RESUMO
Background: Low- and middle-income countries account for most of the global burden of coronary artery disease. There is a paucity of data regarding epidemiology and outcomes for ST-segment elevation myocardial infarction (STEMI) patients in these regions. Objectives: The authors studied the contemporary characteristics, practice patterns, outcomes, and sex differences in patients with STEMI in India. Methods: NORIN-STEMI (North India ST-Segment Elevation Myocardial Infarction Registry) is an investigator-initiated prospective cohort study of patients presenting with STEMI at tertiary medical centers in North India. Results: Of 3,635 participants, 16% were female patients, one-third were <50 years of age, 53% had a history of smoking, 29% hypertension, and 24% diabetes. The median time from symptom onset to coronary angiography was 71 hours; the majority (93%) presented first to a non-percutaneous coronary intervention (PCI)-capable facility. Almost all received aspirin, statin, P2Y12 inhibitors, and heparin on presentation; 66% were treated with PCI (98% femoral access) and 13% received fibrinolytics. The left ventricular ejection fraction was <40% in 46% of patients. The 30-day and 1-year mortality rates were 9% and 11%, respectively. Compared with male patients, female patients were less likely to receive PCI (62% vs 73%; P < 0.0001) and had a more than 2-fold greater 1-year mortality (22% vs 9%; adjusted HR: 2.1; 95% CI: 1.7-2.7; P < 0.001). Conclusions: In this contemporary registry of patients with STEMI in India, female patients were less likely to receive PCI after STEMI and had a higher 1-year mortality compared with male patients. These findings have important public health implications, and further efforts are required to reduce these gaps.
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BACKGROUND: There is a lack of data on age-stratified sex differences in the incidence, treatment, and outcomes of cardiogenic shock (CS). We sought to study these differences from a contemporary database. METHODS: Patients admitted with CS (2004-2018) were identified from the United States National Inpatient Sample. We compared CS (acute myocardial infarction-related cardiogenic shock [AMI-CS] and non-acute myocardial infarction-related cardiogenic shock [Non-AMI-CS]) incidence, management, and outcomes in males and females, stratified into four age groups (20-44, 45-64, 65-84, and ≥85 years of age). Propensity score matching (PSM) was used for adjustment. RESULTS: A total of 1,506,281 weighted hospitalizations for CS were included (AMI-CS, 39%; Non-AMI-CS, 61%). Across all age groups, females had a lower incidence of CS compared with males. After PSM and among the AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 45-64 (28.5% vs. 26.3%) and 65-84 years (39.3% vs. 37.9%) (p < 0.01, for all). Among the Non-AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 20-44 (33.5% vs. 30.5%), 45-64 (35.1% vs. 31.9%), and 65-84 years (41.7% vs. 40.3%) (p < 0.01, for all). Similar age-dependent differences in the management of CS were also observed between females and males. CONCLUSIONS: Females have a lower incidence of CS regardless of age. Significant disparities in the management and outcomes of CS were observed based on sex. However, these disparities varied by age and etiology of CS (AMI-CS vs. Non-AMI-CS) with pronounced disparity among females in the age range of 45-84 years.
Assuntos
Caracteres Sexuais , Choque Cardiogênico , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/terapia , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.
RESUMO
Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
Assuntos
Cardiopatias Congênitas , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Etnicidade , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/terapia , Hispânico ou Latino , Humanos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values < 0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p valueâ¯=â¯0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values < 0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.
