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INTRODUCTION: The real-world distribution of hospital atrial fibrillation (AF) ablation volume and its impact on outcomes are not well-established. We sought to examine patient characteristics, complications, and readmissions after AF ablation stratified by hospital procedural volume. METHODS AND RESULTS: Using the nationally representative inpatient Nationwide Readmissions Database, we evaluated 54 597 admissions for AF ablation between 2010 and 2014. Hospitals were categorized according to tertiles of annual AF ablation volume. Index complications, 30-day readmissions, and early mortality were examined. Multivariable logistic regression was performed to assess the predictors of adverse outcomes. Between 2010 and 2014, low volume tertile hospitals accounted for 79.3% of hospitals performing AF ablations. When stratified by first, second, and third volume tertiles, complication and early mortality rates were higher in low volume centers (8.9% and 0.67% vs 6.1% and 0.33%, vs 4.5% and 0.16%, respectively; P < .001). Patients undergoing AF ablation at low volume centers were older and had a higher prevalence of congestive heart failure, coronary artery disease, and other comorbidities. Low volume hospitals were associated with increased cardiac perforation (adjusted odds ratio [aOR], 4.79; P < .001), vascular complications (aOR 1.49; P < .001), and any complication (aOR 2.06; P < .001) during index admission as well as increased early mortality (aOR 2.43; P = .039). CONCLUSIONS: Among patients hospitalized for AF ablation, low inpatient AF ablation hospital volume was associated with worse outcomes following ablation, which was exacerbated by a greater comorbidity burden among patients at these centers.
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Fibrilação Atrial , Ablação por Cateter , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Hospitais com Baixo Volume de Atendimentos , Humanos , Pacientes Internados , Readmissão do PacienteRESUMO
AIMS: Although catheter ablation has emerged as an important therapy for patients with symptomatic atrial fibrillation (AF), there are limited data on sex-based differences in outcomes. We sought to compare in-hospital outcomes and 30-day readmissions of women and men undergoing AF ablation. METHODS AND RESULTS: Using the United States Nationwide Readmissions Database, we analysed patients undergoing AF ablation between 2010 and 2014. Based on ICD-9-CM codes, we identified co-morbidities and outcomes. Multivariable logistic regression and inverse probability-weighting analysis were performed to assess female sex as a predictor of endpoints. Of 54 597 study patients, 20 623 (37.7%) were female. After adjustment for age, co-morbidities, and hospital factors, women had higher rates of any complication [adjusted odds ratio (aOR) 1.39; P < 0.0001], cardiac perforation (aOR 1.39; P = 0.006), and bleeding/vascular complications (aOR 1.49; P < 0.0001). Thirty-day all-cause readmission rates were higher for women compared to men (13.4% vs. 9.4%; P < 0.0001). Female sex was independently associated with readmission for AF/atrial tachycardia (aOR 1.48; P < 0.0001), cardiac causes (aOR 1.40; P < 0.0001), and all causes (aOR 1.25; P < 0.0001). Similar findings were confirmed with inverse probability-weighting analysis. Despite increased complications and readmissions, total costs for AF ablation were lower for women than men due to decreased resource utilization. CONCLUSIONS: Independent of age, co-morbidities, and hospital factors, women have higher rates of complications and readmissions following AF ablation. Sex-based differences and disparities in the management of AF need to be explored to address these gaps in outcomes.
