Association Between Clinical Trial Participation Status and Outcomes With Mitral Transcatheter Edge-to-Edge Repair.

BACKGROUND: Clinical trials have demonstrated the efficacy and safety of mitral transcatheter edge-to-edge repair (M-TEER) for selected patients with severe mitral regurgitation. However, the generalizability of trial results to real-world patients remains uncertain. OBJECTIVES: The authors aimed to compare baseline characteristics and in-hospital outcomes among trial participants with nonparticipants undergoing M-TEER. METHODS: Using the National Inpatient Sample database years 2016-2020, M-TEER admissions were identified and categorized into trial participants vs none. We also identified a cohort of trial noneligible patients based on clinical exclusion criteria from pivotal trials. Multivariate regression analysis was performed to compare in-hospital outcomes. The primary outcome was in-hospital mortality, and secondary outcomes included in-hospital complications, length of stay, and hospitalization cost. RESULTS: Among 38,770 M-TEER admissions from 2016 to 2020, 11,450 (29.5%) were trial participants, 22,975 (59.3%) were eligible nonparticipants, and 2,960 (7.6%) were noneligible. Baseline characteristics and comorbidity profiles were mostly similar between trial participants vs eligible nonparticipants. In-hospital mortality (adjusted OR [aOR]: 0.98; 95% CI: 0.60-1.62), cardiogenic shock (aOR: 1.06; 95% CI: 0.80-1.42), mechanical circulatory support (aOR: 0.91; 95% CI: 0.58-1.41), mechanical ventilation (aOR: 1.03; 95% CI: 0.74-1.42), and conversion to mitral valve surgery (aOR: 1.08; 95% CI: 0.57-2.03) were not different between both groups. Conversely, M-TEER for noneligible patients was associated with higher rates of mortality (aOR: 6.27; 95% CI: 3.75-10.45) and complications. CONCLUSIONS: The majority of real-world M-TEER patients would have been eligible for clinical trial participation and had comparable clinical profiles and in-hospital outcomes to trial participants. However, noneligible patients had worse in-hospital outcomes compared with trial participants.

Association Between ß-thalassemia and Atrial Fibrillation: Insights from the United States National Inpatient Sample.

Transfusion-dependent ß-thalassemia (thalassemia major and thalassemia intermedia) (BT) requires repeated blood transfusions for survival due to ineffective erythropoiesis. Consequently, iron overload can predispose the patient to atrial fibrillation (AF) despite the improved prognosis achieved with transfusion and chelation therapy. We sought to study the impact of AF on BT patients through a large database analysis. The current study used data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project National Inpatient Sample collected from 2016-2019. A total of 17,150 admissions were included, of which 2100 (12.2%) admissions had a concomitant diagnosis of AF. Admissions with AF were older (mean age, 72.1 vs. 47.3 years; P < .001) and more likely to have congestive heart failure (CHF), hypertension, valvular heart disease, and renal disease. BT admission was associated with a higher AF prevalence than non-BT admission across all age groups. AF was not associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 0.67-2.78; P = .398) or an increased length of stay (LOS) (aOR, 1.00; 95% CI, 0.78-1.29; P = .997) in the general cohort. In a subgroup analysis, AF was associated with increased in-hospital mortality in women (aOR, 2.73; 95% CI, 1.09-6.8; P = .031). Predictors of in-hospital mortality were increasing age, CHF, and liver disease, while predictors of prolonged LOS were diabetes mellitus, CHF, and increasing age. Further studies are warranted to develop strategies to improve the quality of care and outcome in this population.

Disparities in Acute Coronary Syndrome Outcomes in Individuals With Intellectual Disabilities: A Propensity-Matched Analysis of National Inpatient Sample.

