Intersection of sepsis, atrial fibrillation, and severe obesity: a population-based analysis in the United States.

BACKGROUND: Atrial fibrillation (AF) is an indicator of poor prognosis in patients with sepsis and can increase the risk of stroke and mortality. Data on the impact of severe obesity on the outcomes of sepsis complicated by AF remains poorly understood. METHODS: National Inpatient Sample (2018) and ICD-10 CM codes were used to identify the principal sepsis admissions with AF. We assessed comorbidities and outcomes of sepsis in people without obesity (BMI < 30) vs. non-severe obesity (BMI 30-35) and severe obesity (BMI > 35) cohorts. We also did a subgroup analysis to further stratify obesity based on metabolic health and analyzed the findings. The primary outcomes were the prevalence and adjusted odds of AF, AF-associated stroke, and all-cause mortality in sepsis by obesity status. Multivariable regression analyses were adjusted for patient- and hospital-level characteristics and comorbidities. RESULTS: Our main analysis showed that of the 1,345,595 sepsis admissions, the severe obesity cohort was the youngest (median age 59 vs. non-severe 64 and people without obesity 68 years). Patients with obesity, who were often female, were more likely to have hypertension, diabetes, congestive heart failure, chronic pulmonary disease, and chronic kidney disease. The crude prevalence of AF was highest in non-severe obesity (19.9%). The adjusted odds of AF in non-severe obesity (OR 1.21; 95% CI:1.16-1.27) and severe obesity patients with sepsis (OR 1.49; 95% CI:1.43-1.55) were significantly higher than in people without obesity (p < 0.001). Paradoxically, the rates of AF-associated stroke (1%, 1.5%, and 1.7%) and in-hospital mortality (3.3%, 4.9%, and 7.1%) were lowest in the severe obesity cohort vs. the non-severe and people without obesity cohorts, respectively. On multivariable regression analyses, the all-cause mortality revealed lower odds in sepsis-AF patients with severe obesity (OR 0.78; 95% CI:0.67-0.91) or non-severe obesity (OR 0.63; 95% CI:0.54-0.74) vs. people without obesity. There was no significant difference in stroke risk. CONCLUSIONS: A higher prevalence of cardiovascular comorbidities can be linked to a higher risk of AF in people with obesity and sepsis. Paradoxically, lower rates of stroke and all-cause mortality secondary to AF in people with obesity and sepsis warrant further investigation.

Impact of obstructive sleep apnoea on cardiovascular outcomes and mortality in young adults with congenital heart anomalies: insights from the national inpatient sample (2019).

BACKGROUND: Obstructive sleep apnoea is a common sleep disorder, and adult congenital heart disease (CHD) is also a significant burden on the population. Early diagnosis and treatment are important for improving quality of life and reducing the risk of health complications. The limited research on obstructive sleep apnoea and adult CHD highlights the need for further investigation into the relationship between these two conditions and the mechanisms underlying this relationship. METHOD: We used NIS 2019 database to identify adult CHD admissions aged 18-44 years and assess the impact of obstructive sleep apnoea on all-cause mortality, dysrhythmia, and stroke. A propensity-matched cohort of individuals with and without obstructive sleep apnoea was obtained, and the outcomes were assessed using multivariable analysis and compared in terms of resource utilisation. RESULTS: Of the 41,950 young adult CHD admissions, 6.3% (n = 2630) had obstructive sleep apnoea. The obstructive sleep apnoea+ (n = 2590) and obstructive sleep apnoea- (n = 2590) cohorts were comparable in terms of median age (35 years) and were predominantly male (63.1% versus 62.5%). The obstructive sleep apnoea+ cohort had a higher frequency of risk factors like chronic obstructive pulmonary disease, hypothyroidism, and prior venous thromboembolism than the obstructive sleep apnoea cohort. We found significant association of obstructive sleep apnoea with dysrhythmia (adjusted odds ratio 2.99, 95% confidence interval 2.13-4.19, p < 0.001), but no significant impact on the risk of all-cause mortality or stroke. The obstructive sleep apnoea+ cohort also had higher transfers to short-term facilities, prolonged stays, and higher charges (p < 0.001). CONCLUSION: Our study provides important insights into relationship between obstructive sleep apnoea and adult CHD and highlights the need for further investigation into the impact of obstructive sleep apnoea on individuals with adult CHD.