Assuntos
Injúria Renal Aguda/epidemiologia , Estenose da Valva Aórtica/cirurgia , Arritmias Cardíacas/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Mortalidade Hospitalar , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/terapia , Estimulação Cardíaca Artificial , Feminino , Implante de Prótese de Valva Cardíaca , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Marca-Passo Artificial , Complicações Pós-Operatórias/terapia , Pontuação de Propensão , Acidente Vascular Cerebral/epidemiologia , Estados Unidos/epidemiologiaRESUMO
We aimed to identify risk factors of high hospitalization cost after transcatheter aortic valve implantation (TAVI). TAVI expenditure is generally higher compared with surgical aortic valve replacement. We queried the Nationwide Inpatient Sample database from January 2011 to September 2015 to identify those who underwent endovascular TAVI. Estimated cost of hospitalization was calculated by merging the Nationwide Inpatient Sample database with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. Patients were divided into quartiles (lowest, medium, high, and highest) according to the hospitalization cost, and multivariable regression analysis was performed to identify patient characteristics and periprocedural complications associated with the highest cost group. A total of 9,601 TAVI hospitalizations were identified. Median in-hospital costs of the highest and lowest groups were $82,068 and $33,966, respectively. Patients in the highest cost group were older and more likely women compared with the lowest cost group. Complication rates (68.4% vs 22.5%) and length of stay (median 10 days vs 3 days) were both approximately 3 times higher and longer, respectively, in the highest cost group. Co-morbidities such as heart failure, peripheral vascular disease, atrial fibrillation, anemia, and chronic dialysis as well as almost all complications were associated with the highest cost group. The complications with the highest incremental cost were acute respiratory failure requiring intubation ($28,209), cardiogenic shock ($22,401), and acute kidney injury ($16,974). Higher co-morbidity burden and major complications post-TAVI were associated with higher hospitalization costs. Prevention of these complications may reduce TAVI-related costs.
Assuntos
Estenose da Valva Aórtica/cirurgia , Custos Hospitalares , Hospitalização/economia , Pacientes Internados , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/economia , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/economia , Pontuação de Propensão , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologiaAssuntos
Doenças Cardiovasculares/prevenção & controle , Meios de Comunicação , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Disseminação de Informação/métodos , Educação de Pacientes como Assunto , Recusa do Paciente ao Tratamento , Acesso à Informação , Doenças Cardiovasculares/mortalidade , Conflito de Interesses , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Marketing de Serviços de Saúde , Segurança do Paciente , Medição de Risco , Fatores de RiscoRESUMO
Candidates for transcatheter aortic valve implantation (TAVI) are generally older with multiple co-morbidities and are therefore susceptible to nonelective admissions before scheduled TAVI. Frequency, predictors, and outcomes of TAVI after nonelective admission are under-explored. We queried the Nationwide Inpatient Sample database, an administrative database, from January 2012 to September 2015 to identify hospitalization in those age ≥50 who had transarterial TAVI. A propensity-matched cohort was created to compare the outcomes between nonelective and elective admission who had TAVI. The primary outcome was in-hospital mortality. A total of 9,521 TAVI admissions were identified during the study period. Of these admissions, 22.3% were nonelective admissions. Pulmonary circulation disorders (adjusted odds ratio [aOR] 1.38), anemia (aOR 1.54), congestive heart failure (aOR 1.37), chronic kidney disease (aOR 1.28; all p <0.001), and atrial fibrillation (aOR 1.17, pâ¯=â¯0.006) were independent risk factors for nonelective admission. In a propensity-matched cohort (1,683 admissions in each cohort), in-hospital mortality was similar (4.0% vs 2.8%, pâ¯=â¯0.052). Nonelective admissions had higher rates of acute myocardial infarction (5.2% vs 0.7%), fatal arrhythmia (9.4% vs 6.0%), acute kidney injury (25.9% vs 17.1%), respiratory failure requiring intubation (0.26% vs 0.19%), cardiogenic shock (5.1% vs 2.1%; all p <0.001), and bleeding requiring transfusion (13.1% vs 10.1%, pâ¯=â¯0.006) during the index-hospitalization. Hospital length of stay (11.4 days vs 6.5 days, p <0.001) and hospital cost ($68,669 vs $57,442, p <0.001) were both increased in nonelective admissions. Nonelective admission accounted for approximately one-fifth of total TAVI with significantly different cohort profiles. Our results suggest that nonelective TAVI has higher adverse outcomes and increased health resource utilization. Expedition in TAVI process in high-risk cohorts may result in better outcomes.
