RESUMO
BACKGROUND: Acute myocardial infarction (AMI) is a major scenario for the use of an intra-aortic balloon pump (IABP), particularly when complicated by cardiogenic shock, although the utilization of mechanical circulatory support devices varies widely per hospital. We evaluated the relationship, at the hospital level, between the volume of IABP use and mortality in AMI. METHODSâANDâRESULTS: Using a Japanese nationwide administrative database, 26,490 patients with AMI undergoing primary percutaneous coronary intervention (PCI) from 154 hospitals were included in this study. The primary endpoint was the observed-to-predicted in-hospital mortality ratio. Predicted mortality per patient was calculated using baseline variables and averaged for each hospital. The associations among PCI volume for AMI, observed and predicted in-hospital mortality, and observed and predicted IABP use were assessed per hospital. Of 26,490 patients, 2,959 (11.2%) were treated with IABP and 1,283 (4.8%) died during hospitalization. The annualized number of uses of IABP per hospital in AMI was 4.5. In lower-volume primary PCI centers, IABP was more likely to be underused than expected, and the observed-to-predicted in-hospital mortality ratio was higher than in higher-volume centers. CONCLUSIONS: A lower annual number of IABP use was associated with an increased mortality risk at the hospital level, suggesting that IABP use can be an institutional quality indicator in the setting of AMI.
Assuntos
Mortalidade Hospitalar , Balão Intra-Aórtico , Infarto do Miocárdio , Intervenção Coronária Percutânea , Humanos , Balão Intra-Aórtico/mortalidade , Balão Intra-Aórtico/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Idoso , Masculino , Feminino , Intervenção Coronária Percutânea/mortalidade , Pessoa de Meia-Idade , Japão/epidemiologia , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Resultado do Tratamento , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricosRESUMO
Right ventricular dysfunction (RVD) continues to be a significant contributor to both mortality and morbidity, posing a significant challenge in the management of patients undergoing evaluation for mechanical circulatory support (MCS). Currently, there is a paucity of data regarding outcomes in this subset of patients. We analyzed the National Inpatient Sample database (NIS) to identify adult hospitalizations who underwent intra-aortic balloon pump (IABP) placement with or without co-existence of RVD. Multivariate logistic regression, and linear regression analyses were used to compare outcomes, and adjust for possible confounders. Out of 126,985 hospitalizations who underwent IABP placement, 1,475 (1.2%) had RVD. Patients with RVD who received an IABP had higher adjusted odds of inpatient mortality (Adjusted odds ratio [aOR]: 2.33, 95% confidence interval [CI]: 1.7-3.2, p<0.001) than those without co-existing RVD. Hospitalized patients who underwent IABP placement with RVD had higher adjusted odds of worse hospitalization outcomes in general. Conducting additional prospective studies and clinical trials with an emphasis on further subcategorization of patients with RVD is crucial for determining optimal management strategies for these patients.
Assuntos
Balão Intra-Aórtico , Disfunção Ventricular Direita , Humanos , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/terapia , Estados Unidos/epidemiologia , Idoso , Mortalidade Hospitalar/tendências , Adulto , Resultado do Tratamento , Fatores de RiscoRESUMO
PURPOSE: We sought to characterize adaptive changes to the revised United Network for Organ Sharing donor heart allocation policy and estimate long-term survival trends for heart transplant (HTx) recipients. METHODS: Patients listed for HTx between October 17, 2013 and September 30, 2021 were identified from the United Network for Organ Sharing database, and stratified into pre- and postpolicy revision groups. Subanalyses were performed to examine trends in device utilization for extracorporeal membranous oxygenation (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical circulatory support (non-MCS). Survival data post-HTx were fitted to parametric distributions and extrapolated to 5 years. RESULTS: We identified 27,523 HTx waitlist candidates during the study period, most of whom (n = 16,376) were waitlisted in the prepolicy change period. Overall, 19,554 patients underwent HTx during the study period (pre: 12,037 and post: 7517). Listings increased after the policy change for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients. Listings for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients decreased. HTx increased for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients after the policy change and decreased for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients. Waitlist survival increased for the overall ( P < 0.01), ECMO ( P < 0.01), IABP ( P < 0.01), and non-MCS ( P < 0.01) groups. Waitlist survival did not differ for the LVAD ( P = 0.8) and Impella ( P = 0.1) groups. Post-transplant survival decreased for the overall ( P < 0.01), LVAD ( P < 0.01), and non-MCS ( P < 0.01) populations. CONCLUSIONS: Allocation policy revisions have contributed to greater utilization of ECMO, Impella, and IABP, decreased utilization of LVADs and non-MCS, increased waitlist survival, and decreased post-HTx survival.
