Association of Hospital Procedural Volume With Outcomes of Left Ventricular Assist Device Placement.

BACKGROUND: With the advancement in device technology, the use of durable left ventricular assist devices (LVADs) has increased significantly in recent years. However, there is a dearth of evidence to conclude whether patients who undergo LVAD implantation at high-volume centers have better clinical outcomes than those receiving care at low- or medium-volume centers. METHODS: We analyzed the hospitalizations using the Nationwide Readmission Database for the year 2019 for new LVAD implantation. Baseline comorbidities and hospital characteristics were compared among low- (1-5 procedures/year), medium- (6-16 procedures/year) and high-volume (17-72 procedures/year) hospitals. The volume/outcome relationship was analyzed using the annualized hospital volume as a categorical variable (tertiles) as well as a continuous variable. Multilevel mixed-effect logistic regression and negative binomial regression models were used to determine the association of hospital volume and outcomes, with tertile 1 (low-volume hospitals) as the reference category. RESULTS: A total of 1533 new LVAD procedures were included in the analysis. The inpatient mortality rate was lower in the high-volume centers compared with the low-volume centers (9.04% vs 18.49%, aOR 0.41, CI0.21-0.80; P = 0.009). There was a trend toward lower mortality rates in medium-volume centers compared with low-volume centers; however, it did not reach statistical significance (13.27% vs 18.49%, aOR 0.57, CI0.27-1.23; P = 0.153). Similar results were seen for major adverse events (composite of stroke/transient ischemic attack and in-hospital mortality). There was no significant difference in bleeding/transfusion, acute kidney injury, vascular complications, pericardial effusion/hemopericardium/tamponade, length of stay, cost, or 30-day readmission rates between medium- and high-volume centers compared to low-volume centers. CONCLUSION: Our findings indicate lower inpatient mortality rates in high-volume LVAD implantation centers and a trend toward lower mortality rates in medium-volume LVAD implantation centers compared to lower-volume centers.

Endovascular Transcatheter Aortic Valve Replacement Outcomes in Hypertrophic Cardiomyopathy: Insights from the National Inpatient Sample (2014-2018).

BACKGROUND: Outcomes of patients with hypertrophic cardiomyopathy (HCM) following transcatheter aortic valve replacement (TAVR) remain largely unknown. OBJECTIVES: This study sought to assess the clinical characteristics and outcomes of HCM patients following TAVR. METHODS: We queried the National Inpatient Sample from 2014 to 2018 for TAVR hospitalizations with and without HCM, creating a propensity-matched cohort to compare outcomes. RESULTS: 207,880 patients that underwent TAVR during the study period, 810 (0.38%) had coexisting HCM. In the unmatched population, TAVR patients with HCM compared to those without HCM, were more likely to be female, had a higher prevalence of heart failure, obesity, cancer, and history of pacemaker/implantable cardioverter defibrillation, and were more likely to have nonelective and weekend admissions (p for all <0.05). TAVR patients without HCM had higher prevalence of coronary artery disease, prior percutaneous coronary intervention, prior coronary artery bypass grafting, and peripheral arterial disease compared to their counterparts (p for all <0.05). In the propensity-matched cohort, TAVR patients with HCM had significantly higher incidence of in-hospital mortality, acute kidney injury/hemodialysis, bleeding complications, vascular complications, permanent pacemaker requirement, aortic dissection, cardiogenic shock, and mechanical ventilation requirement. CONCLUSION: Endovascular TAVR in HCM patients is associated with an increased incidence of in-hospital mortality and procedural complications.

Association of hospital procedural volume with incidence and outcomes of surgical bailout in patients undergoing transcatheter aortic valve replacement.