Assuntos
Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Idoso , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Pontuação de Propensão , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados UnidosAssuntos
Cardiologistas/educação , Fármacos Cardiovasculares/uso terapêutico , Educação Médica Continuada , Setor de Assistência à Saúde , Cardiopatias/terapia , Adesão à Medicação , Padrões de Prática Médica , Radiologistas/educação , Sociedades Médicas , Atitude do Pessoal de Saúde , Cardiologistas/psicologia , Congressos como Assunto , Fidelidade a Diretrizes , Conhecimentos, Atitudes e Prática em Saúde , Cardiopatias/diagnóstico por imagem , Humanos , Comunicação Interdisciplinar , Guias de Prática Clínica como Assunto , Radiologistas/psicologia , Participação dos InteressadosRESUMO
BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients are at increased risk of respiratory related complications after cardiac surgery. It is unclear whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in favorable outcomes among COPD patients. METHODS AND RESULTS: Patients were identified from the Nationwide Inpatient Sample database from 2011 to 2014. Patients with age ≥60, COPD, and either went transarterial TAVR or SAVR were included in the analysis. A 1:1 propensity-matched cohort was created to examine the outcomes. A matched pair of 1210 TAVR and 1208 SAVR patients was identified. Respiratory-related complications such as tracheostomy (0.8% versus 5.8%; odds ratio [OR], 0.14; P<0.001), acute respiratory failure (16.4% versus 23.7%; OR, 0.63; P=0.002), reintubation (6.5% versus 10.0%; OR, 0.49; P<0.001), and pneumonia (4.5% versus 10.1%; OR, 0.41; P<0.001) were significantly less frequent with TAVR versus SAVR. Use of noninvasive mechanical ventilation was similar between TAVR and SAVR (4.1% versus 4.8%; OR, 0.84; P=0.41). Non-respiratory-related complications, such as in-hospital mortality (3.3% versus 4.2%; OR, 0.64; P=0.035), bleeding requiring transfusion (9.9% versus 21.7%; OR, 0.38; P<0.001), acute kidney injury (17.7% versus 25.3%; OR, 0.63; P<0.001), and acute myocardial infarction (2.4% versus 8.4%; OR, 0.19; P<0.001), were significantly less frequent with TAVR than SAVR. Cost ($56 099 versus $63 146; P<0.001) and hospital stay (mean, 7.7 versus 13.0 days; P<0.001) were also more favorable with TAVR than SAVR. CONCLUSIONS: TAVR portended significantly fewer respiratory-related complications compared with SAVR in COPD patients. TAVR may be a preferable mode of aortic valve replacement in COPD patients.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Nível de Saúde , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/mortalidade , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Pacientes Internados , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Doença Pulmonar Obstrutiva Crônica/economia , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/economia , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To assess the in-hospital mortality and complications in female between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). BACKGROUND: Female is one of the risk factors for increased adverse events in cardiac surgery. METHODS AND RESULTS: Nationwide Inpatient Sample database was queried from 2011 to 2014 for patients who underwent TAVR or SAVR in female patients. The primary endpoint was in-hospital all-cause mortality and second endpoints were perioperative complications. We performed a propensity score analysis to calculate the adjusted odds ratio (OR) for each outcome. Patients who had concomitant cardiac surgery and those who had TAVR or SAVR mainly for aortic regurgitation were excluded. Our query from 2011 to 2014 resulted in a total of 3,067 TAVR and 18,594 SAVR in female patients. TAVR patients were in general elder and had a higher burden of comorbidities. The primary endpoint was similar between TAVR and SAVR (4.2% vs. 3.9%, OR 1.0, P = 0.89). Compared to SAVR, female TAVR patients had less hemorrhage requiring transfusion (12% vs. 21%, OR 0.41, P < 0.001), perioperative cardiac arrest and nonfatal myocardial infarction (9.8% vs. 17%, OR 0.38, P < 0.001), respiratory complication (1.6% vs. 4.4%, OR 0.28, P < 0.001), post-op sepsis (1.7% vs. 2.9%, OR 0.65, P = 0.03), acute myocardial infarction (3.0% vs. 4.9%, OR 0.60, P < 0.001), and acute kidney injury (15% vs. 18%, OR 0.62, P < 0.001). Conversely, female TAVR patients had significantly increased risk of new pacemaker implantation (11% vs. 5.9%, OR 1.7, P < 0.001) and use of extracorporeal membrane oxygenation (0.66% vs. 0.24%, OR 2.8, P < 0.001). TAVR patients had less nonroutine discharge. The median hospital cost was significantly higher in TAVR than SAVR (median $51,274 vs. $43,677, P < 0.001) but the length of stay was shorter (mean 7.8 days vs. 10.5 days). CONCLUSIONS: TAVR may be a better option for those patients with underlying comorbidities that predispose them at higher risk for complications that was less observed in TAVR group. However, higher cost and increased risk of need for extracorporeal membrane oxygenation, although rare, should be taken into consideration upon deciding the optimal mode for aortic valve replacement.