Contraception and Cardiovascular Effects: What Should the Cardiologist Know?

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of death in women. This review highlights contraceptive options and their effects on the cardiovascular system (CVS). It provides guidance to cardiologists to make informed decisions regarding the safety of contraceptive use and cardiovascular risk stratification in the care of women of childbearing age. RECENT FINDINGS: Approximately 44% of American women live with some type of CVD. Many women use hormonal contraception during their lifetime. It is imperative that cardiologists have a robust understanding of the forms of contraception in current use and their cardiovascular effects. This contemporary review provides a comprehensive summary of available contraceptive methods to practicing cardiologists and aims to be used as a resource to guide cardiovascular specialists on contraception in the context of cardiovascular disease.

Gender differences in thrombogenicity among patients with angina and non-obstructive coronary artery disease.

Women more often present with angina and non-obstructive coronary artery disease (ANOCA) and have poorer clinical outcomes than men. These findings may be related to sex associated differences in inflammation and thrombogenicity. Consecutive patients (n = 134) with ANOCA (luminal diameter stenosis < 50%) undergoing elective cardiac catheterization were included in post hoc analysis of Multi-Analyte, thrombogenic, and Genetic Markers of Atherosclerosis (MAGMA, NCT01276678) study. Patients with prior revascularization, coronary artery bypass grafting or myocardial infarction were excluded. Blood for thromboelastography, oxidized LDL ß2-glycoprotein complex (AtherOx), oxidized-LDL, lipid profile, and urine for 11-dehydrothromboxane B2 (dTxB2) were obtained before catheterization. All women (n = 75) were post-menopausal and tended to be older than men (61.4 ± 10.6 vs. 58.6 ± 9.9 year, p = 0.12), and were significantly more thrombogenic with higher thrombin-induced platelet-fibrin strength (TIP-FCS, mm) (68.0 ± 4.5 vs. 64.5 ± 6.2 mm, p = 0.001), clotting index (0.35 ± 2.22 vs. - 0.72 ± 2.75, p = 0.02), K (measure of the speed to reach 20 mm of clot strength from an amplitude of 2 mm) (2.2 ± 1.6 vs. 1.7 ± 0.5 min, p = 0.01), and fibrinogen activity (degrees) (66.6 ± 7.1 vs. 62.9 ± 7.5, p = 0.009). Markers of inflammation were not significantly different between the two groups. Women had higher total cholesterol, total LDL, LDL subtypes 1 and 2, total HDL, HDL subtypes 2 and 3, and ApoA1 (p < 0.05 for all). On multivariate regression, TIP-FCS remained significantly higher in women (p < 0.0001). Women with ANOCA are more thrombogenic than men. This fundamental difference in thrombogenicity may affect gender-related outcomes and warrants further investigation.

"Blueprinting" thrombogenicity and antithrombotic drug response at the bedside in patients presenting emergently with symptoms of acute stroke.

Early assessment of thrombogenicity and antithrombotic drug effects may be important for therapeutic decision making in patients presenting with acute stroke. In this prospective, single center, pilot study, a bedside thrombelastography assay (TEG6s) was used to measure thrombogenicity and antithrombotic drug response in serial patients presenting emergently with symptoms of acute stroke (n = 90). TEG6s measures were compared against diagnosis obtained by NIH Stroke Scale/Score and imaging. Acute ischemic stroke (AIS) was diagnosed in 30 patients, intracerebral hemorrhage (ICH) in 19, transient ischemic attack (TIA) in 10 and stroke mimic (SM) in 31. Patients with AIS had a higher prevalence of A-Fib (33.3% vs. 11.6%, p = 0.01), and ACE inhibitor use (56.3% vs. 21.6%, p < 0.001) compared to combined non-AIS group. Time to initial clot formation (R) was shorter in AIS vs. TIA, ICH, and SM (p < 0.05). Comparing patients with AIS and combined non-AIS group the AUC for R was 0.83 (cut point of ≤ 4.8, sensitivity = 67%; specificity = 84%, p < 0.001). In AIS patients, 46% had suboptimal response (< 30% MAAA inhibition) to aspirin and 80% of patients on P2Y12 therapy had high platelet reactivity (> 50% ADP-induced platelet aggregation). Patients receiving tissue plasminogen activator had significant reduction in clot strength and near complete lysis at 30 min which normalized within 2 h after treatment (p < 0.001 for both). The rapid bedside measurement of thrombogenicity and antithrombotic drug effects is feasible in patients presenting with symptoms of acute stroke. Our preliminary data suggest that AIS is associated with faster ex-vivo clot formation, and poor antiplatelet response. Future study of the TEG6s to "blueprint" hemostasis is warranted in the stroke population.