BACKGROUND: Individuals with intellectual disabilities (IDs) are at similar risk of acute coronary syndrome (ACS) as compared to general population. However, there is a paucity of real-world data evaluating outcomes of ACS in this population. We sought to study ACS outcomes in individuals with IDs using a large national database. METHODS: Adult admissions with a primary diagnosis of ACS were identified from the national inpatient sample of years 2016-2019. Cohort was stratified according to presence of IDs. A 1 to 1 nearest neighbor propensity score matching using 16 patient variables. Outcomes evaluated were in-hospital mortality, coronary angiography (CA), timing of CA (early [day 0] vs. late [>day0]), and revascularization. RESULTS: A total of 5110 admissions (2555 in each group) were included in our matched cohort. IDs admissions had higher rates of in-hospital mortality (9 % vs. 4 %, aOR: 2.84, 95 % CI [1.66-4.86], P < 0.001), and were less likely to receive CA (52 % vs. 71 %, aOR: 0.44, 95 % CI [0.34-0.58], P < 0.001) and revascularization (33 % vs. 52 %, aOR: 0.45, 95 % CI [0.35-0.58], P < 0.001). In-Hospital mortality was higher in the ID admissions whether invasive coronary treatment (CA or revascularization) was performed (6 % vs. 3 %, aOR: 2.34, 95 % CI [1.09-5.06], P = 0.03) or not (13 % vs. 5 %, aOR: 2.56, 95 % CI [1.14-5.78], P = 0.023). CONCLUSION: Significant disparities exist in ACS outcomes and management in individuals with IDs. More research is needed to understand the reasons for these disparities and develop interventions to improve quality of care in this population.

Contemporary Trends, Characteristics, and Outcomes of Transcatheter Aortic Valve Implantation Among Extreme Elderly Patients.

Transcatheter aortic valve implantation (TAVI) has been increasingly performed among extreme elderly patients with symptomatic severe aortic stenosis. We aimed to study the trends, characteristics, and outcomes of TAVI among extreme elderly. The National Readmission Database for the years 2016 to 2019 was queried for extreme elderly who underwent TAVI. Linear regression analysis was used to calculate the temporal trends in outcomes. A total of 23,507 TAVI extreme elderly admissions (50.3% women and 95.9% Medicare insurance) were included. The in-hospital mortality and all-cause 30-day readmissions were 2% and 15% and have been stable over years of analysis (p trend = 0.79 and 0.06, respectively). We evaluated complications, such as permanent pacemaker implantation (12%) and stroke (3.2%). Stroke rates did not decrease (3.4% vs 2.9% in 2016 and 2019 [p trend = 0.24]). The mean length of stay improved from 5.5 days in 2016 to 4.3 days in 2019 (p trend <0.01). The rates of early discharge (day ≤3) has improved from 49% in 2016 to 69% in 2019 (p trend <0.01). In conclusion, this nationwide contemporary observational analysis showed that TAVI was associated with low rates of complications in the extreme elderly.

Nonalcoholic Fatty Liver Disease Predicts Acute Kidney Injury Readmission in Heart Failure Hospitalizations: A Nationwide Analysis.

Nonalcoholic fatty liver disease (NAFLD) has been associated with the progression of chronic kidney disease. However, limited data is available on its impact on acute kidney injury (AKI) in heart failure(HF) patients. All primary adult HF admissions from the national readmission database of 2016-2019 were identified. Admissions from July to December of each year were excluded to allow 6 months of follow-up. Patients were stratified according to the presence of NAFLD. Complex multivariate cox regression was used to adjust for confounders and calculate the adjusted hazard ratio. A total of 420,893 weighted patients admitted with HF were included in our cohort, of whom 780 had a secondary diagnosis of NAFLD. Patients with NAFLD were younger, more likely to be female, and had higher rates of obesity and diabetes mellitus. Both groups had similar rates of chronic kidney disease irrespective of the stage. NAFLD was associated with an increased risk of 6-month readmission with AKI (26.8% vs 16.6%, adjusted hazard ratio:1.44, 95% CI [1.14-1.82], P = 0.003). The mean time to AKI readmission was 150 ± 44 days. NAFLD was associated with a shorter mean time to readmission (145 ± 45 vs 155 ± 42 days, ß =  -10 days, P = 0.044). Our study from a national database suggests that NAFLD is an independent predictor of 6-months readmission with AKI in patients admitted with HF. Further research is warranted to validate these findings.