OBJECTIVES: This study sought to examine the association of hospital procedural volume with the incidence and outcomes of surgical bailout (SB) in patients who undergo transcatheter aortic valve replacement (TAVR). BACKGROUND: SB is required for serious complications during or after TAVR. It remains unclear whether hospital experiences affect the incidence and outcomes of SB. METHODS: We retrospectively identified patients who underwent endovascular TAVR using the Nationwide Readmissions Database 2012-2017. We examined the association of annual hospital procedural volume (annual number of endovascular TAVR cases in each hospital in each year) with the incidence and in-hospital mortality of SB using multivariable logistic regressions and restricted cubic splines. RESULTS: Among 82,764 eligible patients, the incidence of SB was 0.95% (n = 789) and decreased from 2012 to 2017 (from 2.66% to 0.49%; Ptrend < 0.001), while in-hospital mortality of SB remained high over years (from 26.0% to 23.5%; Ptrend  = 0.773). Very-high-volume hospitals (≥200 cases/year), as compared with low-volume hospitals (≤49 cases/year), showed significantly a lower incidence of SB (0.49% vs. 1.81%; adjusted OR = 0.28, 95% CI = 0.21-0.38), but similar in-hospital mortality of SB (26.2% vs. 25.6%; adjusted OR = 0.88, 95% CI = 0.47-1.66). There was a significant nonlinear, inverse association of hospital volume with the incidence of SB, but not with the in-hospital mortality of SB. CONCLUSIONS: Hospitals with higher TAVR volumes have a lower risk of SB, but the in-hospital mortality after SB does not change with hospital TAVR volume. Our findings highlight the importance that physicians should always be aware of the high mortality risk of SB following TAVR regardless of hospital procedural experiences.

Incidence, treatment, and outcomes of acute myocardial infarction following transcatheter or surgical aortic valve replacement.

OBJECTIVES: This study aimed to evaluate the incidence, treatment, and outcomes of acute myocardial infarction (AMI) following transcatheter or surgical aortic valve replacement (TAVR or SAVR). BACKGROUND: Coronary artery disease is common in patients who undergo aortic valve replacement. However, little is known about differences in clinical features of post-TAVR or post-SAVR AMI. METHODS: We retrospectively identified post-TAVR or post-SAVR (including isolated and complex SAVR) patients admitted with AMI using the Nationwide Readmissions Database 2012-2017. Incidence, invasive strategy (coronary angiography or revascularization), and in-hospital outcomes were compared between post-TAVR and post-SAVR AMIs. RESULTS: The incidence of 180-day AMI was higher post-TAVR than post-SAVR (1.59% vs. 0.72%; p < 0.001). Post-TAVR AMI patients (n = 1315), compared with post-SAVR AMI patients (n = 1344), were older, had more comorbidities and more frequent non-ST-elevation AMI (NSTEMI: 86.6% vs. 78.0%; p < 0.001). After propensity-score matching, there was no significant difference in in-hospital mortality between post-TAVR and post-SAVR AMIs (14.7% vs. 16.1%; p = 0.531), but the mortality was high in both groups, particularly in ST-elevation AMI (STEMI: 38.8% vs. 29.2%; p = 0.153). Invasive strategy was used less frequently for post-TAVR AMI than post-SAVR AMI (25.6% vs. 38.3%; p < 0.001). Invasive strategy was associated with lower mortality in both post-TAVR (adjusted odds ratio = 0.40; 95% confidence interval = [0.24-0.66]) and post-SAVR groups (0.60 [0.41-0.88]). CONCLUSIONS: AMI, albeit uncommon, was more frequent post-TAVR than post-SAVR. Patients commonly presented with NSTEMI, but the mortality of STEMI was markedly high. Further studies are needed to understand why a substantial percentage of patients do not receive invasive coronary treatment, particularly after TAVR, despite seemingly better outcomes with invasive strategy.

Association of acute kidney injury with outcomes in patients undergoing percutaneous left atrial appendage closure.

