The association between hypertensive disorders during pregnancy and maternal and neonatal outcomes: a retrospective claims analysis.

BACKGROUND: Hypertensive disorders during pregnancy continue to increase in prevalence and are associated with several adverse outcomes and future cardiovascular risk for mothers. This study evaluated the association of hypertensive disorders compared to no hypertension during pregnancy with neonatal and maternal outcomes. We then evaluated risk factors associated with progression from a less to more severe hypertensive disorder during pregnancy. METHODS: We conducted a propensity-matched retrospective cohort study utilizing Medicaid claims data from a national insurer. The study population consisted of mothers with and without hypertensive disorders who delivered between 7/1/2016-12/31/2018 and their infants. Hypertensive disorders included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Propensity score matching was used to match mothers without to those with hypertensive disorders. Regression models were used to compare maternal and neonatal outcomes. Stepwise logistic regression was used to determine characteristics associated with the progression of gestational hypertension to preeclampsia or chronic hypertension to superimposed preeclampsia. RESULTS: We observed the highest risk of cesarean delivery (odds ratio [OR]:1.61 and 1.99) in mothers and preterm delivery (OR:2.22 and 5.37), respiratory distress syndrome (OR:2.39 and 4.19), and low birthweight (OR:3.64 and 9.61) in babies born to mothers with preeclampsia or superimposed preeclampsia compared to no hypertension, respectively (p < 0.05 for all outcomes). These outcomes were slightly higher among chronic or gestational hypertension compared to no hypertension, however, most were not statistically significant. Risk of neonatal intensive care unit utilization was higher among more severe hypertensive disorders (OR:2.41 for preeclampsia, OR:4.87 for superimposed preeclampsia). Obesity/overweight and having a history of preeclampsia during a prior pregnancy were most likely to predict progression from gestational/chronic hypertension to preeclampsia/superimposed preeclampsia. CONCLUSION: Mothers and neonates born to mothers with preeclampsia or superimposed preeclampsia experienced more adverse outcomes compared to those without hypertension. Mothers and neonates born to mothers with gestational hypertension had outcomes similar to those without hypertension. Outcomes for those with chronic hypertension fell in between gestational hypertension and preeclampsia. Obesity/overweight and having a history of preeclampsia during a prior pregnancy were strong risk factors for hypertension progression.

Clinical Outcomes and Cost Associated With an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump in Patients Presenting With Acute Myocardial Infarction Complicated by Cardiogenic Shock.

Importance: Intravascular microaxial left ventricular assist device (LVAD) compared with intra-aortic balloon pump (IABP) has been associated with increased risk of mortality and bleeding among patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) undergoing percutaneous coronary intervention (PCI). However, evidence on the association of device therapy with a broader array of clinical outcomes, including data on long-term outcomes and cost, is limited. Objective: To examine the association between intravascular LVAD or IABP use and clinical outcomes and cost in patients with AMI complicated by CS. Design, Setting, and Participants: This retrospective propensity-matched cohort study used administrative claims data for commercially insured patients from 14 states across the US. Patients included in the analysis underwent PCI for AMI complicated by CS from January 1, 2015, to April 30, 2020. Data analysis was performed from April to November 2021. Exposures: Use of either an intravascular LVAD or IABP. Main Outcomes and Measures: The primary outcomes were mortality, stroke, severe bleeding, repeat revascularization, kidney replacement therapy (KRT), and total health care costs during the index admission. Clinical outcomes and cost were also assessed at 30 days and 1 year. Results: Among 3077 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.2 (12.5) years, and 986 (32.0%) had cardiac arrest. Among 817 propensity-matched pairs, intravascular LVAD use was associated with significantly higher in-hospital (36.2% vs 25.8%; odds ratio [OR], 1.63; 95% CI, 1.32-2.02), 30-day (40.1% vs 28.3%; OR, 1.71; 95% CI, 1.37-2.13), and 1-year mortality (58.9% vs 45.0%; hazard ratio [HR], 1.44; 95% CI, 1.21-1.71) compared with IABP. At 30 days, intravascular LVAD use was associated with significantly higher bleeding (19.1% vs 14.5%; OR, 1.35; 95% CI, 1.04-1.76), KRT (12.2% vs 7.0%; OR, 1.88; 95% CI, 1.30-2.73), and mean cost (+$51 680; 95% CI, $31 488-$75 178). At 1 year, the association of intravascular LVAD use with bleeding (29.7% vs 24.3%; HR, 1.36; 95% CI, 1.05-1.75), KRT (18.1% vs 10.9%; HR, 1.95; 95% CI, 1.35-2.83), and mean cost (+$46 609; 95% CI, $22 126-$75 461) persisted. Conclusions and Relevance: In this propensity-matched analysis of patients undergoing PCI for AMI complicated by CS, intravascular LVAD use was associated with increased short-term and 1-year risk of mortality, bleeding, KRT, and cost compared with IABP. There is an urgent need for additional evidence surrounding the optimal management of patients with AMI complicated by CS.