Assuntos
Bases de Dados Factuais , Transplante de Coração , Obtenção de Tecidos e Órgãos , Listas de Espera , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Listas de Espera/mortalidade , Adulto , Coração Auxiliar/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Taxa de Sobrevida/tendências , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Estudos Retrospectivos , Balão Intra-Aórtico/estatística & dados numéricosRESUMO
AIMS: Despite increased temporary mechanical circulatory support (tMCS) utilization for acute myocardial infarction complicated by cardiogenic shock (AMI-CS), data regarding efficacy and optimal timing for tMCS support are limited. This study aimed to describe outcomes based on tMCS timing in AMI-CS and to identify predictors of 30-day mortality and readmission. METHODS AND RESULTS: Patients with AMI-CS identified in the National Readmissions Database were grouped according to the use of tMCS and early (<24â h) vs. delayed (≥24â h) tMCS. The correlation between tMCS timing and inpatient outcomes was evaluated using linear regression. Multivariate logistic regression was used to identify variables associated with 30-day mortality and readmission. Of 294 839 patients with AMI-CS, 109 148 patients were supported with tMCS (8067 veno-arterial extracorporeal membrane oxygenation, 33 577 Impella, and 79 161 intra-aortic balloon pump). Of patients requiring tMCS, patients who received early tMCS (n = 79 906) had shorter lengths of stay (7 vs. 15 days, P < 0.001) and lower rates of ischaemic and bleeding complications than those with delayed tMCS (n = 32 241). Patients requiring tMCS had higher in-hospital mortality [odds ratio (95% confidence interval)] [1.7 (1.7-1.8), P < 0.001]. Among patients requiring tMCS, early support was associated with fewer complications, lower mortality [0.90 (0.85-0.94), P < 0.001], and fewer 30-day readmissions [0.91 (0.85-0.97), P = 0.005] compared with patients with delayed tMCS. CONCLUSION: Among patients receiving tMCS for AMI-CS, early tMCS was associated with fewer complications, shorter lengths of stay, lower hospital costs, and fewer deaths and readmissions at 30 days.
Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Mortalidade Hospitalar , Balão Intra-Aórtico , Infarto do Miocárdio , Choque Cardiogênico , Humanos , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Masculino , Feminino , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Pessoa de Meia-Idade , Mortalidade Hospitalar/tendências , Idoso , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/tendências , Estados Unidos/epidemiologia , Resultado do Tratamento , Taxa de Sobrevida/tendências , Tempo de Internação/estatística & dados numéricos , SeguimentosRESUMO
Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality in patients with cardiogenic shock the large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on outcome. ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. A total of 101,870 patients were treated with IABP and 39645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR = 0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR = 1.32, CI 1.26-1.39). After adjusting for 47 variables, Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p < 0.001), whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p < 0.001). Separating rural vs teaching hospitals revealed similar findings. In patients with cardiogenic shock, the use of Impella was associated with the highest whereas IABP was associated with the lowest in-hospital mortality regardless of comorbid condition.