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Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/economia , Readmissão do Paciente/estatística & dados numéricos , Idoso , Fibrilação Atrial/epidemiologia , Bases de Dados Factuais , Feminino , Traumatismos Cardíacos/epidemiologia , Hemorragia/epidemiologia , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Distribuição por Sexo , Taquicardia/epidemiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Although much attention has been paid to admission and transfer patterns for cardiogenic shock, contemporary data are lacking on decompensated heart failure (HF) admissions and transfers and the impact of advanced therapy centers (ATCs) on outcomes. METHODS: HF hospitalizations were obtained from the Nationwide Readmissions Database 2016 to 2019. Centers performing at least 1 heart transplant or left ventricular assist device were classified as ATCs. Patient characteristics, outcomes, and procedural volume were compared among 3 cohorts: admissions to non-ATCs, admissions to ATCs, and transfers to ATCs. A secondary analysis evaluated outcomes for severe HF hospitalizations (cardiogenic shock, cardiac arrest, and mechanical ventilation). Multivariable logistic regression was performed to adjust for the presence of HF decompensations and significant clinical variables during univariate analysis. RESULTS: A total of 2â 331â 690 hospitalizations (81.2%) were admissions to non-ATCs (94.5% of centers), 525â 037 (18.3%) were admissions to ATCs (5.5% of centers), and 15â 541 (0.5%) were transferred to ATCs. Patients treated at ATCs (especially those transferred) had higher rates of HF decompensations, procedural frequency, lengths of stay, and costs. Unadjusted mortality was 2.6% at non-ATCs and was higher at ATCs, both for directly admitted (2.9%, P<0.001) and transferred (11.2%, P<0.001) patients. However, multivariable-adjusted mortality was significantly lower at ATCs, both for directly admitted (odds ratio, 0.82 [95% CI, 0.78-0.87]; P<0.001) and transferred (odds ratio, 0.66 [95% CI, 0.57-0.78]; P<0.001) patients. For severe HF admissions, unadjusted mortality was 37.2% at non-ATCs and was lower at ATCs, both for directly admitted (25.3%, P<0.001) and transferred (25.2%, P<0.001) patients, with similarly lower multivariable-adjusted mortality. CONCLUSIONS: Patients with HF treated at ATCs were sicker but associated with higher procedural volume and lower adjusted mortality.
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Parada Cardíaca , Insuficiência Cardíaca , Humanos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/complicações , Choque Cardiogênico/complicações , Hospitalização , Mortalidade HospitalarRESUMO
BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra-aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA-ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA-ECMO. METHODS AND RESULTS: Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA-ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P-trend<0.001). In-hospital mortality was higher with ECMO with Impella (54.8%) compared with ECMO only (50.4%) and ECMO with IABP (48.4%). After adjustment, ECMO with IABP versus ECMO only was associated with lower in-hospital mortality (adjusted odds ratio [aOR], 0.83; P=0.02). ECMO with Impella versus ECMO only had similar in-hospital mortality (aOR, 1.09; P=0.695) but was associated with more bleeding (aOR, 1.21; P=0.007) and more acute kidney injury requiring hemodialysis (aOR, 1.42; P<0.001). ECMO with Impella versus ECMO with IABP was associated with greater risk of acute kidney injury requiring hemodialysis (aOR, 1.49; P=0.002), higher in-hospital mortality (aOR, 1.32; P=0.001), and higher 40-day mortality (hazard ratio, 1.25; P<0.001). CONCLUSIONS: In patients with cardiogenic shock on VA-ECMO, LVU with Impella, particularly with 2.5/CP, was not associated with improved survival at 40 days but was associated with increased adverse events compared with IABP. More data are needed to assess Impella platform-specific comparative outcomes of LVU.
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Injúria Renal Aguda , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Humanos , Choque Cardiogênico , Balão Intra-Aórtico/efeitos adversos , Terapia Combinada , Injúria Renal Aguda/etiologia , Resultado do TratamentoRESUMO
Background: Previous studies have shown that women have worse outcomes for cardiogenic shock (CS) than men. Patients who receive care in CS "hubs" have also been shown to have improved outcomes when compared to those treated at "spokes." This study aimed to examine the presence of sex disparities in the outcomes of CS in relation to hospital type. Methods: Hospitalizations of adults with a diagnosis of CS were identified using data from the 2016-2019 Nationwide Readmissions Database. CS "hubs" were defined as any centers receiving at least 1 interhospital transfer with CS, while those without such transfers were classified as "spokes." Data were combined across years and multivariable logistic regression modeling was used to evaluate the association of sex with in-hospital mortality, invasive procedures, and transfer to hubs. Results: There were a total of 618,411 CS hospitalizations (62.2% men) with CS related to acute myocardial infarction comprising 15.3 to 17.3% of women hospitalizations and 17.8 to 20.3% of men hospitalizations. In-hospital mortality was lower at hubs (34.5% for direct admissions, 31.6% for transfers) than at spokes (40.3%, all P < .01). Women underwent fewer invasive procedures (right heart catheterization, percutaneous coronary intervention, mechanical circulatory support) and had higher mortality than men. Female sex was independently associated with decreased transfers to hubs (odds ratio, 0.93; 95% CI, 0.89-0.96) and increased mortality (odds ratio, 1.09; 95% CI, 1.05-1.12). Conclusions: Women with CS were less likely to be treated at a hub or transferred to a hub, had higher in-hospital mortality, and had a lower likelihood of receiving CS-related procedures than men. Further research is needed to understand sex-specific gaps in CS outcomes.
