Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study.

BACKGROUND: Constrictive pericarditis is a rare complication of open heart surgery (OHS), but little is known regarding the etiologic determinants, and prognostic factors. The purpose of this study was to investigate clinical predictors and long term prognosis of post-operative constrictive pericarditis (CP). METHODS: Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 142,837 patients who were admitted for OHS in New Jersey hospitals between 1995 and 2015. Ninety-one patients were hospitalized with CP 30 days or longer after discharge from OHS. Differences in proportions were analyzed using Chi square tests. Controls were matched to cases for demographics, surgical procedure type, history of OHS, and propensity score. Cox proportional hazard models were used to evaluate the risk of all-cause death. Log-rank tests and Cox models were used to assess differences in the Kaplan-Meier survival curves with and without adjustments for comorbidities. RESULTS: Patients with CP were more likely to have history of valve disease (VD, p < 0.001), atrial fibrillation (AF, p = 0.024) renal disease (CKD, p = 0.028), hemodialysis (HD, p = 0.008), previous OHS (p < 0.001). Patients with CP compared to matched controls had a higher 7-year mortality (p < 0.001). This difference became statistically significant at 1-year after surgery. CONCLUSION: CP is a rare complication of OHS that occurs more frequently in patients with VD, AF, CKD, HD, multiple OHS, and it is associated with an unfavorable long-term prognosis. Given the large number of OHS performed every year, the results highlight the need for clinicians to recognize and properly manage this complication of OHS.

Frequency of Stroke After Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting (from an Eleven-Year Statewide Analysis).

We compared stroke rates associated with coronary artery bypass grafting (CABG), both on-pump and off-pump, and percutaneous coronary intervention (PCI) with both drug-eluting stent (DES) and bare-metal stent (BMS) and the impact on 30-day and 1-year all-cause mortality. The Myocardial Infarction Data Acquisition System database was used to study patients who had on-pump CABG (n = 47,254), off-pump CABG (n = 19,118), and PCI with BMS (n = 46,641), and DES (n = 115,942) in New Jersey from 2002 to 2012. Multiple logistic and Cox proportional hazard models were used to compare the risk of stroke and mortality. Adjustments were made for demographics, year of hospitalization, and co-morbidities. The rate of postprocedural stroke was lowest with DES (0.5%), followed by BMS (0.6%), off-pump CABG (1.3%), and on-pump CABG (1.8%). After adjustment, on-pump CABG had a higher risk of stroke compared with off-pump (odds ratio 1.36, 95% CI 1.18 to 1.56, p <0.0001). DES had lower risk of stroke compared with off-pump CABG (odds ratio 0.64, 95% CI 0.55 to 0.74, p <0.0001). There was a significant excess risk of 1-year mortality due to the interaction between stroke and procedure type (on-pump vs off-pump CABG and PCI with DES vs BMS; p value for interaction = 0.02). In conclusion, in this retrospective analysis of nonrandomized data from a statewide database, PCI with DES was associated with the lowest rate of postprocedural stroke, and off-pump CABG had a lower rate of postprocedural stroke than on-pump CABG; there was an excess 1-year mortality risk with on-pump versus off-pump CABG and with DES versus BMS in patients with stroke.

Incidence and trends of heart failure admissions after coronary artery bypass grafting surgery.

AIMS: Factors related to hospitalization for heart failure (HF) following coronary artery bypass grafting (CABG) surgery were studied. METHODS AND RESULTS: Patients (n = 65 377) undergoing CABG surgery in New Jersey from 1998 to 2007 were identified from the state cardiac surgery database; subsequent hospitalizations for HF were assessed using the Myocardial Infarction Data Acquisition System database. Patients were classified based on pre-operative ejection fraction (EF). Multivariate models were used to identify factors related to HF admission and mortality. Post-CABG HF admission rates among patients with pre-operative EF <35% increased over the 10-year period (P = 0.02), but no significant trend was seen among patients with EF ≥35%. Independent factors associated with post-CABG HF admission within 2 years were: EF, age, female gender, Black race, smoking, diabetes, renal disease, hypertension, and cerebrovascular disease. Pre-operative use of beta-blockers increased over the years (P < 0.0001) and reduced the risk of admission for HF by 13%, with greater benefit in patients with lower EF. Mortality remained unchanged from 1998 to 2007, averaging 1.8% in-hospital and 5.1% and 7.2% at 1-year and 2-year follow-up, respectively. CONCLUSIONS: Pre-operative EF is a strong predictor of HF admission within 2 years after CABG surgery. The use of beta-blockers decreased HF admission after CABG, especially in patients with EF <35%. Despite the more pronounced benefit and increasing use of beta-blockers in patients with a low EF, HF admission rates in this group of patients are rising. This suggests that more comprehensive management of factors associated with HF is necessary.

Trends in mortality of acute myocardial infarction after discharge from the hospital.

BACKGROUND: We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened. METHODS AND RESULTS: Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, -0.44; 95% confidence interval, -0.49 to -0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, +0.15; 95% confidence interval, +0.10 to +0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, +0.10; 95% confidence interval, +0.06 to +0.23). The effect was more evident in the older age groups and was due to noncardiovascular mortality, especially from respiratory and renal diseases, septicemia, and cancer. All effects remained statistically significant (P<0.0001) after adjustment for demographics, comorbidities, infarction type, complications, and interventions. Piecewise linear regressions confirmed these trends. CONCLUSIONS: Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups.

Weekend versus weekday admission and mortality from myocardial infarction.

BACKGROUND: Management of acute myocardial infarction requires urgent diagnostic and therapeutic procedures, which may not be uniformly available throughout the week. METHODS: We examined differences in mortality between patients admitted on weekends and those admitted on weekdays for a first acute myocardial infarction, using the Myocardial Infarction Data Acquisition System. All such admissions in New Jersey from 1987 to 2002 (231,164) were included and grouped in 4-year intervals. RESULTS: There were no significant differences in demographic characteristics, coexisting conditions, or infarction site between patients admitted on weekends and those admitted on weekdays. However, patients admitted on weekends were less likely to undergo invasive cardiac procedures, especially on the first and second days of hospitalization (P<0.001). In the interval from 1999 to 2002 (59,786 admissions), mortality at 30 days was significantly higher for patients admitted on weekends (12.9% vs. 12.0%, P=0.006). The difference became significant the day after admission (3.3% vs. 2.7%, P<0.001) and persisted at 1 year (1% absolute difference in mortality). The difference in mortality at 30 days remained significant after adjustment for demographic characteristics, coexisting conditions, and site of infarction (hazard ratio, 1.048; 95% confidence interval [CI], 1.022 to 1.076; P<0.001), but it became nonsignificant after additional adjustment for invasive cardiac procedures (hazard ratio, 1.023; 95% CI, 0.997 to 1.049; P=0.09). CONCLUSIONS: For patients with myocardial infarction, admission on weekends is associated with higher mortality and lower use of invasive cardiac procedures. Our findings suggest that the higher mortality on weekends is mediated in part by the lower rate of invasive procedures, and we speculate that better access to care on weekends could improve the outcome for patients with acute myocardial infarction.