Assuntos
Coração Auxiliar , Mortalidade Hospitalar , Balão Intra-Aórtico , Choque Cardiogênico , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Bases de Dados Factuais , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Índice de Gravidade de DoençaRESUMO
The last several years have seen a rise in use of mechanical circulatory support (MCS) to bridge heart transplant recipients. A controlled hypothermic organ preservation system, the SherpaPak Cardiac Transport System (SCTS), was introduced in 2018 and has grown in utilization with reports of improved posttransplant outcomes. The Global Utilization And Registry Database for Improved heArt preservatioN (GUARDIAN)-Heart registry is an international, multicenter registry assessing outcomes after transplant using the SCTS. This analysis examines outcomes in recipients bridged with various MCS devices in the GUARDIAN-Heart Registry. A total of 422 recipients with donor hearts transported using SCTS were included and identified. Durable ventricular assist devices (VADs) were used exclusively in 179 recipients, temporary VADs or intra-aortic balloon pump (IABP) in 197, and extracorporeal membrane oxygenation (ECMO) in 14 recipients. Average ischemic times were over 3.5 hours in all cohorts. Severe primary graft dysfunction (PGD) posttransplant increased across groups (4.5% VAD, 5.1% temporary support, 21.4% ECMO), whereas intensive care unit (ICU) length of stay (18.2 days) and total hospital stay (39.4 days) was longer in the ECMO cohort than the VAD and IABP groups. A comparison of outcomes of MCS bridging in SCTS versus traditional ice revealed significantly lower rates of both moderate/severe right ventricular (RV) dysfunction and severe PGD in the SCTS cohort; however, upon propensity matching only the reductions in moderate/severe RV dysfunction were statistically significant. Use of SCTS in transplant recipients with various bridging strategies results in excellent outcomes.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Coração , Coração Auxiliar , Humanos , Transplante de Coração/métodos , Masculino , Pessoa de Meia-Idade , Feminino , Adulto , Oxigenação por Membrana Extracorpórea/métodos , Preservação de Órgãos/métodos , Resultado do Tratamento , Sistema de Registros/estatística & dados numéricos , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Idoso , Estudos RetrospectivosRESUMO
BACKGROUND: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking. METHODSâANDâRESULTS: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001). CONCLUSIONS: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.
Assuntos
Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Mortalidade Hospitalar , Balão Intra-Aórtico , Choque Cardiogênico , Humanos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Balão Intra-Aórtico/mortalidade , Balão Intra-Aórtico/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/mortalidade , Masculino , Feminino , Japão/epidemiologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Coração Auxiliar/estatística & dados numéricos , Resultado do Tratamento , Adulto , Tempo de Internação , População do Leste AsiáticoRESUMO
BACKGROUND: There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS). METHODS: Adult (>18âyears) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS: In â¼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; Pâ<â0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all Pâ<â0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all Pâ<â0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; Pâ<â0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (Pâ>â0.05). CONCLUSIONS: In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.
Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/terapia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardiovasculares , Estudos de Coortes , Angiografia Coronária/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Choque Cardiogênico/diagnóstico , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation is a rescue therapy for patients in cardiogenic shock. We hypothesize that patients bridged to heart transplant with extracorporeal membrane oxygenation have decreased survival. METHODS: The United Network of Organ Sharing database was retrospectively reviewed from January 1, 1999, to March 31, 2018, for heart transplant recipients. Recipients bridged with any form of mechanical support and those without support were compared with recipients bridged with extracorporeal membrane oxygenation. The primary end point was restricted mean survival time through 16.7 years. RESULTS: Of 26,918 recipients, 15,076 required no pretransplant mechanical support (56.0%). Support patients included 9321 with left ventricular assist devices (34.6%), 53 with right ventricular assist devices (0.2%), 258 with total artificial hearts (1.0%), 686 with biventricular assist devices (2.6%), 1378 with intra-aortic balloon pumps (5.1%), and 146 who required extracorporeal membrane oxygenation (0.5%). In the first 16.7 years post-transplant, compared with recipients bridged with extracorporeal membrane oxygenation, estimated adjusted restricted mean survival time was higher in patients who required no mechanical support (16.6 months [14.0-19.4]) and patients with a left ventricular assist device (16.5 months [99% confidence interval, 13.9-19.2]), an intra-aortic balloon pump (11.2 months [8.3-14.7]), or a biventricular assist device (6.6 months [3.6-10.3]). Restricted mean survival time in patients with a right ventricular assist device or a total artificial heart was similar to patients with extracorporeal membrane oxygenation. CONCLUSIONS: Recipients bridged with extracorporeal membrane oxygenation were estimated to survive 16.6 months less than nonmechanical circulatory support recipients. Bridge to heart transplant with extracorporeal membrane oxygenation is a viable option, and these patients should be considered transplant candidates.