OBJECTIVES: Using a large nationally representative database, we aimed to examine risk factors for acute kidney injury (AKI) and its association with outcomes in patients undergoing percutaneous left atrial appendage closure (LAAC). BACKGROUND: Previous small-scale studies have reported poor outcomes with AKI following percutaneous LAAC. METHODS: We queried the Nationwide Readmission Database to identify LAAC procedures performed from 2016 to 2017. Multivariable logistic and linear regression models were used to identify risk factors for AKI and determine the association between AKI and clinical outcomes. The primary outcome of interest was in-hospital mortality. RESULTS: Of 20,703 patients who underwent LAAC during the study period, 1,097 (5.3%) had a diagnosis of AKI. Chronic kidney disease, non-elective admission, coagulopathy, weight loss, prior coronary artery disease, heart failure, diabetes mellitus, and anemia were independently associated with an increased risk of AKI after LACC. In patients undergoing LAAC, AKI was associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR], 16.01; 95% CI, 8.48-30.21), stroke/transient ischemic attack (aOR, 2.50; 95% CI, 1.69-3.70), systemic embolization (aOR, 3.78; 95% CI, 1.64-8.70), bleeding/transfusion (aOR, 1.96; 95% CI, 1.50-2.56), vascular complications (aOR, 3.53; 95% CI, 1.94-6.42), pericardial tamponade requiring intervention (aOR, 6.83; 95% CI, 4.37-10.66), index length of stay (adjusted parameter estimate, 7.46; 95% CI, 7.02-7.92), and 180-day all-cause readmissions (aOR, 1.43; 95% CI, 1.09-1.88). CONCLUSION: AKI in the setting of LAAC is uncommon but is associated with poor clinical outcomes. Further studies are needed to determine if a similar association exists for long-term outcomes.

Impact of thoracic aortic aneurysm on outcomes of transcatheter aortic valve replacement: A nationwide cohort analysis.

BACKGROUND: The use of transcatheter aortic valve replacement (TAVR) has expanded to patient populations of varying surgical risk in light of recent clinical trials, yet its role in patients with aortic stenosis and coexisting thoracic aortic aneurysm (TAA) is not well-delineated. We aimed to evaluate whether risk factors and in-hospital outcomes vary between TAVR patients with and without an unruptured TAA. METHODS: The Nationwide Readmissions Database was queried for patients hospitalized between January 2012 and December 2017 who underwent TAVR with and without an unruptured TAA. In-hospital outcomes were compared between cohorts after adjusting for sex, comorbidities, and TAVR approach, and in a subgroup analysis that excluded those with bicuspid aortic valves. RESULTS: Among 171,011 TAVR patients, 1,677 (1%) presented with TAA. Patients with TAA were younger (median age 80 vs. 82 years, p < .001) and more likely to have bicuspid aortic valves (9.3% vs. 0.9%, p < .001). Among patients with aneurysm, 2.6% died, 2.2% developed stroke, 1% developed aortic dissection, and 1.4% experienced cardiac tamponade while hospitalized. After adjusting for age, sex, bicuspid aortic valve, and all comorbidities, TAA was associated with significantly higher risk of post-TAVR aortic dissection (OR = 2.117, 95% CI [1.304-3.435], p = .002) and cardiac tamponade (OR = 1.682, 95% CI [1.1-2.572], p = .02). CONCLUSIONS: While the overall incidence of post-TAVR complications is low, patients with an unruptured TAA should be carefully considered by the Heart Team in weighing the additional risks of aortic dissection and cardiac tamponade after TAVR with those associated with surgery.

Incidence and short-term outcomes of surgical bailout after transcatheter mitral valve repair with the MitraClip system.