Prevalence and impact of cannabis use disorder on acute ischemic stroke and subsequent mortality in elderly peripheral vascular disease patients: A population-based analysis in the USA (2016 - 2019).

BACKGROUND: Given current evidence linking peripheral atherosclerotic disease, also known as cannabis arteritis, and acute ischemic stroke (AIS) in individuals with cannabis use disorder (CUD), we investigated the frequency and implications of CUD in relation to AIS risk and outcomes among elderly patients with peripheral vascular disease (PVD). METHODS: The National Inpatient Sample (2016-2019) was used to compare geriatric patients with PVD and cannabis use disorder CUD. CUD was correlated with AIS admissions. Adjusted multivariable regression models assessed in-hospital mortality rates. RESULTS: Of 5,115,824 geriatric admissions with PVD, 50.6 % were male and 77.5 % were white. 21,405 admissions had cardiovascular and CUD co-occurrence. 19.7 % of CUD patients had diabetes mellitus (DM), compared to 33.7 % of non-CUD patients. Smoking and HTN rates were comparable between groups. Patients with CUD used more recreational drugs concurrently than those without CUD. AIS prevalence was 5.2 % in CUD patients and 4.0 % in controls (p < 0.001). In the geriatric population with PVD, the presence of CUD was found to be associated with increased odds of hospitalizations due to AIS, with an adjusted odds ratio (aOR) of 1.34 (95 % confidence interval [CI] 1.18-1.52, p < 0.001). All-cause in-hospital mortality was not statistically significant, with an aOR of 0.71 (95 %CI 0.36-1.37, p = 0.302). In our study, older patients with PVD and hypertension (aOR 1.73) had a greater risk of AIS. Intriguingly, when we analyzed AIS predictors in elderly PVD patients with concurrent tobacco use disorder, we identified a counterintuitive protective effect (aOR 0.58, 95 % CI 0.42-0.79, p < 0.001). CONCLUSIONS: Our findings indicate that among geriatric patients with PVD and concurrent CUD, there is a notable 34 % risk of AIS. Importantly, this risk persists despite controlling for other CVD risk factors and substance use. Further investigations are warranted to elucidate and validate the intriguing phenomenon known as the smoker's paradox.

Examining the Role of Cerebral Embolic Protection Devices in Preventing Postoperative Stroke in Patients with a History of Stroke or Transient Ischemic: Insights from the National Inpatient Sample.

Cerebral embolic protection devices (CEPD) during transcatheter aortic valve replacement (TAVR) have been shown to lower the risk of stroke during the procedure. However, their long-term and clinical effects on neuro-cognition are unknown. Therefore, we hypothesized the benefit of CEPD in TAVR patients with a prior history of stroke or transient ischemic attack (TIA). National Inpatient Sample (2019) and International Classification of Diseases, 10th Revision codes were used to identify patients undergoing TAVR with prior stroke or TIA. Propensity-matched analysis was performed to adjust for baseline characteristics and comorbidities. Primary outcome measures were postoperative stroke and all-cause mortality. Length of stay and hospital cost were secondary outcomes. Of 8450 unmatched TAVR patients with prior stroke or TIA in 2019, 1095 (13%) utilized CEPD. After propensity matching previous myocardial infarction (MI), coronary artery bypass grafting, and drug abuse were higher in the TAVR-only cohort. Postoperative stroke rate (1.4% vs 2.2%; P = 0.081) and odds [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.11-2.17; P = 0.341] were lower in the CEPD group. There was no difference in all-cause in-hospital mortality between the 2 groups (0.9% vs 1.0%). Length of stay (3 vs 2 days, P <0.001) and hospital expenditure ($172,711 vs $162,284; P = 0.002) were higher for the TAVR-only cohort. CEPD in TAVR patients with prior stroke or TIA did not show statistically significant postoperative stroke benefits. However, further larger-scale prospective studies are needed to evaluate the long-term neurocognitive benefits of CEPD in these patients. As the use of TAVR continues to expand, optimizing peri-procedural strategies such as the use of CEPD remains a critical area of research to improve patient outcomes.