Assuntos
Circulação Assistida , Oxigenação por Membrana Extracorpórea , Rejeição de Enxerto/mortalidade , Transplante de Coração , Insuficiência de Múltiplos Órgãos , Complicações Pós-Operatórias/mortalidade , Cuidados Pré-Operatórios , Circulação Assistida/instrumentação , Circulação Assistida/métodos , Circulação Assistida/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Transplante de Coração/métodos , Transplante de Coração/mortalidade , Transplante de Coração/estatística & dados numéricos , Coração Auxiliar/classificação , Coração Auxiliar/estatística & dados numéricos , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Cuidados Pré-Operatórios/instrumentação , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Taxa de Sobrevida , Estados Unidos , Listas de EsperaRESUMO
OBJECTIVES: To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND: Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS: We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS: Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; Pâ¯=â¯.005). In-hospital mortality was lower in the recent cohort (48% vs 56%; Pâ¯=â¯.043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, Pâ¯=â¯.59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS: Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.
Assuntos
Coração Auxiliar/estatística & dados numéricos , Infarto do Miocárdio/terapia , Choque Cardiogênico/terapia , Injúria Renal Aguda/epidemiologia , Idoso , Estudos de Coortes , Intervalos de Confiança , Feminino , Monitorização Hemodinâmica , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Razão de Chances , Intervenção Coronária Percutânea , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Choque Cardiogênico/complicações , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento , Doenças Vasculares/complicações , Doenças Vasculares/cirurgiaRESUMO
BACKGROUNDS: Intra-aortic balloon counterpulsation is increasingly used in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to explore the preference, effect, and prognosis of intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock patients. METHODS: Data of acute myocardial infarction complicated by cardiogenic shock patients at the Fourth Medical Center of PLA General Hospital were collected retrospectively. A propensity score was calculated with a logistic regression which contained clinically meaningful variables and variables selected by Lasso and then used to match the control group. The cumulative incidence curve and Gray's test were employed to analyse the effect and prognosis of intra-aortic balloon counterpulsation on mortality. RESULTS: A total of 1962 acute myocardial infarction cases admitted between May 2015 and November 2018 were identified, and 223 cases with acute myocardial infarction complicated by cardiogenic shock were included as the study cohort, which contained 34 cases that received IABP and 189 cases that did not receive IABP. Patients with higher alanine aminotransferase (OR = 1.93, 95% CI 1.29-2.98), higher triglyceride (OR = 3.71, 95% CI 1.87-7.95), and higher blood glucose (OR = 1.08, 95% CI 0.99-1.18) had a higher probability of receiving intra-aortic balloon counterpulsation. In the propensity score matching analysis, 34 cases received intra-aortic balloon counterpulsation and 102 matched controls were included in the comparison. By comparing the cumulative incidence of in-hospital mortality, there was no statistically significant difference between the intra-aortic balloon counterpulsation group and matched control group (P = 0.454). CONCLUSION: The use of intra-aortic balloon counterpulsation may not improve the prognosis of the acute myocardial infarction complicated by cardiogenic shock patients.