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BACKGROUND: Cardiac implantable electronic device (CIED)-associated infections are associated with substantial morbidity, mortality, and costs. Guidelines have cited endocarditis as a Class I indication for transvenous lead removal/extraction (TLE) among patients with CIEDs. OBJECTIVES: The authors sought to study utilization of TLE among hospital admissions with infective endocarditis using a nationally representative database. METHODS: Using the Nationwide Readmissions Database (NRD), 25,303 admissions for patients with CIEDs and endocarditis between 2016 and 2019 were evaluated on the basis of International Classification of Diseases-10th Revision, Clinical-Modification (ICD-10-CM) codes. RESULTS: Among admissions for patients with CIEDs and endocarditis, 11.5% were managed with TLE. The proportion undergoing TLE increased significantly from 2016 to 2019 (7.6% vs 14.9%; P trend < 0.001). Procedural complications were identified in 2.7%. Index mortality was significantly lower among patients managed with TLE (6.0% vs 9.5%; P < 0.001). Presence of Staphylococcus aureus infection, implantable cardioverter-defibrillator, and large hospital size were independently associated with TLE management. TLE management was less likely with older age, female sex, dementia, and kidney disease. After adjustment for comorbidities, TLE was independently associated with significantly lower odds of mortality (adjusted OR: 0.47; 95% CI: 0.37-0.60 by multivariable logistic regression, and adjusted OR: 0.51; 95% CI: 0.40-0.66 by propensity score matching). CONCLUSIONS: Utilization of lead extraction among patients with CIEDs and endocarditis is low, even in the presence of low rates of procedural complications. Lead extraction management is associated with significantly lower mortality, and its use has trended upward between 2016 and 2019. Barriers to TLE for patients with CIEDs and endocarditis require investigation.
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Desfibriladores Implantáveis , Endocardite Bacteriana , Endocardite , Cardiopatias , Marca-Passo Artificial , Humanos , Feminino , Remoção de Dispositivo/efeitos adversos , Endocardite/epidemiologia , Endocardite/cirurgia , Endocardite/etiologia , Desfibriladores Implantáveis/efeitos adversos , Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/cirurgia , Endocardite Bacteriana/complicações , Cardiopatias/complicações , Marca-Passo Artificial/efeitos adversos , Estudos RetrospectivosRESUMO
Background: There are limited data on the feasibility of Impella-assisted percutaneous coronary intervention (PCI) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Methods: To assess the feasibility of the Impella-assisted PCI in patients with severe symptomatic AS, we retrospectively reviewed the medical records to identify patients who were electively admitted for Impella-assisted PCI with a subsequent TAVR at Weill Cornell Medical Center from 2016 to 2021. Results: During the study period, 15 patients were identified to be eligible for the study, but the Impella failed to cross the aortic valve in 1 patient despite a concomitant balloon aortic valvuloplasty requiring a switch to an intra-aortic balloon pump to assist PCI. A total of 14 patients underwent successful PCI with the Impella CP and were included in the analysis. The median age was 89 years, and women accounted for 43% of the cohort. The median aortic valve area and mean gradient were 0.85 cm2 and 40 mm Hg, respectively, with a median left ventricular ejection fraction of 51%. The median SYNTAX score was 13. The left main stent was placed in 6 patients (43%), with a rotational atherectomy performed in 10 patients (71%). The balloon aortic valvuloplasty was performed in 2 patients before Impella placement. The TAVR was performed in all 14 patients on a median post-Impella-assisted PCI day of 25. No procedural complications were noted post-TAVR with no in-hospital or 30-day death. Conclusions: In this single-center study of patients with severe AS, the elective Impella-assisted high-risk PCI was feasible and safe before TAVR in selected patients.