OBJECTIVES: This study sought to investigate the incidence and outcomes of surgical bailout (SB) after transcatheter mitral valve repair (TMVr) with MitraClip. BACKGROUND: TMVr poses a risk of serious procedural complications, possibly requiring urgent open surgery for SB. However, little is known about the risk of SB cases after TMVr. METHODS: We retrospectively identified patients who underwent TMVr using the Nationwide Readmissions Database 2014-2017. SB was defined as open thoracotomy for heart and aorta during the same hospitalization. Annual hospital volume was defined as the annual number of TMVr cases in each hospital in each year. RESULTS: Among 15,032 eligible patients, SB was required in 214 (1.42%), of whom 134 (62.6%) underwent mitral valve surgery (113 replacements; 21 repairs). The incidence of SB was decreasing significantly over the 4 years (5.26% in 2014; 0.43% in 2017; ptrend < .001). There was a significant nonlinear, inverse association of annual hospital volume with the incidence of SB. In-hospital death (15.0 vs. 2.1%; p < .001) and other in-hospital adverse events were significantly more frequent in patients with than without SB, whereas the 30-day readmission rate was similar (13.2 vs. 15.1%; p = .572). After adjustment for patient and hospital characteristics, SB was significantly associated with higher in-hospital mortality (odds ratio = 6.67, 95% confidence interval = 4.35, 10.23, p < .001). CONCLUSIONS: This study suggests that although the incidence of SB after TMVr is decreasing, SB is required more frequently in lower-volume hospitals and carries high in-hospital mortality. Further efforts are needed to understand the reasons for SB and improve outcomes in patients needing SB.

Association of baseline kidney disease with outcomes of transcatheter mitral valve repair by MitraClip.

OBJECTIVES: This study sought to determine the impact of baseline chronic kidney disease (CKD) on in-hospital outcomes of transcatheter mitral valve repair with MitraClip (MC). BACKGROUND: MC is now an established treatment in high surgical risk patients. However, limited data are available on outcomes of MC in patients with baseline renal dysfunction. METHODS: The authors used data from January 2014 to December 2017 National Readmission Database to identify all patients ≥18 years of age who underwent MC. International classification of diseases (ICD)-9 and ICD-10 codes were used to identify patients with no-CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes. RESULTS: Of 13,563 patients undergoing MC, 8,935 (65.8%) had no-CKD, 4,152 (30.6%) had CKD, and 476 (3.5%) had ESRD. ESRD patients compared to CKD and no-CKD had significantly higher mortality (7.2% vs. 2.5% vs. 2.0%; p < .001), higher incidence of bleeding, blood transfusions, and 30 day all cause readmission. CKD patients compared to no-CKD had significantly higher mortality (odds ratio-1.29; CI 1.01-1.65; p = .04), acute kidney injury (odds ratio-3.0; CI 2.69-3.34; p < .001), new in-hospital hemodialysis (odds ratio- 2.70; CI 1.57-4.62; p < .001), blood transfusions, 30 day all cause and congestive heart failure (CHF) readmissions. In-hospital stroke and cardiac tamponade did not differ between the three groups. Patients with baseline kidney disease undergoing MC had higher mortality at high volume centers compared to low volume centers. CHF was the most common cause of readmission postMC in patients with or without preprocedural kidney disease. CONCLUSION: Patients with baseline kidney disease have worse outcomes after MC with higher readmission rates requiring careful patient selection and follow up in this population.

Association of Acute Kidney Injury with Outcomes in Patients Undergoing Transcatheter Mitral Valve Repair.

INTRODUCTION: Although transcatheter mitral valve repair (TMVr) is a contrast-free procedure, prior single-center studies have demonstrated a high incidence of acute kidney injury (AKI) following TMVr. The main objective of this study was to examine risk factors for AKI, and its association with outcomes in patients undergoing TMVr. METHODS: We queried the National Readmission Database to identify TMVr procedures performed between January 2014 and December 2017. Complex samples multivariable logistic and linear regression models were used to identify risk factors associated with AKI, as well as to determine the association between AKI and clinical outcomes (in-hospital mortality, index length of stay (LOS), 30-day all-cause readmissions, and 30-day heart failure [HF] readmissions). RESULTS: Of 14,623 patients who underwent TMVr during the study period, 2,001 (13.6%) had a diagnosis of AKI. HF, chronic kidney disease, chronic liver disease, fluid/electrolyte disorder, weight loss, nonelective admission, cardiogenic shock, and bleeding/transfusion were independently associated with an increased risk of AKI. In patients undergoing TMVr, AKI was associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR], 4.94; 95% confidence interval [CI], 2.92-8.34), 30-day all-cause readmissions (aOR, 1.91; 95% CI, 1.49-2.46), 30-day HF readmissions (aOR, 2.30; 95% CI, 1.38-3.84), and longer index LOS (adjusted parameter estimate, 5.78; 95% CI, 5.26-6.41). CONCLUSION: AKI in the setting of TMVr is common and is associated with worse clinical outcomes. Further studies are needed to determine if optimizing renal function prior to TMVr may improve outcomes, as well as to understand the impact of TMVr itself on renal function.