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Complicações Pós-Operatórias/mortalidade , Substituição da Valva Aórtica Transcateter/mortalidade , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Comorbidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/economia , Custos Hospitalares , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/economia , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: There is a concerted push for adopting a minimalist strategy with emphasis on early hospital discharge for patients undergoing Transcatheter aortic valve implantation (TAVI). However, studies on discharge patterns and predictors of early discharge (≤3 days post-TAVI) are sparse, in the United States. METHODS: We analyzed using Healthcare Utilization Project, Nationwide Inpatient Sample database, 2011-2012. A total of 7321 TAVI procedures were identified. We compared in-hospital outcomes between early and late discharge cohorts, and determined the predictors of early discharge. Correlation of costs and post-TAVI length of stay was also performed. RESULTS: Early discharge rate post-TAVI was about 21% in the United States, in 2011-2012. Overall mean age was 81 years. In-hospital adverse outcomes post-TAVI were higher in late discharge cohort (P < 0.001). Mean length of stay post-TAVI (7.7 days vs 2.6 days) and costs ($208 752 vs $157 663) were significantly higher in late discharge than early discharge cohort. Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support, acute kidney injury were associated with significantly lower adjusted odds for early discharge. Transfemoral TAVI approach, prior aortic valvuloplasty, and procedure year 2012 were associated with significantly higher odds for early discharge. We observed positive correlation between costs of hospitalization and post-TAVI length of stay (R = 0.58; P < 0.001). CONCLUSIONS: Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support devices, renal failure were associated with lower odds for early discharge. Transfemoral approach and prior aortic valvuloplasty increased the likelihood for early discharge. Post-TAVI length of stay was associated with significantly higher hospitalization costs.
Assuntos
Estenose da Valva Aórtica , Alta do Paciente , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Peripartum cardiomyopathy (PPCM) is associated with significant morbidity and mortality. Arrhythmogenic causes of death have been implicated in a significant number of patients. However, there is a dearth of systematic studies evaluating the burden of arrhythmias in PPCM. METHODS: We used the Healthcare Utilization Project, Nationwide Inpatient Sample database (2007-2012) and identified 9841 hospitalizations for women aged ≥18years with a primary diagnosis of PPCM. Frequency of arrhythmias, utilization of electrophysiologic procedures, length of stay, hospitalization costs and outcomes associated with arrhythmias were determined. RESULTS: Mean age was 30.05±6.69years. Arrhythmias were present in 18.7% of hospitalized PPCM cohort. Ventricular tachycardia was the most common arrhythmia and was noted in 4.2%. Approximately 2.2% of cases experienced cardiac arrest. Electrical cardioversion was performed in 0.3%, Catheter ablation in 1.9%, PPM implantation in 3.4% and ICD in 6.8% of hospitalizations for PPCM with arrhythmias. In-hospital mortality was 3-times more frequent in arrhythmia cohort (2.1% vs. 0.7%). Hospitalization costs were significantly higher in PPCM with arrhythmias. Elixhauser comorbidity score (adjusted OR:1.10; 95%CI:1.02-1.18; p=0.016), in-hospital mortality (adjusted OR:2.35; 95%CI:1.38-4.02; p=0.002), cardiogenic shock (adjusted OR:2.61; 95%CI:1.44-4.72; p=0.002), utilization of balloon pump (adjusted OR:13.4; 95%CI: 2.55-70.53; p<0.001), Swan-Ganz catheterization (adjusted OR:3.12; 95%CI:1.21-8.06; p=0.019), and coronary angiography (adjusted OR:1.79; 95%CI:1.19-2.70; p=0.005) were significantly associated with arrhythmias in PPCM. CONCLUSIONS: Arrhythmias were present in 18.7% of PPCM related hospitalizations. Morbidity, in-hospital mortality, length of inpatient stay, hospitalization costs and cardiac procedure utilization were significantly higher in the arrhythmia cohort.
