study and 26% (n=4296) of patients had cardiac arrhythmias. Following arrhythmias were present in the descending order of frequency: atrial fibrillation (Afib) 6.9%, ventricular tachycardia (VT) 3.2%, atrial flutter (Afl) 1.9%, ventricular fibrillation and flutter 1%, paroxysmal supraventricular tachycardia (PSVT) 0.8%. Nearly two percent of the patients had sudden cardiac arrest (SCA). Males were more likely to have cardiac arrhythmias in general compared to females (OR: 1.5, 95% CI: 1.3-1.7, p-value 0.001). Occurrence of ventricular tachycardia (OR: 1.7, 95% CI: 1.3-2.2, p-value<0.001) and sudden cardiac arrest OR: 1.6, 95% CI: 1.1-2.2, p<0.001) were significantly higher in males. In contrast, Afib was significantly less in males compared to females (OR:0.8, 95% CI:0.6-0.9). Patients with arrhythmias had significantly longer length of stay, and increased cost of hospitalization and mortality. CONCLUSIONS Arrhythmias are present in nearly one-quarter of patients with TTC and worsen the outcome. While TTC has been established as a disease mainly of females, life threatening arrhythmias like VT and SCA are more common in males.

Fasting Serum C‐Peptide Levels Predict Cardiovascular and Overall Death in Nondiabetic Adults

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide and the most common arrhythmia leading to hospitalization. Due to a substantial increase in incidence and prevalence of AF over the past few decades, it attributes to an extensive economic and public health burden. The increasing number of hospitalizations, aging population, anticoagulation management, and increasing trend for disposition to a skilled facility are drivers of the increasing cost associated with AF. There has been significant progress in AF management with the release of new oral anticoagulants, use of left atrial catheter ablation, and novel techniques for left atrial appendage closure. In this article, we aim to review the trends in epidemiology, hospitalization, and cost of AF along with its future implications on public health.

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.