Trends and Predictors of Poor Outcomes in Patients With Right Heart Failure: Insights From the National Readmission Database.

Right heart failure (RHF) is a complex clinical syndrome that confers high risk of morbidity and mortality. We sought to study RHF using large national database. The study is a retrospective analysis of the National Readmission Database (NRD) of years 2017-2019. Admissions with a primary diagnosis of RHF were included. Study outcomes were temporal trends of RHF diagnosis and predictors of in-hospital mortality and 30-day readmission. Subgroup analysis according to co-presence of reduced or preserved left ventricular ejection fraction (LVEF). Multivariate logistic regression was utilized to detect predictors of poor outcome and difference between subgroups. A total of 127,503 admissions were identified from the database of which 4,717 primary RHF admissions were included in our cohort. There was a trend of increasing RHF diagnosis from 2017 4th Quarter to 2019 4th Quarter. Age, liver disease and reduced LVEF were amongst predictors of in-hospital mortality while iron deficiency anemia and a Charlson Comorbidity Score ≥ 3 were predictors of 30-day readmission. The study of real-world data contributes to a better understanding of RHF outcomes. Further studies are needed to investigate the association between RHF and different types of heart failure and its implications on clinical practice.

Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials. METHODS: We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders. RESULTS: Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P<0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P<0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P<0.001). CONCLUSION: LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients.

National Trends of Structural Heart Disease Interventions from 2016 to 2020 in the United States and the Associated Impact of COVID-19 Pandemic.

The Coronavirus Disease-2019 (COVID-19) pandemic placed an enormous strain on the healthcare system. Data on the impact of COVID-19 on the utilization and outcomes of structural heart disease interventions in the United States are scarce. The National Inpatient Sample from 2016 to 2020 was queried to identify adult admissions for transcatheter aortic valve replacement (TAVR), left atrial appendage occlusion (LAAO), and transcatheter end-to-end repair (TEER). The primary outcome was temporal trends of procedure utilization rate per 100,000 admissions over quarters from 2016 to 2020. The secondary outcomes were adjusted rates of in-hospital mortality, major complications, and length of stay (LOS). Among 434,630 weighted admissions (TAVR: 305,550; LAAO: 89,300; TEER: 40,160), 95,010 admissions (22%) were during the COVID-19 era. There was a decline during the second quarter of 2020 followed by an increase to the pre pandemic levels (TAVR: 220 to 253, LAAO: 57 to 109, and TEER: 31 to 36 per 100,000 admissions, Ptrend<0.001). There were no differences in the mortality or major complication rates. Median LOS has decreased in TAVR (4 days-1 day) and in TEER (3 days-1 day) but remained stable in LAAO (1 day). This nationwide analysis showed that structural heart disease interventions decreased during the early waves of COVID-19 pandemic. There was a significant reduction in hospital LOS without differences in in-hospital mortality or complication rates during the pandemic. These data suggest that hospitals adapted to the unprecedent challenges during the pandemic to provide advanced cardiac care to patients.

Temporal Trends and Sex Differences in Patients With Cardiac Amyloidosis and Heart Failure With Preserved Ejection Fraction: Retrospective Analysis of 22,015 Admissions From the National Inpatient Sample.