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Objective: The proportion of ST-segment elevation myocardial infarction (STEMI) patients without standard modifiable risk factors (SMuRFs: hypertension, diabetes, hypercholesterolemia and smoking) has increased over time. The absence of SMuRFs is known to be associated with worse outcomes, but its association with age and sex is uncertain. We sought to evaluate the association between age and sex with the outcomes of post-STEMI patients without SMuRFs among patients without preexisting coronary artery disease. Methods: Patients who underwent primary PCI for STEMI were identified from the Nationwide Readmission Database of the United States. Clinical characteristics, in-hospital, and 30-day outcomes in patients with or without SMuRFs were compared in men versus women and stratified into five age groups. Results: Between January 2010 and November 2014, of 474,234 patients who underwent primary PCI for STEMI, 52,242 (11.0%) patients did not have SMuRFs. Patients without SMuRFs had higher in-hospital mortality rates than those with SMuRFs. Among those without SMuRFs, the in-hospital mortality rate was significantly higher in women than men (10.6% vs 7.3%, p<0.001), particularly in older age groups. The absence of SMuRFs was associated with higher 30-day readmission-related mortality rates (0.5% vs 0.3% with SMuRFs, p<0.001). Among patients without SMuRFs, women had a higher 30-day readmission-related mortality rates than men (0.6% vs 0.4%, p<0.001). After multivariable adjustment, the increased rates of in-hospital (odds ratio 1.89 (95% CI 1.72 to 2.07) and 30-day readmission-related mortality (hazard ratio 1.30 (95% CI 1.01 to 1.67)) in patients without SMuRFs remained significant. Conclusions: STEMI patients without SMuRFs have a significantly higher risk of in-hospital and 30-day mortality than those with SMuRFs. Women and older patients without SMuRFs experienced significantly higher in-hospital and 30-day readmission-related mortality.
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BACKGROUND: Clostridioides difficile (formerly known as Clostridium difficile) infection (CDI) is one of the most prevalent healthcare-associated infections in the United States (US). In the early 2000s, CDI emerged as a great threat with increasing prevalence, mortality, and severity, especially in advanced age. We investigated the US national trends in in-hospital CDI prevalence, mortality, severity, and age composition from 2003 to 2014. METHODS: We identified the patients with CDI using the national inpatient sample data from 2003 to 2014. We performed Poisson regression model and Kendall's tau-b correlation test for our analyses. RESULTS: Adjusted overall CDI prevalence did not significantly change during 2003-2014. In-hospital mortality of overall CDI did not significantly change during 2003-2008, then significantly decreased during 2008-2014. Severity of overall CDI significantly increased during 2003-2008, then decreased during 2008-2014. The proportions of patients with age ≥ 65 years decreased in CDI prevalence, mortality, and severity during 2003-2014. CONCLUSIONS: Compared to the earlier years 2003-2008, overall CDI outcome improved in the later years 2008-2014. Younger patients increasingly contributed to CDI prevalence, mortality, and severity during 2003-2014. More studies to understand underlying driving forces of changes in CDI trends are warranted to mitigate CDI.
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Clostridioides difficile , Idoso , Clostridioides , Bases de Dados Factuais , Humanos , Pacientes Internados , Prevalência , Estados Unidos/epidemiologiaRESUMO
Background There are limited data on the sex-based differences in the outcome of readmission after cardiac arrest. Methods and Results Using the Nationwide Readmissions Database, we analyzed patients hospitalized with cardiac arrest between 2010 and 2015. Based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified comorbidities, therapeutic interventions, and outcomes. Multivariable logistic regression was performed to assess the independent association between sex and outcomes. Of 835 894 patients, 44.4% (n=371 455) were women, of whom 80.7% presented with pulseless electrical activity (PEA)/asystole. Women primarily presented with PEA/asystole (80.7% versus 72.4%) and had a greater comorbidity burden than men, as assessed using the Elixhauser Comorbidity Score. Thirty-day readmission rates were higher in women than men in both PEA/asystole (20.8% versus 19.6%) and ventricular tachycardia/ventricular fibrillation arrests (19.4% versus 17.1%). Among ventricular tachycardia/ventricular fibrillation arrest survivors, women were more likely than men to be readmitted because of noncardiac causes, predominantly infectious, respiratory, and gastrointestinal illnesses. Among PEA/asystole survivors, women were at higher risk for all-cause (adjusted odds ratio [aOR], 1.07; [95% CI, 1.03-1.11]), cardiac-cause (aOR, 1.15; [95% CI, 1.06-1.25]), and noncardiac-cause (aOR, 1.13; [95% CI, 1.04-1.22]) readmission. During the index hospitalization, women were less likely than men to receive therapeutic procedures, including coronary angiography and targeted therapeutic management. While the crude case fatality rate was higher in women, in both ventricular tachycardia/ventricular fibrillation (51.8% versus 47.4%) and PEA/asystole (69.3% versus 68.5%) arrests, sex was not independently associated with increased crude case fatality after adjusting for differences in baseline characteristics. Conclusions Women are at increased risk of readmission following cardiac arrest, independent of comorbidities and therapeutic interventions.