Prevalence and emerging resistance of Moraxella catarrhalis in lower respiratory tract infections in Karachi.

OBJECTIVE: To determine the prevalence of Moraxella catarrhalis in sputum cultures from patients with lower respiratory tract infection and their antimicrobial sensitivity profiles. METHODS: The study comprised sputum specimens of 776 patients at various branches of Dr Essa's Diagnostic Lab, Karachi. The specimens were cultured on blood, chocolate, and eosin methylene blue agars between October 2010 and October 2011. The isolates were identified by conventional methods and anti-biograms were determined by the Kirby-Bauer Agar Disc Diffusion Method. RESULTS: Moraxella catarrhalis was isolated from 39 (5.02%) sputa of which 18 (46.15%) belonged to males. The bimodal age prevalence was 238 (30.7%) in age group 20-29 years, and 180 (23.1%) in 70 years and above. Amoxicillin/clavulanate, cefotaxime, and ceftriaxone were most effective (100%). Very high resistance was seen with amikacin (92.3%), cefixime (92.3%), fosfomycin (84.6%), cefuroxime (84.6%), erythromycin and amoxicillin (76.9%), cotrimoxazole (90%) and doxycycline (76.9%). CONCLUSIONS: The incidence of Moraxella catarrhalis in sputum encourages routine culture and sensitivity of sputa from patients suffering from lower respiratory tract infection, especially the elderly and immunocompromised, for tailored drug prescription.

Transcatheter Versus Surgical Aortic Valve Replacement in Hypertrophic Cardiomyopathy Patients with Aortic Stenosis.

Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are well established treatment options for severe aortic stenosis (AS). However, patients with hypertrophic cardiomyopathy (HCM) were excluded from pivotal randomized controlled trials of TAVR vs SAVR. We queried the 2016 to 2019 National Inpatient Sample to identify adult hospitalizations with HCM who underwent SAVR or TAVR for severe AS. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac arrest, new permanent pacemaker (PPM), cardiac tamponade, bleeding requiring transfusion, stroke/transient ischemic attack, acute kidney injury (AKI), and resource utilization (length of stay [LOS], hospital costs, and discharge to facility). Of 1245 HCM hospitalizations with severe AS, 595(47.8%) underwent TAVR and 650 (52.2%) underwent SAVR. In-hospital mortality rate was lower in the TAVR group. Cardiac arrest, cardiogenic shock, pressor use, new PPM, and cardiac tamponade were not significantly different between the 2 groups. When compared to SAVR, TAVR was associated with lower rates of bleeding requiring transfusion, vascular complications, AKI, and invasive mechanical ventilation. Furthermore, TAVR was associated with a shorter hospital stay, fewer facility discharges, but comparable hospital costs. Our findings indicate that TAVR is associated with lower risk of in-hospital mortality, certain peri-procedural complications, shorter hospital stay, and fewer facility discharges in HCM patients with isolated AS compared to SAVR. Further studies are needed to assess the mid- and long-term outcomes of TAVR vs SAVR in HCM patients with AS.

Derivation and Validation of Risk Prediction Model for 30-Day Readmissions Following Transcatheter Mitral Valve Repair.