Assuntos
Contrapulsação/métodos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio/terapia , Choque Cardiogênico/complicações , Idoso , Idoso de 80 Anos ou mais , Contrapulsação/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/patologia , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
Extensive data on early nutrition support for patients requiring critical care are available. However, whether early initiation of feeding could be beneficial for patients hospitalized for acute heart failure (HF) remains unclear. We sought to compare outcomes of early and delayed initiation of feeding for hospitalized patients with acute HF using a nationwide inpatient database. We retrospectively analyzed data from the Diagnosis Procedure Combination database. We included patients hospitalized for HF between January 2010 and March 2018. We excluded patients with length of hospital stay ≤2 days, those patients who underwent major procedures under general anesthesia, and those requiring advanced mechanical supports within 2 days after admission including intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation. Propensity score matching and instrumental variable analyses were conducted to compare in-hospital mortality, complications and length of stay between the early and delayed feeding groups. Among 432,620 eligible patients, 403,442 patients (93%) received early initiation of feeding (within 2 days after admission) and 29,178 patients (7%) received delayed initiation of feeding. Propensity score matching created 29,153 pairs and delayed initiation of feeding was associated with higher in-hospital mortality (odds ratio 1.32; 95% confidence interval 1.26 to 1.39), longer hospital stay and higher incidence of pneumonia and sepsis. The instrumental variable analysis also showed patients with delayed initiation of feeding had higher in-hospital mortality (odds ratio 1.34; 95% confidence interval 1.28 to 1.40). In conclusion, our analysis suggested a potential benefit of early initiation of feeding for in-hospital outcomes in hospitalized patients hospitalized for acute HF. Further investigations are required to confirm our results and to clarify the underlying mechanisms.
Assuntos
Nutrição Enteral/métodos , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Pneumonia/epidemiologia , Sepse/epidemiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Japão/epidemiologia , Masculino , Pontuação de Propensão , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de TempoRESUMO
Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.
Assuntos
Plantão Médico/estatística & dados numéricos , Circulação Assistida/estatística & dados numéricos , Cateterismo Cardíaco/estatística & dados numéricos , Parada Cardíaca/epidemiologia , Mortalidade Hospitalar , Revascularização Miocárdica/estatística & dados numéricos , Choque Cardiogênico/terapia , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/terapia , Ponte de Artéria Coronária/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Transplante de Coração/estatística & dados numéricos , Coração Auxiliar/estatística & dados numéricos , Hospitalização , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/estatística & dados numéricos , Choque Cardiogênico/epidemiologiaRESUMO
Postinfarction ventricular septal defect (pVSD) due to acute myocardial infarction complicated by cardiogenic shock (CS) is associated with high mortality. The aim of this study was to determine the outcome of primary surgical repair of pVSD in patients with CS and examine whether it is influenced by the use of mechanical circulatory support (MCS) devices. Between October 1994 and April 2016, primary surgical repair of pVSD complicated by CS was performed in 53 patients. Thirty-six (68%) were implanted pre-operatively with an intra-aortic balloon pump (IABP), 4 (8%) with extracorporeal life support (ECLS), and 13 (24%) received no MCS device. Prospectively collected demographic and perioperative data were analyzed retrospectively. All-cause, 30-day mortality rates were analyzed and multivariate analysis was performed to differentiate independent risk factors. No pre-operatively implanted MCS device was able to improve 30-day survival, whereas pre-operatively implanted ECLS tended to have a positive effect (P = .106). The post-operative need for a MCS device or escalation of MCS invasiveness (IABP upgrade to ECLS) was associated with a higher 30-day mortality (P = .001) compared with patients without any MCS device or those with pre-operatively implanted MCS devices. An independent risk factor for 30-day mortality was the interval between acute myocardial infarction and surgery <7 days (OR 5.895, CI 1.615-21.515; P = .007). Pre-operative implantation of ECLS for CS tends to improve the outcome of early primary surgical pVSD repair. The need for a post-operative MCS device is associated with a worse 30-day survival after early primary surgical pVSD repair.