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Parada Cardíaca , Taquicardia Ventricular , Arritmias Cardíacas/terapia , Bases de Dados Factuais , Feminino , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Humanos , Masculino , Readmissão do Paciente , Fibrilação VentricularRESUMO
BACKGROUND: Pseudo-Wellens syndrome is a rare entity characterized by the presence of electrocardiogram (ECG) changes of Wellens syndrome but without the stenosis of the left anterior descending (LAD) coronary artery. In previous reports, pseudo-Wellens syndrome most commonly resulted from recreational drug use or unidentified etiologies. We present a unique case of pseudo-Wellens syndrome due to sepsis-induced cardiomyopathy and a review of the literature. CASE PRESENTATION: A 62-year-old Caucasian woman was admitted for sepsis from left foot cellulitis. Laboratory data were notable for elevated lactate of 2.5 mmol/L and evidence of acute kidney injury. She developed chest pain on the third day of hospitalization. ECG showed symmetric T-wave inversion in leads V1-V4. Serial troponin I levels were within normal limits. Chest imaging showed no pulmonary embolism. Echocardiogram showed ejection fraction of 25%, left ventricular diastolic diameter of 4.6 cm, and multiple segmental wall motion abnormalities. Cardiac catheterization showed patent coronary arteries. The hospital course was complicated by transient sinus bradycardia and hypotension. She was hospitalized for a total of 17 days. ECG prior to discharge showed resolution of T-wave changes. CONCLUSION: Pseudo-Wellens syndrome may result from myocardial ischemia due to vasospasm or myocardial edema from external insults. In our case, we suspect sepsis-related cytokine production resulting in cardiomyopathy and pseudo-Wellens syndrome. The clinical manifestations were indistinguishable between Wellens and pseudo-Wellens syndrome. Physicians should include the diagnosis of pseudo-Wellens syndrome when considering the presence of LAD coronary artery occlusion given risk stratifications.
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Cardiomiopatias , Sepse , Cardiomiopatias/diagnóstico , Cardiomiopatias/etiologia , Dor no Peito , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Sepse/complicações , SíndromeRESUMO
INTRODUCTION: Poor sleep is a pervasive problem for hospitalized patients and can contribute to adverse health outcomes. METHODS: We aimed to improve self-reported sleep for patients on a general medicine ward as measured by the Richards-Campbell Sleep Questionnaire (RCSQ) as well as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question addressing quietness at night. We utilized a non-pharmacologic sleep hygiene bundle composed of a short script with sleep hygiene prompts, such as whether patients would like the shades closed or the lights turned off, as well as a sleep package including an eye mask, earplugs, lavender scent pad, and non-caffeinated tea. Relaxing music was played at bedtime and signs promoting the importance of quietness at night were placed around the unit. Front-line champions were identified to aid with implementation. RESULTS: A total of 931 patients received the intervention. In a sample of surveyed patients, we observed an increase in the RCSQ global score from 6.0 (IQR 3.0-7.0) to 6.2 (IQR 4.0-7.8) from the pre- to post- intervention periods (p = 0.041), as well as increases in three of the five individual survey components. Additionally, HCAHPS "quietness at night" score increased on the unit from 34.1% pre-intervention to 42.5% post-intervention. CONCLUSION: A nonpharmacologic sleep hygiene protocol paired with provider education and use of champions was associated with modest improvements in patients' perceived sleep and unit HCAHPS scores.