Assuntos
Arritmias Cardíacas , Cardiomiopatias , Cardioversão Elétrica/estatística & dados numéricos , Técnicas Eletrofisiológicas Cardíacas , Parada Cardíaca , Complicações Cardiovasculares na Gravidez , Adulto , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/terapia , Cardiomiopatias/complicações , Cardiomiopatias/diagnóstico , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Bases de Dados Factuais/estatística & dados numéricos , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/estatística & dados numéricos , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/mortalidade , Complicações Cardiovasculares na Gravidez/fisiopatologia , Complicações Cardiovasculares na Gravidez/terapia , Análise de Sobrevida , Estados Unidos/epidemiologiaRESUMO
The comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in diabetes mellitus (DM) patients are scarce. We aimed to assess and compare the outcomes of TAVR versus SAVR in DM patients using the Nationwide Inpatient Sample database from 2011 to 2013. A complete case analysis was performed for the multivariate analysis and cases with missing data were excluded. The primary end point was in-patient all-cause mortality and secondary outcomes were perioperative complications. An estimated 5,719 TAVR procedures and 65,096 SAVR procedures were performed among DM patients in the United States between 2011 and 2013. TAVR patients were older (80 ± 8.1 vs 70 ± 10, p <0.001), majority of them were women (45% vs 38%, p <0.001), and predominantly white race (total of 80%). The adjusted odds ratio (OR) for the primary outcome was significantly lower in TAVR patients (2.8% vs 3.6%, OR 0.63, p = 0.02). TAVR patients were also at lower risk for bleeding requiring transfusions (13% vs 20%, OR 0.43, p <0.01), cardiac complications (6.1% vs 14%, OR 0.34, p <0.01), respiratory complications (1.2% vs 3.7%, OR 0.26, p <0.01), postoperative sepsis (1.7% vs 3.6%, OR 0.45, p = 0.03), and acute myocardial infarction (2.5% vs 2.9%, OR 0.62, p <0.01), compared with SAVR patients. Conversely, TAVR patients were at increased risk for vascular complications (5.7% vs 3.9%, OR 1.5, p <0.01) and new pacemaker implantation (10% vs 5.7%, OR 1.5, p <0.01). The mean hospitalization cost was lower for TAVR than SAVR ($58,878 vs $63,869, p = 0.003). Length of stay (median 6 vs 8 days, p <0.001) was shorter in TAVR patients. In conclusion, TAVR may result in better in-hospital outcome than SAVR in DM patients.
Assuntos
Diabetes Mellitus/epidemiologia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Injúria Renal Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Implante de Prótese de Valva Cardíaca/economia , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Infarto do Miocárdio/epidemiologia , Marca-Passo Artificial/estatística & dados numéricos , Sepse/epidemiologia , Substituição da Valva Aórtica Transcateter/economia , Estados Unidos/epidemiologiaRESUMO
The primary objective of our study was to evaluate the in-hospital outcomes in terms of mortality, procedural complications, hospitalization costs, and length of stay (LOS) after multivessel percutaneous coronary intervention (MVPCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, years 2006 to 2012. Percutaneous coronary interventions (PCI) performed during STEMI were identified using appropriate International Classification of Diseases, Ninth Revision, diagnostic and procedural codes. Patients in cardiogenic shock were excluded. Hierarchical mixed-effects logistic regression models were used for categorical dependent variables such as in-hospital mortality and composite of in-hospital mortality and complications, and hierarchical mixed-effects linear regression models were used for continuous dependent variables such as cost of hospitalization and LOS. We identified 106,317 (weighted n = 525,161) single-vessel PCI and 15,282 (weighted n = 74,543) MVPCIs. MVPCI (odds ratio, 95% confidence interval [CI], p value) was not associated with significant increase in in-hospital mortality (0.99, 0.85 to 1.15, 0.863) but predicted a higher composite end point of in-hospital mortality and postprocedural complications (1.09, 1.02 to 1.17, 0.013) compared to single-vessel PCI. MVPCI was also predictive of longer LOS (LOS +0.19 days, 95% CI +0.14 to +0.23 days, p <0.001) and higher hospitalization costs (cost +$4,445, 95% CI +$4,128 to +$4,762, p <0.001). MVPCI performed during STEMI in hemodynamically stable patients is associated with no increase in in-hospital mortality but a higher rate of postprocedural complications and longer LOS and greater hospitalization costs compared to single-vessel PCI.