Impact of D-dimer on in-hospital mortality following aortic dissection: A systematic review and meta-analysis.

BACKGROUND: The utility of D-dimer (DD) as a biomarker for acute aortic dissection (AD) is recognized. Yet, its predictive value for in-hospital mortality remains uncertain and subject to conflicting evidence. AIM: To conduct a meta-analysis of AD-related in-hospital mortality (ADIM) with elevated DD levels. METHODS: We searched PubMed, Scopus, Embase, and Google Scholar for AD and ADIM literature through May 2022. Heterogeneity was assessed using I 2 statistics and effect size (hazard or odds ratio) analysis with random-effects models. Sample size, study type, and patients' mean age were used for subgroup analysis. The significance threshold was P < 0.05. RESULTS: Thirteen studies (3628 patients) were included in our study. The pooled prevalence of ADIM was 20% (95%CI: 15%-25%). Despite comparable demographic characteristics and comorbidities, elevated DD values were associated with higher ADIM risk (unadjusted effect size: 1.94, 95%CI: 1.34-2.8; adjusted effect size: 1.12, 95%CI: 1.05-1.19, P < 0.01). Studies involving patients with a mean age of < 60 years exhibited an increased mortality risk (effect size: 1.43, 95%CI: 1.23-1.67, P < 0.01), whereas no significant difference was observed in studies with a mean age > 60 years. Prospective and larger sample size studies (n > 250) demonstrated a heightened likelihood of ADIM associated with elevated DD levels (effect size: 2.57, 95%CI: 1.30-5.08, P < 0.01 vs effect size: 1.05, 95%CI: 1.00-1.11, P = 0.05, respectively). CONCLUSION: Our meta-analysis shows elevated DD increases in-hospital mortality risk in AD patients, highlighting the need for larger, prospective studies to improve risk prediction models.

Outcomes of cardiac arrest hospitalizations in patients with obesity with versus without prior bariatric surgery status:A nationwide propensity-matched analysis.

Introduction: Prior bariatric surgery (PBS) status in obese patients is thought to curtail the risk of cardiovascular events, but its role in change of outcomes of patients with obesity developing new acute cardiac events such as cardiac arrests (CA) remains largely unknown. Methods: Hospitalizations among adult patients with obesity and CA were identified retrospectively using the National Inpatient Sample (2015 October-2017 December). Propensity-matched analysis (1:1) was performed for sociodemographic/hospital characteristics to identify two cohorts, with (PBS+) or without (PBS-) status. The primary endpoint was in-hospital mortality, and the secondary endpoint was healthcare resource utilization. Results: Both cohorts (n = 1275 each), had patients with comparable age (mean 58 years), with a higher frequency of white (>70 %), females (>60 %), and Medicare enrollees (>40 %). PBS + cohort had lower rates of diabetes (27.8 % vs 36.1 %), hyperlipidemia (33.7 % vs 48.6 %), renal failure (17.3 % vs 22.0 %), chronic pulmonary disease (11.8 % vs 21.2 %) and higher rates of anemias (18.4 % vs 12.2 %), liver disease (5.1 % vs 2.4 %) and alcohol abuse (6.7 % vs 2.4 %) than PBS- cohort (p < 0.05). All-cause mortality (46.3 % vs 45.1 %, p = 0.551) was comparable between the two cohorts. The PBS + cohort was less often transferred routinely (p<0.001) but had a shorter hospital stay (p<0.001) with equivalent hospital charges compared to the PBS- cohort. Conclusions: The PBS status (regardless of chronology) did not increase survival in CA admissions among patients with obesity. Preventive measures are necessary to manage enduring cardiovascular disease risk factors that may limit the advantages of surgery for patients with obesity and aggravate the worse outcomes of future cardiac events.