Blood Pressure, Antihypertensive Polypharmacy, Frailty, and Risk for Serious Fall Injuries Among Older Treated Adults With Hypertension.

Antihypertensive medication and low systolic blood pressure (BP) and diastolic BP have been associated with an increased falls risk in some studies. Many older adults have indicators of frailty, which may increase their risk for falls. We contrasted the association of systolic BP, diastolic BP, number of antihypertensive medication classes taken, and indicators of frailty with risk for serious fall injuries among 5236 REGARDS study (Reasons for Geographic and Racial Difference in Stroke) participants ≥65 years taking antihypertensive medication at baseline with Medicare fee-for-service coverage. Systolic BP and diastolic BP were measured, and antihypertensive medication classes being taken assessed through a pill bottle review during a study visit. Indicators of frailty included low body mass index, cognitive impairment, depressive symptoms, exhaustion, impaired mobility, and history of falls. Serious fall injuries were defined as fall-related fractures, brain injuries, or joint dislocations using Medicare claims through December 31, 2014. Over a median of 6.4 years, 802 (15.3%) participants had a serious fall injury. The multivariable-adjusted hazard ratio for a serious fall injury among participants with 1, 2, or ≥3 indicators of frailty versus no frailty indicators was 1.18 (95% confidence interval, 0.99-1.40), 1.49 (95% confidence interval, 1.19-1.87), and 2.04 (95% confidence interval, 1.56-2.67), respectively. Systolic BP, diastolic BP, and number of antihypertensive medication classes being taken at baseline were not associated with risk for serious fall injuries after multivariable adjustment. In conclusion, indicators of frailty, but not BP or number of antihypertensive medication classes, were associated with increased risk for serious fall injuries among older adults taking antihypertensive medication.

Association of Reduced eGFR and Albuminuria with Serious Fall Injuries among Older Adults.

BACKGROUND AND OBJECTIVES: Falls are common and associated with adverse outcomes in patients on dialysis. Limited data are available in earlier stages of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We analyzed data from 8744 Reasons for Geographic and Racial Differences in Stroke Study participants ≥65 years old with Medicare fee for service coverage. Serious fall injuries were defined as a fall-related fracture, brain injury, or joint dislocation using Medicare claims. Hazard ratios (HRs) for serious fall injuries were calculated by eGFR and albumin-to-creatinine ratio (ACR). Among 2590 participants with CKD (eGFR<60 ml/min per 1.73 m(2) or ACR≥30 mg/g), cumulative mortality after a serious fall injury compared with age-matched controls without a fall injury was calculated. RESULTS: Overall, 1103 (12.6%) participants had a serious fall injury over 9.9 years of follow-up. The incidence rates per 1000 person-years of serious fall injuries were 21.7 (95% confidence interval [95% CI], 20.3 to 23.2), 26.6 (95% CI, 22.6 to 31.3), and 38.3 (95% CI, 31.2 to 47.0) at eGFR levels ≥60, 45-59, and <45 ml/min per 1.73 m(2), respectively, and 21.3 (95% CI, 20.0 to 22.8), 31.7 (95% CI, 27.5 to 36.5), and 42.2 (95% CI, 31.3 to 56.9) at ACR levels <30, 30-299, and ≥300 mg/g, respectively. Multivariable adjusted HRs for serious fall injuries were 0.91 (95% CI, 0.76 to 1.09) and 1.09 (95% CI, 0.86 to 1.37) for eGFR=45-59 and <45 ml/min per 1.73 m(2), respectively, versus eGFR≥60 ml/min per 1.73 m(2) and 1.31 (95% CI, 1.11 to 1.54) and 1.81 (95% CI, 1.30 to 2.50) for ACR=30-299 and ≥300 mg/g, respectively, versus ACR<30 mg/g. Among participants with CKD, cumulative 1-year mortality rates among patients with a serious fall and age-matched controls were 21.0% and 5.5%, respectively. CONCLUSIONS: Elevated ACR but not lower eGFR was associated with serious fall injuries. Evaluation for fall risk factors and fall prevention strategies should be considered for older adults with elevated ACR.