Assuntos
Custos Hospitalares , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/economia , Estudos de Coortes , Bases de Dados Factuais , Feminino , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Nefropatias/economia , Nefropatias/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Intervenção Coronária Percutânea/economia , Complicações Pós-Operatórias/economia , Hemorragia Pós-Operatória/economia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/terapia , Embolia Pulmonar/economia , Embolia Pulmonar/epidemiologia , Insuficiência Respiratória/economia , Insuficiência Respiratória/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Estados Unidos/epidemiologia , Trombose Venosa/economia , Trombose Venosa/epidemiologia , Adulto JovemRESUMO
PURPOSE: To examine the impact of intravascular ultrasound (IVUS) utilization during lower limb endovascular interventions as regards postprocedural complications and amputation. METHODS: The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database between the years 2006 and 2011. Peripheral endovascular interventions were identified using appropriate ICD-9 procedure codes. Two-level hierarchical multivariate mixed models were created. The co-primary outcomes were in-hospital mortality and amputation; the secondary outcome was postprocedural complications. Model results are given as the odds ratio (OR) and 95% confidence interval (CI). Hospitalization costs were also assessed. RESULTS: Overall, among the 92,714 patients extracted from the database during the observation period, IVUS was used in 1299 (1.4%) patients. IVUS utilization during lower extremity peripheral vascular procedures was independently predictive of a lower rate of postprocedural complications (OR 0.80, 95% CI 0.66 to 0.99, p=0.037) as well as lower amputation rates (OR 0.59, 95% CI 0.45 to 0.77, p<0.001) without any significant impact on in-hospital mortality. Multivariate analysis also revealed IVUS utilization to be predictive of a nonsignificant increase in hospitalization costs ($1333, 95% CI -$167 to +$2833, p=0.082). CONCLUSION: IVUS use during lower limb endovascular interventions is predictive of lower postprocedural complication and amputation rates with a nonsignificant increase in hospitalization costs.
Assuntos
Procedimentos Endovasculares/estatística & dados numéricos , Extremidade Inferior/irrigação sanguínea , Doenças Vasculares Periféricas/terapia , Padrões de Prática Médica , Ultrassonografia de Intervenção/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Distribuição de Qui-Quadrado , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Salvamento de Membro , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/mortalidade , Doenças Vasculares Periféricas/cirurgia , Padrões de Prática Médica/economia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/economia , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Transcatheter mitral valve repair (TMVR) is a complex procedure for patients with mitral regurgitation who cannot get surgery. However, there is a lack of data on how hospital volumes affect these outcomes. METHODS: We performed a cross sectional study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012 and identified subjects using the ICD-9-CM procedure code of 35.97, which was introduced in October 2010 for percutaneous mitral valve repair if present in the primary or secondary procedure field. Hospital volumes were divided into tertiles. The primary outcome was a composite of in-hospital mortality and peri-procedural complications. Length of stay and hospitalization cost were also assessed. RESULTS: A total of 95 (weighted n = 475) TMVR procedures were identified. The mean age of the overall cohort was 70 years; 43.2% were female and 63.2% had a significant baseline burden of co-morbidities. The composite of in-hospital mortality and peri-procedural complications decreased with increasing TMVR hospital volume: 48.7% in the first tertile, 17.4% in the second tertile, and 9.1% in the third tertile. Additionally, we saw a decrease in the length of stay and a trend in decrease in the hospitalization cost. CONCLUSION: In hospitals performing TMVR, higher hospital volumes are associated with a reduction in a composite of in-hospital mortality and post-procedural complications, in addition to the shorter length of stay.
Assuntos
Custos Hospitalares , Hospitais , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/economia , Idoso , Cateterismo Cardíaco/métodos , Estudos Transversais , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Hospitais/classificação , Hospitais/normas , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/economia , Anuloplastia da Valva Mitral/métodos , Anuloplastia da Valva Mitral/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Melhoria de Qualidade , Estados UnidosRESUMO
Transcatheter aortic valve implantation (TAVI) is associated with a significant learning curve. There is paucity of data regarding the effect of hospital volume on outcomes after TAVI. This is a cross-sectional study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012. Subjects were identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes, 35.05 (Trans-femoral/Trans-aortic Replacement of Aortic Valve) and 35.06 (Trans-apical Replacement of Aortic Valve). Annual hospital TAVI volumes were calculated using unique identification numbers and then divided into quartiles. Multivariate logistic regression models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and periprocedural complications. Length of stay (LOS) and cost of hospitalization were assessed. The study included 1,481 TAVIs (weighted n = 7,405). Overall inhospital mortality rate was 5.1%, postprocedural complication rate was 43.4%, median LOS was 6 days, and median cost of hospitalization was $51,975. Inhospital mortality rates decreased with increasing hospital TAVI volume with a rate of 6.4% for lowest volume hospitals (first quartile), 5.9% (second quartile), 5.2% (third quartile), and 2.8% for the highest volume TAVI hospitals (fourth quartile). Complication rates were significantly higher in hospitals with the lowest volume quartile (48.5%) compared to hospitals in the second (44.2%), third (39.7%), and fourth (41.5%) quartiles (p <0.001). Increasing hospital volume was independently predictive of shorter LOS and lower hospitalization costs. In conclusion, higher annual hospital volumes are significantly predictive of reduced postprocedural mortality, complications, shorter LOS, and lower hospitalization costs after TAVI.