Key hypertension breakthroughs and emerging trends from the AHA's scientific sessions.

We aim to summarize selected late-breaking science on hypertension management strategies and disease presented at the 2023 American Heart Association (AHA) conference. The trials discussed below encompass stricter goals of blood pressure management and were expanded into different population groups from different countries with varied socioeconomic backgrounds and settings, collectively advancing our understanding of hypertension treatment and its impact on public health. We summarized the china rural health care project (CRHCP), a four-year study involving over 34,000 participants in rural China, emphasizing the potential of stricter blood pressure goals in lowering the incidence of all-cause dementia and cognitive impairment. Next, we explore the US-based CARDIA-SSBP study, which highlights the impact of dietary sodium on systolic blood pressure in middle-aged individuals. Through a randomized-order cross-over design, the study provides compelling evidence supporting the effectiveness of sodium reduction as a non-pharmacological approach to blood pressure control. The UK-based POP-HT trial offers critical insights into postpartum women with a history of hypertensive pregnancy. The trial emphasizes the benefits of self-monitoring and physician-optimized antihypertensive titration, showcasing significant blood pressure reductions in the intervention group. Furthermore, the KARDIA-1 study introduces us to Zilebesiran, an innovative RNA interference drug. This phase 2 study highlights its potential for achieving sustained blood pressure reductions and its favorable safety profile, marking a significant step forward in hypertension treatment. Lastly, we expand the practical application of the previously conducted landmark SPRINT trial, which showed cardiovascular benefit with intensive SBP control to less than 120 mm Hg in high-risk non-diabetic patients with hypertension compared with routine BP control to <140 mm Hg. The ESPRIT trial and the IMPACTS trial build upon the SPRINT trial, demonstrating the effects of intensive blood pressure lowering in Asian hypertensive patients and in 36 health care clinics in medically underserved states in the US: Louisiana and Mississippi. The IMPACTS trial and the "Hypertension Treatment in Nigeria Program" demonstrate the effectiveness of implementing comprehensive blood pressure control strategies in real-world settings. These studies highlight the feasibility and scalability of such interventions, especially in low-resource environments, and their potential to significantly improve public health outcomes.

Which should you choose for post operative atrial fibrillation, carvedilol or metoprolol? A systemic review and meta-analysis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. Current guidelines suggest beta-blockers for the prevention of POAF. In comparing metoprolol succinate with carvedilol, the later has sparked interest in its usage as an important medication for POAF prevention. METHODS: We considered randomized controlled studies (RCTs) and retrospective studies that evaluated the efficacy of carvedilol versus metoprolol for the prevention of POAF. After literature search, data extraction, and quality evaluation, pooled data were analyzed using either the fixed-effect or random-effect model using Review Manager 5.3. The Cochrane risk of bias tool was used to assess the bias of included studies. The incidence of POAF was the primary endpoint, while mortality rate and bradycardia were secondary outcomes. RESULTS: In meta-analysis 5 RCTs and 2 retrospective studies with a total of 1000 patients were included. The overall effect did not favor the carvedilol over metoprolol groups in terms of mortality rate [risk ratio 0.45, 95 % CI (0.1-1.97), P=0.29] or incidence of bradycardia [risk ratio 0.63, 95 % CI (0.32-1.23), P=0.17]. However, the incidence of POAF was lower in patients who received carvedilol compared to metoprolol [risk ratio 0.54, 95 % CI (0.42-0.71), P < 0.00001]. CONCLUSION: In patients undergoing cardiac surgery, carvedilol may minimize the occurrence of POAF more effectively than metoprolol. To definitively establish the efficacy of carvedilol compared to metoprolol and other beta-blockers in the prevention of POAF, a large-scale, well-designed randomized controlled trials are required.

Does Statin Use in Frail Patients Provide Survival Benefits? Insights From a Meta-Analysis.