Assuntos
Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Comunicação Interventricular/cirurgia , Balão Intra-Aórtico/estatística & dados numéricos , Infarto do Miocárdio/terapia , Choque Cardiogênico/terapia , Idoso , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Comunicação Interventricular/etiologia , Comunicação Interventricular/mortalidade , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Período Pós-Operatório , Período Pré-Operatório , Estudos Retrospectivos , Fatores de Risco , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Resultado do TratamentoRESUMO
BACKGROUND: Patients suffering an acute myocardial infarction complicated by cardiogenic shock (AMICS) may experience clinical deterioration with concomitant atrial fibrillation (AF). Recent data suggest that percutaneous ventricular assist devices (pVADs) provide superior hemodynamic support over intra-aortic balloon pump (IABP) in AMICS. In patients with AF+AMICS, however, outcomes data comparing these two devices remain limited. METHODS: Using the National Inpatient Sample datasets (2008-2014) and a propensity-score matched analysis, we compared the outcomes of AMICS+AF hospitalized patients undergoing PCI with pVAD vs. IABP support. RESULTS: A total of 12,842 AMICS+AF patients were identified (pVAD=468, IABP=12,374). The matched groups (pVAD=443, IABP=443) were comparable in terms of mean age (70.3 ± 12.0 vs. 70.4 ± 11.0yrs, p = 0.92). The utilization of pVAD was higher in whites but lower in Medicare/Medicaid beneficiaries as compared to IABP. The pVAD group demonstrated higher rates of obesity (13.6% vs. 7.8%, p = 0.006) and dyslipidemia (48.4% vs. 41.8%, p = 0.05). There was no difference in the in-hospital mortality (40.5% vs. 36.8%, p = 0.25); however, pVAD group had a lower incidence of post-procedural MI and higher incidences of stroke (7.8% vs. 4.4%, p = 0.03), hemorrhage (5.6% vs. 2.3%, p = 0.01), discharges to home health care (13.5% vs. 10.1%, p<0.001) and to other facilities (29.1% vs. 24.9%, p<0.001) as compared to IABP group. There was no difference between the groups in terms of mean length of stay or hospital charges. CONCLUSIONS: All-cause inpatient mortality was similar in AMICS+AF patients undergoing PCI who were treated with either pVAD or IABP. The pVAD group, however, experienced more complications while consuming greater healthcare resources.
Assuntos
Fibrilação Atrial/terapia , Coração Auxiliar/estatística & dados numéricos , Hemodinâmica , Balão Intra-Aórtico/estatística & dados numéricos , Infarto do Miocárdio/complicações , Choque Cardiogênico/terapia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/etiologia , Estados UnidosRESUMO
BACKGROUND: Intra-aortic balloon pumping (IABP) counterpulsation provides potent supports on hemodynamic status of patients with cardiogenic shock. However, only limited numbers of patients with acute heart failure (AHF) under collapsed hemodynamic status received such benefit of IABP. We aimed to evaluate the impact of the timing of IABP induction on clinical prognosis in AHF patients at very high risk. METHODS: Of 404 consecutive AHF patients, 57 patients both with left ventricular ejection fraction (LVEF) <35% and systolic blood pressure on admission <100 mmHg were ultimately enrolled in this observational study. They were divided into 3 groups depending on IABP use; Early-IABP group (induction at ≤3 days after admission, n = 17), Late-IABP group (>3 days, n = 15) and No-IABP group (n = 25). The primary endpoint was a composite of in-hospital cardiovascular (CV) death and ventricular assisted device implantation. RESULTS: This high-risk population was typically mid-age (60 years-old), 61% male, and 75% with chronic kidney disease, and its average LVEF was 24.7%. Clinical profiles on admission were comparable among 3 subgroups, except prehospital prescription rate of loop diuretics. During hospital stay, intravenous inotropes were significantly more frequently administered in the Late-IABP group than other 2 groups. The primary endpoint was developed in 17.6% of patients in the Early-IABP group, which was significantly lower than that in the Late-IABP group (53.3%, p = 0.034) and was comparable to the No-IABP group (40.0%, p = 0.12). CONCLUSIONS: Early induction of IABP is one of the therapeutic options for improvement of in-hospital prognosis in AHF patients at very high risk.