Assuntos
Estenose da Valva Aórtica/cirurgia , Custos de Cuidados de Saúde , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Estudos Transversais , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/economia , Resultado do TratamentoRESUMO
Left ventricular (LV) thrombus is one of the most common complications in patients with anterior acute myocardial infarction (AMI) and LV dysfunction. Although anticoagulation is frequently prescribed, data regarding the appropriate drug, duration, risks, and effect on echocardiographic indices of thrombus are lacking. Moreover, given the difficulty in obtaining adequate anticoagulation with warfarin, it is possible that short-term treatment with a more predictable agent would be effective. We randomized 60 patients at high risk of developing LV mural thrombus (anterior acute myocardial infarction with Q waves and ejection fraction≤40%) to receive either enoxaparin 1 mg/kg (maximum 100 mg) subcutaneously every 12 hours for 30 days or traditional anticoagulation (intravenous heparin followed by oral warfarin for 3 months). Clinical evaluations and transthoracic echocardiograms were obtained at baseline, in-hospital, and at 3.5 months. There were no differences between the groups regarding baseline demographics, acute echocardiographic findings, and in-hospital outcomes. The length of hospital stay tended to be shorter for the enoxaparin group (4.6 vs 5.6; p=0.066) and the corresponding hospital costs ($25,837 vs $34,666; p=0.18). At 3 months, bleeding and thromboembolic events were rare and similar between enoxaparin and warfarin groups. Although more patients had probable mural thrombus in the enoxaparin group compared with warfarin at 3.5 months (15% vs 4%; p=0.35), this was not significantly different. In conclusion, the use of enoxaparin tends to shorten hospitalization and lower cost of care. However, at 3.5 months, there appears to be numerically higher (but statistically insignificant) rates of LV thrombus in the enoxaparin group.
Assuntos
Infarto Miocárdico de Parede Anterior/complicações , Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Cardiopatias/prevenção & controle , Trombose/prevenção & controle , Varfarina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Infarto Miocárdico de Parede Anterior/terapia , Feminino , Cardiopatias/etiologia , Heparina/uso terapêutico , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Volume Sistólico , Trombose/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Safety data on percutaneous left atrial appendage closure arises from centers with considerable expertise in the procedure or from clinical trial, which might not be reproducible in clinical practice. We sought to estimate the frequency and predictors of adverse outcomes and costs of percutaneous left atrial appendage closure procedure in the US. METHODS AND RESULTS: The data were obtained from the Nationwide Inpatient Sample from the years 2006 to 2010. The Nationwide Inpatient Sample is the largest all-payer inpatient data set in the US. Complications were calculated using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 268 (weighted=1288) procedures were analyzed. The overall composite rate of mortality or any adverse event was 24.3% (65), with 3.4% patients required open cardiac surgery after procedure. Average length of stay was 4.61±1.05 days and cost of care was 26,024±34,651. Annual hospital procedural volume was significantly associated with reduced complications and mortality (every unit increase: odds ratio, 0.89; 95% confidence interval, 0.85-0.94; P<0.001), decrease in length of stay (every unit increase: hazard ratio, 0.95; 95% confidence interval, 0.92-0.98; P<0.001) and cost of care (every unit increase: hazard ratio, 0.96; 95% confidence interval, 0.93-0.98; P<0.001). CONCLUSIONS: Our study demonstrates that the frequency of inhospital adverse outcomes associated with percutaneous left atrial appendage closure is higher in the real-world population than in clinical trials. We also demonstrate that higher annual hospital volume is associated with safer procedures, with lower length of stay and cost.