Frailty is a complex syndrome that increases with age and predisposes older adults to adverse outcomes, including mortality. Statins are proven to lower the risk of atherosclerotic cardiovascular disease, but there is limited data on their survival benefit in frail older people. This meta-analysis was conducted to determine whether statins can lower mortality in frail persons. A comprehensive search of PubMed, Google Scholar, and SCOPUS was conducted until September 2022 to identify studies reporting mortality outcomes with statin therapy in adults aged 75 with a validated frailty assessment. The pooled odds ratio for all-cause mortality was calculated using a random effects model. Leave-one-out method was used for sensitivity analysis. Of 5 studies (2013-2022) included (Total = 14,324, 3 prospective and 2 retrospectives, Males: 49%, Mean follow-up duration: 4.7 years), 41.6% (5971/14,324) were frail. 52.7% of patients were on a moderate-dose/no-statin, while 47.2% took a high-dose statin. Nonstatin users were older (83.35 vs 81.5) than users. Frail patients often had diabetes, hypertension, hyperlipidemia, a history of Stroke/MI, and dementia. High-dose atorvastatin was the most used statin. Pooled analysis revealed that statins lower all-cause mortality in elderly adults, however, the association was not significant (OR 0.67, 95% CI 0.38-1.18; P = 0.17). The meta-analysis demonstrated that using statins to reduce mortality in frail patients does not appear justifiable. Further prospective studies are needed to guide statin use among frail older adults for survival benefits.

Rising Trends in Metabolically Healthy Obesity in Cancer Patients and Its Impact on Cardiovascular Events: Insights from a Contemporary Nationwide Analysis in the USA (2016-2020).

Background: Obesity or overweight raises the risk of developing 13 types of cancer, representing 40% of all cancers diagnosed in the United States annually. Given the ongoing debate surrounding the impact of metabolically healthy obesity (MHO) on cardiovascular outcomes, it is crucial to comprehend the incidence of Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs) and the influence of MHO on these outcomes in cancer patients. Methods: Data of hospitalized cancer patients with and without obesity were analyzed from the National Inpatient Sample 2016-2020. Metabolically healthy patients were identified by excluding diabetes, hypertension, and hyperlipidemia using Elixhauser comorbidity software, v.2022.1. After that, we performed a multivariable regression analysis for in-hospital MACCEs and other individual outcomes. Results: We identified 3,111,824 cancer-related hospitalizations between 2016 and 2020. The MHO cohort had 199,580 patients (6.4%), whereas the MHnO (metabolically healthy non-obese) cohort had 2,912,244 patients (93.6%). The MHO cohort had a higher proportion of females, Blacks, and Hispanics. Outcomes including in-hospital MACCEs (7.9% vs. 9.5%; p < 0.001), all-cause mortality (6.1% vs. 7.5%; p < 0.001), and acute myocardial infarction (AMI) (1.5% vs. 1.6%; p < 0.001) were lower in the MHO cohort compared to the MHnO cohort. Upon adjusting for the baseline characteristics, the MHO group had lower odds of in-hospital MACCEs [adjusted odds ratio (AOR) = 0.93, 95% CI (0.90-0.97), p < 0.001], all-cause mortality [AOR = 0.91, 95% CI (0.87-0.94); p < 0.001], and acute ischemic stroke (AIS) [AOR = 0.76, 95% CI (0.69-0.84); p < 0.001], whereas there were higher odds of acute myocardial infarction (AMI) [AOR = 1.08, 95% CI (1.01-1.16); p < 0.001] and cardiac arrest (CA) [AOR = 1.26, 95% CI (1.01-1.57); p = 0.045] in the MHO cohort compared to the MHnO cohort. Conclusions: Hospitalized cancer patients with MHO exhibited a lower prevalence of in-hospital MACCEs than those with MHnO. Additional prospective studies and randomized clinical trials are imperative to validate these findings, particularly in stratifying MHO across various cancer types and their corresponding risks of in-hospital MACCEs.

Examining prevalence and predictors of pulmonary hypertension in adults with idiopathic pulmonary fibrosis: a population-based analysis in the United States.