Cardiac amyloidosis (CA) often goes unrecognized as a cause of heart failure with preserved ejection fraction (HFpEF). There is paucity of contemporary data evaluating the trends of CA diagnosis and associated sex differences. Adult heart failure hospitalizations were identified from the National Inpatient Sample between 2016 and 2019. Hospitalizations with heart failure other than HFpEF were excluded. Hospitalizations with a diagnosis of CA were identified. A Linear regression was utilized to calculate the trend of CA diagnosis over time. A multivariate logistic regressions analysis was performed to analyze sex differences. There was an increasing trend of CA from 1.2 to 2.3 per 1000 HFpEF admission in the first quarter of 2016 to the fourth quarter of 2019 (Ptrend <0.001). In females, as compared to males, there was an increased risk of AIS (6% vs 3%, aOR: 1.68[1.24-2.27], P=0.001) and major bleeding events (10% vs 5%, aOR: 1.97[1.53-2.52], P<0.001). No difference was observed in the in-hospital mortality outcome (8% vs 7%, aOR: 1.2[0.95-1.53], P=0.12) between both groups. Our real-world contemporary analysis showed an increase in CA diagnosis from 2016 to 2019. Despite similar in-hospital mortality, females were associated with higher AIS and major bleeding events rates. Further prospective studies are needed to validate these results.

Right Heart Catheterization Timing and Outcomes of Cardiogenic Shock: Analysis from the National Readmission Database.

Recent studies showed significant mortality benefit with right heart catheterization (RHC) use in cardiogenic (CS). The optimal timing of RHC in those patients is unknown owing to the lack of available data. The Nationwide Readmission Database 2016-2018 was queried for hospitalizations with CS. We excluded patients presented with cardiac arrest or with a history of ventricular assist devices or heart transplantation. Complex samples multivariable logistic, cox, and linear regression models were used to determine the association between RHC timing in the index admission (<2 days [early RHC] vs ≥ 2 days [late RHC]) and in-hospital outcomes (mortality, acute kidney injury [AKI], mechanical circulatory device use [MCD], index length of stay [LOS], hospital charges), and all-cause 30-day readmissions. A total of 46,963 hospitalizations [18,632 in the early group and 28,332 in the late group] were included in this analysis. RHC was more likely to happen in large teaching hospitals. Although there was no difference in mortality (adjusted odds ratio [aOR]: 1.05; Confidence interval [CI] 0.97-1.14; P= 0.233). Patients in the early RHC group had a lower incidence of AKI (aOR: 0.69; CI: 0.64-0.74; P < 0.01), higher rate of MCS use (aOR:1.67; CI:1.54-1.81; P < 0.001), shorter LOS (aß :-6.2; CI -6.62 to -5.77; P <.001), lower hospital charges, and lower readmission rates (adjusted hazards ratio [aHR]: 0.91; CI: 0.84- 0.98; P = 0.01) compared to the late RHC group. Early RHC was associated with decreased incidence of AKI, decreased LOS, total charges, and readmission rates with no difference in survival. Subgroup analysis of patients who did not receive MCS during the index admission showed similar outcomes albeit with increased mortality. Further randomized controlled trials are needed to validate these results.

Impact of Chronic Obstructive Pulmonary Disease on Atrial Fibrillation Ablation Outcomes According to the National Readmission Database.

Chronic obstructive pulmonary disease (COPD) is a risk factor for the development of atrial fibrillation (AF). There is a paucity of contemporary data studying the association between COPD and outcomes of AF ablation. The objective of this study was to investigate the impact of COPD on AF ablation outcomes using a large nationwide database. This study was a retrospective analysis of the National Readmission Database for the years 2016-2018 and included patients admitted with a diagnosis of AF who underwent catheter ablation. Admissions were stratified according to COPD diagnosis using International Classification of Diseases, 10th Revision, Clinical Modification codes. Multivariate, linear, Cox, and logistic regressions were performed to study the impact of COPD on AF ablation. A total of 18,224 admissions (mean age, 68 years; standard deviation, 10 years) were included, of whom 3,494 (19%) had a diagnosis of COPD. The COPD group was older (72 ± 8 vs. 67 ± 11 years, P < .001) and more likely to have congestive heart failure (73% vs. 44%, P < .001) and renal failure (31% vs. 17%, P < .001). COPD was associated with an increased risk of readmission (adjusted hazard ratio [aHR], 1.40; 95% confidence interval [CI], 1.26-1.56; P < .001) and all-cause in-hospital mortality (adjusted odds ratio, 2.83; 95% CI, 1.74-4.60; P < .001). However, COPD was not associated with an increased risk of readmission due to recurrent AF (aHR, 0.97; 95% CI, 0.75-1.27; P = .844) or the need for re-ablation (aHR, 0.85; 95% CI, 0.44-1.65; P = .639), respectively. In conclusion, COPD was not associated with an increased risk of recurrent AF after ablation despite higher periprocedural risks. The present study contributes to a better understanding of this high-risk subgroup of patients undergoing AF ablation.