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Unidades de Terapia Intensiva , Higiene do Sono , Humanos , Autorrelato , Sono , Inquéritos e QuestionáriosRESUMO
Although abdominal aortic aneurysms (AAA) are more common in men, women with AAA have increased morbidity and mortality. Additionally, there are discrepancies among professional society guidelines for AAA screening in women. In this retrospective study from the Nationwide Inpatient Sample (NIS) database from 2003 to 2014, we compared rates of AAA repair (rupture and elective) and AAA-related mortality in men vs. women to identify predictors of death among men and women with AAA. We divided the population into 1) AAA rupture 2) elective AAA repair. The main outcomes included temporal trends in AAA rupture, rupture-related death, AAA repair, in-hospital death, and predictors of AAA-related death. There were 570,253 discharge records for AAA admissions between 2003 and 2014, including 22.8% women and 77.2% men. Women had a higher proportion of rupture (18.4% vs 12.6%, p <0.01). A smaller proportion of women underwent endovascular aortic repair (EVAR) compared with men in the ruptured AAA (13.9% vs. 20.3%, p <0.01) and elective repair (55.7% vs. 67.4%, p <0.01) cohorts. Within the ruptured cohort, a higher proportion of women did not receive repair (46.4% vs. 26.1%, p <0.01). On multivariable analysis, female gender was a significant predictor of death with rupture (OR 1.39, 95% CI 1.16 to 1.66) and elective repair (OR 1.74, 95% CI 1.36 to 2.22), with both elective EVAR (OR 2.52, 95% CI 2.06 to 3.09) and elective open aortic repair (OAR; OR 1.50, 95% CI 1.33 to 1.68). Propensity score matching confirmed a higher risk of death in women in both the rupture (OR 1.19, 95% CI 1.09 to 1.30) and elective repair (OR 1.50, 95% CI 1.35 to 1.67) cohorts. In conclusion, AAA poses significant morbidity and mortality, especially in women. Women were more likely to die before repair with AAA rupture and female gender was an independent predictor of mortality in both the rupture and elective repair groups.
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Aneurisma da Aorta Abdominal/epidemiologia , Hospitalização/tendências , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
BACKGROUND: Cardiovascular disease is the leading cause of death for women in the United States. Revascularization is considered the standard of care for treatment of ST-segment elevation myocardial infarction (STEMI) and is known to reduce readmission. However there is a paucity of data that examines the sex-dependent impact of revascularization on readmission. We aimed to investigate sex differences in revascularization rates, 30-day readmission rates, and primary cause of readmissions following STEMIs. METHODS: STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. Revascularization rates, 30-day readmission rates, and primary cause of readmission were examined. Interaction between sex and revascularization was assessed. Multivariable regression analysis was performed to identify predictors of 30-day readmission and revascularization for both sexes. RESULTS: 219,944 women and 489,605 men were admitted with STEMIs. Women were more likely to be older, and have more comorbidities. Women were less likely to undergo revascularization by percutaneous coronary intervention (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.66-0.70) or coronary artery bypass graft surgery (adjusted OR 0.40; CI 0.39-0.44). Women had higher 30-day readmission rates (15.7% vs. 10.8%, p < 0.001; OR 1.20, CI 1.17-1.23), and revascularization in women was not associated with a decreased likelihood of 30-day readmission. The primary cardiac cause of readmission in women was heart failure. CONCLUSION: Compared to men, women with STEMIs had lower rates of revascularization and higher rates of 30-day readmission. When revascularized, women were still more likely to be readmitted as compared to non-revascularized women.
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Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Feminino , Humanos , Masculino , Revascularização Miocárdica , Readmissão do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Caracteres Sexuais , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Background The independent prognostic value of troponin and other biomarker elevation among patients with coronavirus disease 2019 (COVID-19) are unclear. We sought to characterize biomarker levels in patients hospitalized with COVID-19 and develop and validate a mortality risk score. Methods and Results An observational cohort study of 1053 patients with COVID-19 was conducted. Patients with all of the following biomarkers measured-troponin-I, B-type natriuretic peptide, C-reactive protein, ferritin, and d-dimer (n=446) -were identified. Maximum levels for each biomarker were recorded. The primary end point was 30-day in-hospital mortality. Multivariable logistic regression was used to construct a mortality risk score. Validation of the risk score was performed using an independent patient cohort (n=440). Mean age of patients was 65.0±15.2 years and 65.3% were men. Overall, 444 (99.6%) had elevation of any biomarker. Among tested biomarkers, troponin-I ≥0.34 ng/mL was the only independent predictor of 30-day mortality (adjusted odds ratio, 4.38; P<0.001). Patients with a mortality score using hypoxia on presentation, age, and troponin-I elevation, age (HA2T2) ≥3 had a 30-day mortality of 43.7% while those with a score <3 had mortality of 5.9%. Area under the receiver operating characteristic curve of the HA2T2 score was 0.834 for the derivation cohort and 0.784 for the validation cohort. Conclusions Elevated troponin and other biomarker levels are commonly seen in patients hospitalized with COVID-19. High troponin levels are a potent predictor of 30-day in-hospital mortality. A simple risk score can stratify patients at risk for COVID-19-associated mortality.