Pulmonary hypertension (PH) often complicates idiopathic pulmonary fibrosis (IPF), a progressive parenchymal lung disease. We investigated predictors of PH in IPF hospitalizations in the United States. We identified IPF hospital- izations with or without PH using the National Inpatient Sample (2018) and relevant ICD-10-CM codes. We com- pared demographics, comorbidities, PH prevalence, and its multivariable predictors adjusted for confounders among patients with IPF. In 2018, 30,335 patients from 30,259,863 hospitalizations had IPF, of which 8,075 (26.6%) had PH. Black (41%), Hispanic (21.3%), and female (28.7%) patients had higher rates of PH compared to white patients (25%). The IPF-PH cohort was hospitalized more often in urban teaching (77.7% vs. 72.2%), Midwest, and West hospitals vs. non-PH cohort. Comorbidities including congestive heart failure (2.08 [1.81-2.39]), valvular disease (2.12 [1.74-2.58]), rheumatoid arthritis/collagen vascular disease (1.32 [1.08-1.61]) predicted higher odds of PH. The PH-IPF cohort was less often routinely discharged (35.4%) and more likely to be transferred to intermediate care facilities (22.6%) and home health care (27.1%) (P < 0.001). The PH-IPF group had higher rates of all-cause mortality (12.3% vs. 9.4%), cardiogenic shock (2.4% vs. 1%), dysrhythmia (37.6% vs. 29%), and cardiac arrest (2.7% vs. 1.5%) vs. non-PH cohort (all P < 0.001). Patients with PH-IPF also had longer hospital stays (9 vs. 8) and a higher median cost ($23,054 vs. $19,627, P < 0.001). Nearly 25% of IPF hospitalizations with PH were linked to higher mortality, extended stays, and costs, emphasizing the need to integrate demographic and comorbidity predictors into risk stratification for improved outcomes in patients with IPF-PH.

Association of Cannabis Use Disorder With Hospitalizations for Pulmonary Embolism and Subsequent in-Hospital Mortality in Young Adults: A Contemporary Nationwide Analysis.

BACKGROUND: With the increase in popularity of cannabis and its use and the lack of large-scale data on cannabis use and venous thromboembolism and pulmonary embolism (PE), we used a nationally representative cohort of young adults (aged 18-44 years) to compare the odds of admissions and in-hospital mortality of PE with and without cannabis use disorder (CUD). METHODS AND RESULTS: Identified patients with PE using the National Inpatient Sample (2018) were compared for baseline, comorbidities, and outcomes. Multivariable regression analysis, adjusted for covariates, was used to compare the odds of PE in young patients with CUD (CUD+) versus those without (CUD-) and those with prior venous thromboembolism. Propensity score-matched analysis (1:6) was also performed to assess in-hospital outcomes. A total of 61 965 (0.7%) of 8 438 858 young adult admissions in 2018 were PE related, of which 1705 (0.6%) had CUD+. On both unadjusted (odds ratio, 0.80 [95% CI, 0.71-0.90]; P<0.001) and adjusted regression analyses, the CUD+ cohort had a lower risk of PE admission. The CUD+ cohort had fewer routine discharges (58.3% versus 68.3%) and higher transfers to short-term (7.9% versus 4.8%) and nursing/intermediate care (12.6% versus 9.5%) (P<0.001). The PE-CUD+ cohort of in-hospital mortality did not differ from the CUD- cohort. Propensity score-matched (1:6) analysis revealed comparable mortality odds with higher median hospital stay and cost in the CUD+ cohort. CONCLUSIONS: Young adults with CUD demonstrated lower odds of PE hospitalizations without any association with subsequent in-hospital mortality. The median hospital stay of the CUD+ cohort was longer, they were often transferred to other facilities, and they had a higher cost.

Comparing the efficacy and safety of endovascular therapy versus surgical revascularization for critical limb-threatening ischemia: A systematic review and Meta-analysis.