Morbid obesity in hospitalized young adults: Insights from a national database.

Morbid obesity (MO) is a national health problem. We sought to study the prevalence and contemporary trends of MO in hospitalized young adults. Nationwide Readmission Database (NRD) for the years 2016-2019 was queried for young adult MO admissions (aged 18-35 years). A total of 750,972 (7.1%) MO admissions were analyzed. There was a trend of increasing MO admissions from 6.5% in 2016 to 7.7% in 2019 (Ptrend <0.001). MO was independently associated with an increase in mean costs by 270 million dollars per year of analysis. Authors suggest developing national programs targeting MO in young adults.

Differences According to Sex in Short-term Clinical Outcomes After Supraventricular Tachycardia Catheter Ablation: Insights from the Nationwide Readmission Database.

Catheter ablation is indicated for the management of supraventricular tachycardias (SVTs). We investigated the effect of sex on short-term outcomes after catheter ablation for SVTs other than atrial fibrillation (AF). Using the Healthcare Cost and Utilization Project Nationwide Readmission Database for the years 2016-2018, SVT patients who underwent catheter ablation were identified using the appropriate International Classification of Diseases, 10th Revision, codes. The primary outcome was 30-day readmissions. Secondary outcomes included 30-day readmissions for SVT, postprocedural bleeding, acute myocardial infarction, transient ischemic attack, stroke, hemopericardium, cardiac tamponade, length of stay (LOS) in the hospital, and total hospital charges (in USD). Female sex was not associated with an increased risk of the primary outcome (P = .168) but was associated with a significantly decreased risk of postprocedural revascularization (P = .001), LOS (P = .003), and total hospital charges (P = .002). There were no significant differences in other secondary outcomes. Among patients admitted for catheter ablation for SVTs (other than AF), female sex was associated with decreased LOS and total hospital charges, which may be attributed to increased comorbidity rates in men and gender-based biases.

Type 2 Myocardial Infarction in Young Adults: Insights From the National Readmission Database.

Introduction Type 2 myocardial infarction (T2MI) is an ischemic myocardial injury in the context of oxygen supply/demand mismatch in the absence of a primary coronary event. T2MI is often diagnosed in patients with a higher risk of morbidity and mortality. T2MI in young adults is poorly understood due to limited available data. Methods The Nationwide Readmission Database 2017-2018 was queried for admission with T2MI diagnosis in young adults (age ≤ 45 years). Index admissions with T2MI were identified. Other types of myocardial infarction and observations with missing data were excluded. December admissions were excluded to allow the 30-day follow-up. Cox proportional hazard multivariate regression model was used to determine predictors of readmissions. All P-values were two-sided, with 0.05 as the threshold for statistical significance. Results A total of 11,750 patients with a secondary diagnosis of T2MI were admitted between October 2017 and November 2018. The main primary etiologies of index admission were sepsis (14%) followed by hypertensive heart disease with heart failure (11%) and hypertensive emergency (7%), while main etiologies of readmission were hypertensive heart disease with heart failure (12%) followed by sepsis (9%) and acute kidney injury (3%). Valvular heart disease, chronic pulmonary disease, drug abuse, and depression were amongst the predictors of all-cause readmission. Conclusion We identified primary etiologies of admission and readmission, and predictors of readmissions in young adults presenting with T2MI. Further studies are needed to guide the management of T2MI in this age group.