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COVID-19/diagnóstico , Doenças Cardiovasculares/diagnóstico , Indicadores Básicos de Saúde , Hospitalização , Troponina I/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Proteína C-Reativa/análise , COVID-19/sangue , COVID-19/mortalidade , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/mortalidade , Feminino , Ferritinas/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Regulação para CimaRESUMO
AIMS: Cardiogenic shock (CS) is associated with significant mortality, and there is a movement towards regional 'hub-and-spoke' triage systems to coordinate care and resources. Limited data exist on outcomes of patients treated at CS transfer hubs. METHODS AND RESULTS: Cardiogenic shock hospitalizations were obtained from the Nationwide Readmissions Database 2010-2014. Centres receiving any interhospital transfers with CS in a given year were classified as CS transfer 'hubs'; those without transfers were classified as 'spokes.' In-hospital mortality was compared among three cohorts: (A) direct admissions to spokes, (B) direct admissions to hubs, and (C) interhospital transfer to hubs. Among hospitals treating CS, 70.6% were classified as spokes and 29.4% as hubs. A total of 130 656 (31.7%) hospitalizations with CS were direct admission to spokes, 253 234 (61.4%) were direct admissions to hubs, and 28 777 (7.0%) were transfer to hubs. CS mortality was 47.8% at spoke hospitals and was lower at hub hospitals, both for directly admitted (39.3%, P < 0.01) and transferred (33.4%, P < 0.01) patients. Hospitalizations at hubs had higher procedural frequency (including coronary artery bypass graft, right heart catheterization, mechanical circulatory support), greater length of stay, and greater costs. On multivariable analysis, direct admission to CS hubs [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.84-0.89, P < 0.01] and transfer to hubs (OR 0.72, 95% CI 0.69-0.76, P < 0.01) were both associated with lower mortality. CONCLUSION: While acknowledging the limited ability of the Nationwide Readmissions Database to classify CS severity on presentation, treatment of CS at transfer hubs was associated with significantly lower mortality within this large real-world sample.
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Insuficiência Cardíaca , Choque Cardiogênico , Mortalidade Hospitalar , Hospitais , Humanos , Estudos Retrospectivos , Choque Cardiogênico/terapiaRESUMO
The association between malignancy and readmission after Takotsubo syndrome (TTS) hospitalization has not been fully described. We sought to examine the rates, cause, and cost of 30-day readmissions of TTS, with or without malignancy, by utilizing Nationwide Readmissions Databases from 2010 to 2014. We identified 61,588 index hospitalizations for TTS. TTS patients with malignancy tended to be older (70.6 ± 0.2 vs. 66.1 ± 0.1, p < 0.001), and the overall burden of comorbidities was higher than in those without malignancy. TTS patients with malignancy had significantly higher 30-day readmission rates than those without malignancy (15.9% vs. 11.0%; odds ratio (OR), 1.35; 95% confidence interval (CI), 1.18-1.56). Non-cardiac causes were the most common causes of readmission for TTS patients with malignancy versus without malignancy (75.5% vs. 68.1%, p < 0.001). The 30-day readmission rate due to recurrent TTS was very low in both groups (0.4% and 0.5%; p = 0.47). The total costs were higher by 25% (p < 0.001) in TTS patients with vs. without malignancy. In summary, among patients hospitalized with TTS, the presence of malignancy was associated with increased risk of 30-day readmission and increased costs. These findings highlight the importance of optimized management for TTS patients with malignancy.