Transcatheter mitral valve repair (TMVr) has shown to reduce heart failure (HF) rehospitalization and all cause mortality. However, the 30-day all-cause readmission remains high (∼15%) after TMVr. Therefore, we sought to develop and validate a 30-day readmission risk calculator for TMVr. Nationwide Readmission Database from January 2014 to December 2017 was utilized. A linear calculator was developed to determine the probability for 30-day readmission. Internal calibration with bootstrapped calculations was conducted to assess model accuracy. The root mean square error and mean absolute error were calculated to determine model performance. Of 8339 patients who underwent TMVr, 1246 (14.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: Heart failure, Atrial Fibrillation, Anemia, length of stay ≥4 days, Acute kidney injury (AKI), and Non-Home discharge, Non-Elective admission and Bleeding/Transfusion. The c-statistic of the prediction model was 0.63. The validation c-statistic for readmission risk tool was 0.628. On internal calibration, our tool was extremely accurate in predicting readmissions up to 20%. A simple and easy to use risk prediction tool identifies TMVr patients at increased risk of 30-day readmissions. The tool can guide in optimal discharge planning and reduce resource utilization.

Home Health Care Utilization Trend, Predictors, and Association With Early Rehospitalization Following Endovascular Transcatheter Aortic Valve Replacement.

BACKGROUND/PURPOSE: Home healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS: We queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes. RESULTS: Of 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29-1.40), non-elective admission (OR, 1.49; 95% CI, 1.42-1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05-1.13), prior stroke (OR, 1.06; 95% CI, 1.01-1.12), anemia (OR, 1.16; 95% CI, 1.11-1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16-1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00-1.50), stroke (OR, 2.62; 95% CI, 2.20-3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41-1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC. CONCLUSIONS: Our study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.

Transfusion strategies in patients with acute coronary syndrome and anemia: a meta-analysis.

BACKGROUND: Anemia is a known risk factor for ischemic heart disease and serves as an independent predictor of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). This meta-analysis pools data from randomized controlled trials (RCTs) to better define hemoglobin (Hb) thresholds for transfusion in this setting. RESULTS: MEDLINE, EMBASE, and Cochrane databases were searched using the terms "Acute Coronary Syndrome" AND "Blood Transfusion" including their synonyms. A total of three randomized controlled trials were included. Restrictive transfusion strategy (RTS) was defined as transfusing for Hb ≤ 8 g/dl with a post-transfusion goal of 8 to 10 g/dl. Liberal transfusion strategy (LTS) was defined as Hb ≤ 10 g/dl and post-transfusion goal of at least 11 g/dl. The primary end point was 30-day mortality. Secondary outcomes included recurrent ACS events, new or worsening CHF within 30 days, and major adverse cardiac events (MACE). The primary analytic method used was random effects model. Out of 821 patients, 400 were randomized to LTS, and 421 to RTS. Mean age was 70.3 years in RTS versus 76.4 in LTS. There was no statistically significant difference for 30-day mortality in LTS compared to RTS [odds ratio (OR) 1.69; 95% CI 0.35 to 8.05]. Similarly, there was no difference in MACE (OR 0.74; 95% CI 0.21 to 2.63), CHF (OR 0.82; 95% CI 0.18 to 3.76), or the incidence of recurrent ACS (OR 1.21; 95% CI 0.49 to 2.95). CONCLUSIONS: In the setting of ACS, there is no difference between LTS and RTS for the outcomes of mortality, MACE, recurrent ACS, or CHF at 30 days. Further evidence in the form of high-quality RCTs are needed to compare RTS and LTS.

Therapeutic Hypothermia Is Associated With a Decrease in All-cause Mortality in Cardiac Arrest Due to Shockable Rhythm.