Relation of Type 2 Myocardial Infarction and Readmission With Type 1 Myocardial Infarction in Hypertensive Crises (from a Nationwide Analysis).

Type 2 myocardial infarction (T2MI) is an ischemic injury that occurs due to a mismatch between myocardial oxygen supply and demand. T2MI can occur with hypertensive crisis. Nevertheless, the impact of T2MI on hypertensive crisis outcome is poorly understood due to limited data. This study was a retrospective analysis of the National Readmission Database year 2018. Patients were included if the primary diagnosis was hypertensive crisis, hypertensive urgency, or hypertensive emergency. Patients were excluded if they had type 1 myocardial infarction (T1MI), severe sepsis, septic shock, gastrointestinal bleeding, or hemorrhagic anemia at index admission. The primary outcome was 90-day readmission with T1MI. Secondary outcomes were in-hospital mortality, length of stay, resource utilization, and all-cause 90-day readmission. Subgroup analysis was done according to urgency and emergency presentation. A total of 101,211 index hospitalizations were included in our cohort, of whom 3,644 (3.6%) received a diagnosis of T2MI. A total of 912 patients were readmitted within 90 days with T1MI. T2MI was an independent predictor of 90-day readmission with T1MI (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] 1.90 to 3.66, p <0.01). Subgroup analysis including only hypertensive urgency and hypertensive emergency yielded similar results (aOR 2.80, 95% CI 1.56 to 5.01, p <0.01 and aOR 2.28, 95% CI 1.59 to 3.27, p <0.01, respectively). In conclusion, T2MI was an independent predictor of poor outcome in patients presenting with hypertensive crisis. Further studies are needed to guide the management of T2MI in this population.

Predictors of thirty-day readmission in nonagenarians presenting with acute heart failure with preserved ejection fraction: a nationwide analysis.

BACKGROUD: Acute heart failure with preserved ejection fraction (HFpEF) is a common but poorly studied cause of hospital admissions among nonagenarians. This study aimed to evaluate predictors of thirty-day readmission, in-hospital mortality, length of stay, and hospital charges in nonagenarians hospitalized with acute HFpEF. METHODS: Patients hospitalized between January 2016 and December 2018 with a primary diagnosis of diastolic heart failure were identified using ICD-10 within the Nationwide Readmission Database. We excluded patients who died in index admission, and discharged in December each year to allow thirty-day follow-up. Univariate regression was performed on each variable. Variables with P-value < 0.2 were included in the multivariate regression model. RESULTS: From a total of 45,393 index admissions, 43,646 patients (96.2%) survived to discharge. A total of 7,437 patients (15.6%) had a thirty-day readmission. Mean cost of readmission was 43,265 United States dollars (USD) per patient. Significant predictors of thirty-day readmission were chronic kidney disease stage III or higher [adjusted odds ratio (aOR) = 1.20, 95% CI: 1.07-1.34,P = 0.002] and diabetes mellitus (aOR = 1.18, 95% CI: 1.07-1.29,P = 0.001). Meanwhile, female (aOR = 0.90, 95% CI: 0.82-0.99,P = 0.028) and palliative care encounter (aOR = 0.27, 95% CI: 0.21-0.34,P < 0.001) were associated with lower odds of readmission. Cardiac arrhythmia (aOR = 1.46, 95% CI: 1.11-1.93, P = 0.007) and aortic stenosis (aOR = 1.36, 95% CI: 1.05-1.76,P = 0.020) were amongst predictors of in-hospital mortality. CONCLUSIONS: In nonagenarians hospitalized with acute HFpEF, thirty-day readmission is common and costly. Chronic comorbidities predict poor outcomes. Further strategies need to be developed to improve the quality of care and prevent the poor outcome in nonagenarians.