Assuntos
Insuficiência Cardíaca/terapia , Balão Intra-Aórtico/estatística & dados numéricos , Doença Aguda/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , PrognósticoRESUMO
BACKGROUND: A central element in the management of cardiogenic shock (CS) comprises mechanical circulatory support (MCS) systems to maintain cardiac output (CO). This study aims to quantify incidence, outcome and influence of MCS in CS over the last decade. METHODS: All patients hospitalized with CS in a tertiary university hospital in Germany between 2007 and 2017 were identified utilizing the international coding system ICD-10 with code R57.0. Application of MCS was identified via German procedure classification codes (OPS). RESULTS: 383,983 cases of cardiogenic shock were reported from 2007 to 2017. Patients had a mean age of 71 years and 38.5% were female. The incidence of CS rose by 65.6% from 26,828 cases in 2007 (33.1 per 100,000 person-years, hospital survival 39.2%) to 44,425 cases in 2017 (53.7 per 100,000 person-years, survival 41.2%). In 2007, 16.0% of patients with CS received MCS (4.6 per 100,000 person-years, survival 46.6%), dropping to 13.9% in 2017 (6.6 per 100,000 person-years, survival 38.6%). Type of MCS changed over the years, with decreasing use of the intra-aortic balloon pump (IABP), an increase in extracorporeal membrane oxygenation (VA-ECMO) and percutaneous ventricular assist device (pVAD) usage. Significant differences regarding in-hospital survival were observed between the devices (survival: overall: 40.2%; medical treatment = 39.5%; IABP = 49.5%; pVAD = 36.2%; VA-ECMO = 30.5%; p < 0.001). CONCLUSIONS: The incidence of CS is increasing, but hospital survival remains low. MCS was used in a minority of patients, and the percentage of MCS usage in CS has decreased. The use rates of the competing devices change over time.
Assuntos
Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Coração Auxiliar/estatística & dados numéricos , Balão Intra-Aórtico/estatística & dados numéricos , Choque Cardiogênico/terapia , Idoso , Oxigenação por Membrana Extracorpórea/tendências , Feminino , Alemanha , Coração Auxiliar/tendências , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Incidência , Balão Intra-Aórtico/tendências , Masculino , Sistema de Registros , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Fatores de TempoRESUMO
Bleeding after acute myocardial infarction (AMI) is associated with an increased morbidity and mortality. The frequency and consequences of bleeding events in patients with AMICS are not well described. The objective was to investigate incidence and outcome of bleeding complications among unselected patients with AMI complicated by cardiogenic shock (AMICS) and referred for immediate revascularization. Bleeding events were assessed by review of medical records in consecutive AMICS patients admitted between 2010 and 2017. Bleedings during admission were classified according to Bleeding Academic Research Consortium classification. Patients who did not survive to admission in the intensive care unit were excluded. Of the 1,716 patients admitted with AMICS, 1,532 patients (89%) survived to ICU admission. At 30 days, mortality was 48%. Severe bleedings classified as BARC 3/5 were seen in 87 non-coronary bypass grafting patients (6.1%). Co-morbidity did not differ among patients; however, patients who had a BARC 3/5 bleeding had significantly higher lactate and lower systolic blood pressure at admission, indicating a more severe state of shock. The use of mechanical assist devices was significantly associated with severe bleeding events. Univariable analysis showed that patients with a BARC 3/5 bleeding had a significantly higher 30-day mortality hazard compared with patients without severe bleedings. The association did not sustain after multivariable adjustment (hazard ratio 0.90, 95% confidence interval 0.64; 1.26, pâ¯=â¯0.52). In conclusion, severe bleeding events according to BARC classification in an all-comer population of patients with AMICS were not associated with higher mortality when adjusting for immediate management, hemodynamic, and metabolic state. This indicates that mortality in these patients is primarily related to other factors.
Assuntos
Hemorragia/epidemiologia , Infarto do Miocárdio/terapia , Choque Cardiogênico/terapia , Injúria Renal Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Oxigenação por Membrana Extracorpórea , Feminino , Coração Auxiliar/estatística & dados numéricos , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva , Balão Intra-Aórtico/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Intervenção Coronária Percutânea , Modelos de Riscos Proporcionais , Fatores de Risco , Choque Cardiogênico/etiologiaRESUMO
BACKGROUND: Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown. METHODS: Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year. RESULTS: Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR]â¯=â¯0.76, P < .001), Black patients compared to white ones (aORâ¯=â¯0.73, P < .001), those insured by Medicare (aORâ¯=â¯0.75, P < .001), Medicaid (aORâ¯=â¯0.74, P < .001), or uninsured (aORâ¯=â¯0.90, Pâ¯=â¯.015) compared to privately insured, and those in the lowest income neighborhoods (aORâ¯=â¯0.94, Pâ¯=â¯.003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation. CONCLUSIONS: There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.