BACKGROUND: The benefits of therapeutic hypothermia (TH) in comatose patients postcardiac arrest remain uncertain. While some studies have shown benefit, others have shown equivocal results. We pooled data from randomized controlled trials to better study the outcomes of TH. METHODS: Electronic research databases were queried up till September 21, 2021. Randomized controlled trials comparing TH (32-34 °C) with control (normothermia or temperature ≥36 °C) in comatose postcardiac arrest patients were included. RESULTS: The study included 10 randomized controlled trials with 3988 subjects (1999 in the TH arm and 1989 in the control arm). There was no difference in all-cause mortality between TH and control (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.66-1.05; P = 0.08; I2 = 41%). There was no difference in the odds of poor neurological outcomes (OR, 0.78; 95% CI, 0.61-1.01; P = 0.07; I2 = 43%). Subgroup analysis showed a decrease in all-cause mortality and poor neurological outcomes with TH in shockable rhythms (OR, 0.55; 95% CI, 0.37-0.80; P = 1.00; I2 = 0% and OR, 0.48; 95% CI, 0.32-0.72; P = 0.92; I2 = 0%, respectively). CONCLUSIONS: TH may be beneficial in reducing mortality and poor neurological outcomes in comatose postcardiac arrest patients with shockable rhythms.

Outcomes of Patients With Type 2 Myocardial Infarction Complicating Acute Ischemic Stroke.

OBJECTIVE: To study the patient profiles and the prognostic impact of type 2 myocardial infarction (MI) on outcomes of acute ischemic stroke (AIS). METHODS: The National Readmission Database 2018 was queried for patients with primary AIS hospitalizations with and without type 2 MI. Baseline characteristics, inpatient outcomes, and 30-day all-cause readmissions between cohorts were compared. RESULTS: Of 587,550 AIS hospitalizations included in the study, 4182 (0.71%) had type 2 MI. Patients with type 2 MI were older (73.6 years vs 70.1 years; P<.001) and more likely to be female (52% vs 49.7%; P<.001), and they had a higher prevalence of heart failure (32.6% vs 15.5%; P<.001), atrial fibrillation (38.5% vs 24.2%; P<.001), prior MI (8.8% vs 7.7%; P<.001), valvular heart disease (17% vs 9.8%; P<.001), peripheral vascular disease (12.2% vs 9.2%; P<.001), and chronic kidney disease (24.4% vs 16.7%; P<.001). Compared with patients without type 2 MI, AIS patients with type 2 MI had significantly higher in-hospital mortality (adjusted odds ratio [aOR], 1.96; 95% CI, 1.65 to 2.32), poor functional outcome (aOR, 1.80; 95% CI, 1.62 to 2.00), more hospital costs (adjusted parameter estimate, $5618; 95% CI, $4480 to $6755), higher rate of discharge to a facility (aOR, 1.70; 95% CI, 1.52 to 1.90), increased length of stay (adjusted parameter estimate, 2.22; 95% CI, 1.72 to 2.72), and higher rate of 30-day all-cause readmissions (aOR, 1.38; 95% CI, 1.18 to 1.60). CONCLUSION: Type 2 MI in patients hospitalized with AIS is associated with poor prognosis and higher resource utilization.

Factors Associated With Revascularization in Women With Spontaneous Coronary Artery Dissection and Acute Myocardial Infarction.