RESUMO
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Arritmias Cardíacas/epidemiologia , COVID-19/epidemiologia , Saúde Global/tendências , Idoso , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , COVID-19/mortalidade , COVID-19/terapia , Eletrofisiologia Cardíaca/tendências , Comorbidade , Técnicas Eletrofisiológicas Cardíacas/tendências , Feminino , Pesquisas sobre Atenção à Saúde , Disparidades em Assistência à Saúde , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/tendências , Prevalência , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de TempoRESUMO
Background Readmission after ST-segment-elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. There are limited data on the association between length of hospital stay (LOS), readmission rate, and overall costs in patients who underwent primary percutaneous coronary intervention for STEMI. Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent primary percutaneous coronary intervention, we examined the 30-day outcomes including readmission, mortality, reinfarction, repeat revascularization, and hospital charges/costs according to LOS (1-2, 3, 4, 5, and >5 days) stratified by infarct locations. The 30-day readmission rate after percutaneous coronary intervention for STEMI was 12.0% in the anterior wall (AW) STEMI group and 9.9% in the non-AW STEMI group. Patients with a very short LOS (1-2 days) were readmitted less frequently than those with a longer LOS regardless of infarct locations. However, patients with a very short LOS had significantly increased 30-day readmission mortality versus an LOS of 3 days (hazard ratio, 1.91; CI, 1.16-3.16 [P=0.01]) only in the AW STEMI group. Total costs (index admission+readmission) were the lowest in the very short LOS cohort in both the AW STEMI group (P<0.001) and the non-AW STEMI group (P<0.001). Conclusions For patients who underwent primary percutaneous coronary intervention for STEMI, a very short LOS was associated with significantly lower 30-day readmission and lower cumulative cost. However, a very short LOS was associated with higher 30-day mortality compared with at least a 3-day stay in the AW STEMI cohort.
Assuntos
Infarto Miocárdico de Parede Anterior/economia , Infarto Miocárdico de Parede Anterior/terapia , Custos Hospitalares , Tempo de Internação/economia , Readmissão do Paciente/economia , Intervenção Coronária Percutânea/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Infarto Miocárdico de Parede Anterior/diagnóstico , Infarto Miocárdico de Parede Anterior/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Recidiva , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: With the expected growth in the elderly segment of the U.S. population particularly in women, the prevalence of valvular heart disease is bound to increase in the coming years. We sought to delineate the impact of gender on in-hospital clinical outcomes in Medicare-age patients undergoing isolated left-side heart valve surgery. METHODS: Using the National Inpatient Sample files from 2003 to 2014, we compared the in-hospital major adverse cardiac and cerebral events (MACCE: all-cause mortality, stroke, or myocardial infarction) and composite complications (MACCE, permanent pacemaker implantation, bleeding requiring transfusion, iatrogenic vascular complications, acute respiratory failure, acute kidney injury requiring hemodialysis, sepsis and prolonged hospital stay) following isolated mitral or aortic surgery between genders with 1:1 propensity score analysis. Further, we examined gender-specific temporal trends of in-hospital clinical outcomes over the study period. RESULTS: There were 336,506 isolated left-side heart valve surgeries over the study period. Following propensity score matching, 24,637 unweighted pairs were identified for gender-specific comparison. Female gender was independently associated with a higher in-hospital MACCE (9.4% vs. 8.3%; ORâ¯=â¯1.14, 95% CIâ¯=â¯1.07-1.21, Pâ¯<â¯0.0001) driven mostly by all-cause mortality (5.2% vs. 4.3%; ORâ¯=â¯1.33, 95% CIâ¯=â¯1.12-1.33, Pâ¯<â¯0.0001). The composite complication rate (37.9% vs. 35.3%; ORâ¯=â¯1.12, 95% CI-1.08-1.16, Pâ¯<â¯0.0001) was also higher in women. Significant reduction in both in-hospital MACCE and all-cause mortality was observed over time regardless of gender. CONCLUSIONS: Following isolated left-side heart valve surgery, women experienced higher in-hospital MACCE including all-cause mortality compared to men. Continued temporal improvements in in-hospital clinical outcomes were observed in both genders. SUMMARY FOR THE ANNOTATED TABLE OF CONTENTS: The influence of gender on surgical aortic or mitral valve replacement/repair outcome is unclear. The current study showed that women fared worse than men including all-cause mortality following isolated left-side valve surgery and significant temporal improvements have been made in in-hospital clinical outcomes in both genders during the 12-year study period. Further research in gender-specific approach in management of valve disease is warranted.