In contrast to atherosclerotic acute myocardial infarction (AMI), conservative therapy is considered preferable in the acute management of spontaneous coronary artery dissection (SCAD) if clinically possible. The present study aimed to investigate factors associated with treatment strategy for SCAD. Women aged ≤60 years with AMI and SCAD were retrospectively identified in the Nationwide Readmissions Database 2010 to 2015 and were divided into revascularization and conservative therapy groups. The revascularization group (n = 1,273, 68.0%), compared with the conservative therapy group (n = 600, 32.0%), had ST-elevation AMI (STEMI) (anterior STEMI, 20.3% vs 10.5%; inferior STEMI, 25.1% vs 14.5%; p <0.001) and cardiogenic shock (10.8% vs 1.8%; p <0.001) more frequently. Multivariable logistic regression analysis demonstrated that anterior STEMI (vs non-STEMI, odds ratio 2.89 [95% confidence interval 2.08 to 4.00]), inferior STEMI (2.44 [1.85 to 3.21]), and cardiogenic shock (5.13 [2.68 to 9.80]) were strongly associated with revascularization. Other factors associated with revascularization were diabetes mellitus, dyslipidemia, smoking, renal failure, and pregnancy/delivery-related conditions; whereas known fibromuscular dysplasia and admission to teaching hospitals were associated with conservative therapy. Propensity-score matched analyses (546 pairs) found no significant difference in in-hospital death, 30-day readmission, and recurrent AMI between the groups. In conclusion, STEMI presentation, hemodynamic instability, co-morbidities, and setting of treating hospital may affect treatment strategy in women with AMI and SCAD. Further efforts are required to understand which patients benefit most from revascularization over conservative therapy in the setting of SCAD causing AMI.

Demographic and Regional Trends of Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019.

Acute myocardial infarction (AMI)-related mortality has been decreasing within the United States because of improvements in management and preventive efforts; however, persistent disparities in demographic subsets such as race may exist. In this study, the nationwide trends in mortality related to AMI in adults in the United States from 1999 to 2019 are described. Trends in mortality related to AMI were assessed through a cross-sectional analysis of the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100,000 people and associated annual percentage change and average annual percentage changes with 95% confidence intervals (CIs) were determined. Joinpoint regression was used to assess the trends in the overall, demographic (gender, race/ethnicity, age), and regional groups. Between 1999 and 2019, a total of 3,655,274 deaths related to AMI occurred. In the overall population, age-adjusted mortality rates decreased from 134.7 (95% CI 134.2 to 135.3) in 1999 to 48.5 (95% CI 48.3 to 48.8) in 2019 with an average annual percentage change of -5.0 (95% CI -5.5 to -4.6). Higher mortality rates were seen in Black individuals, men, and those living in the South. Patients older than 85 years experienced substantial decreases in mortality. In addition, rural counties had persistently higher mortality rates in comparison with urban counties. In conclusion, despite decreasing mortality rates in all groups, persistent disparities continued to exist throughout the study period.

Trends in Clinical Characteristics and Outcomes in ST-Elevation Myocardial Infarction Hospitalizations in the United States, 2002-2016.

ST-segment Elevation Myocardial Infarction (STEMI) remains a major modern-day public health problem. We aimed to assess the demographic trends in STEMI related hospitalizations in the United States over a period of fifteen years. The nationwide inpatient sample was queried to obtain information of patients hospitalized with STEMI from January 1, 2002, to December 31, 2016. Annual hospitalization rates were calculated and annual percentage change (APC) was evaluated using regression analysis. A total of 4,121,155 eligible patients were included in this analysis. Overall, the total number of STEMI hospitalization decreased from 421,043 in 2002 to 208,510 in 2016 (P-trend <0.01). With the decreasing trend, the rate was relatively higher among males as compared to females, whites as compared to non-whites, and lower as compared to high socioeconomic status (SES). The rate of PCI in STEMI patients increased from 32.8% in 2002 to 67.8% in 2016 (APC = 5.392%, 95% CI [4.384-6.411], P < 0.001), but was higher among males as compared to females, urban as compared to rural hospitals and higher as compared to lower SES. In-hospital mortality decreased from 11% in 2002 to 10.5% in 2016 (APC = -0.771%, 95% CI [-1.230 to -0.311], P = 0.003), but remained higher among females, rural hospitals and low SES as compared to their correspondent groups. Among STEMI patients, the prevalence of individual comorbidities was noted to be increasing over the study period. Although there has been a declining trend in the number of STEMI hospitalizations, patients with modifiable risk factors presenting with STEMI has been on the rise. Females, rural communities and lower SES groups need special attention because of greater vulnerability.