INTRODUCTION: Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral artery disease (PAD) that can lead to limb amputation and significantly reduce quality of life. In addition to guideline-directed medical therapy (GDMT), endovascular therapy and surgical revascularization are the two revascularization options for CLTI. In recent years, there has been an ongoing debate about the best approach for CLTI patients. The purpose of this meta-analysis is to examine the current evidence and compare the clinical outcomes of endovascular therapy and surgical revascularization for CLTI. METHODS: We conducted a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) for studies comparing the outcomes of endovascular therapy versus surgery in patients with CLTI. The primary outcomes were major adverse limb events (MALE) and major adverse cardiovascular events (MACE), while secondary outcomes included risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and length of hospital stay. Pooled data was analyzed using the fixed-effect model or the random-effect model in Review Manager 5.3. The Newcastle-Ottawa Scale and Cochrane risk of bias assessment tool were used to assess the bias of included studies. RESULTS: A total of 16 studies (47,609 patients) were included in this meta-analysis. The overall effect favors surgery over endovascular intervention in terms of MALE [odds ratio (OR) 1.13, 95% CI (1.01-1.28), P = 0.04]. Endovascular therapy is associated with lower MACE rates compared to surgery [OR 0.62, 95% CI (0.51-0.76), P < 0.00001]. Furthermore, the risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure as well as the length of hospital stay was lower for endovascular intervention. Finally, there was no statistically significant difference in 30-day mortality between the two groups [OR 0.94, 95% CI 0.79-1.12, P = 0.52; Fig. 3i], and the pooled studies were homogeneous [P = 0.39; I2 = 5%]. CONCLUSION: Surgery may be the preferred treatment option for CLTI patients, as it is associated with a lower risk of MALE than endovascular therapy. However, endovascular therapy may be associated with a lower risk of MACE and lower rates of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and shorter hospital stays. There was no statistically significant difference in 30-day mortality between the two groups. Ultimately, the decision to use endovascular therapy or surgery as the primary treatment strategy should be based on a multi-disciplinary team approach with careful consideration of patient characteristics and anatomy.

Cardiovascular Disease Burden and Major Adverse Cardiac Events in Young Black Patients: A National Analysis of 2 Cohorts 10 Years Apart (2017 Versus 2007).

Background We aim to compare the burden of cardiovascular disease risk factors and major adverse cardiac events and in-hospital outcomes among young Black patients (aged 18-44 years) hospitalized in 2007 and 2017 using data obtained from the National Inpatient Sample database. Method and Results Comparison of the sociodemographic characteristics, comorbidities, and inpatient outcomes, including major adverse cardiac events (all-cause mortality, acute myocardial infarction, cardiogenic shock, cardiac arrest, ventricular fibrillation/flutter, pulmonary embolism, and coronary intervention), between 2017 and 2007 was performed. Multivariable analyses were performed, controlling for potential covariates. A total of 2 922 743 (mean age, 31 years; 70.3% women) admissions among young Black individuals were studied (1 341 068 in 2007 and 1 581 675 in 2017). The 2017 cohort had a younger population (mean, 30 versus 31 years; P<0.001), more male patients (30.4% versus 28.8%; P<0.001), and patients with higher nonelective admissions (76.8% versus 75%; P<0.001), and showed an increasing burden of traditional cardiometabolic comorbidities, congestive heart failure, chronic pulmonary disease, coagulopathy, depression, along with notable reductions in alcohol abuse and drug abuse, compared with the 2007 cohort. The adjusted multivariable analysis showed worsening in-hospital outcomes, including major adverse cardiac events (adjusted odds ratio [aOR], 1.21), acute myocardial infarction (aOR, 1.34), cardiogenic shock (aOR, 3.12), atrial fibrillation/flutter (aOR, 1.34), ventricular fibrillation/flutter (aOR, 1.32), cardiac arrest (aOR, 2.55), pulmonary embolism (aOR, 1.89), and stroke (aOR, 1.53). The 2017 cohort showed a decreased rate of percutaneous coronary intervention/coronary artery bypass grafting and all-cause mortality versus the 2007 cohort (P<0.001). Conclusions In conclusion, young Black patients have had an increasing burden of cardiovascular disease risk factors and worsened in-hospital outcomes, including major adverse cardiac events and stroke, in the past decade, although with improved survival odds.

Role of Intravascular Ultrasound in Pulmonary Embolism Patients Undergoing Mechanical Thrombectomy: A Systematic Review.

BACKGROUND: Traditionally, mechanical thrombectomy performed for pulmonary embolism (PE) necessitates the utilization of iodinated contrast. Intravascular ultrasound (IVUS) has been used as a diagnostic and therapeutic modality in the management of acute high and intermediate-risk PE. Recently, with the shortage of contrast supplies and the considerable incidence of contrast-induced acute kidney injury (CI-AKI), other safer and more feasible IVUS methods have become desirable. The purpose of this systematic review was to evaluate the importance of IVUS in patients with PE undergoing thrombectomy. METHODS: Medline/PubMed, Embase, Scopus, and Google Scholar were searched for review studies, case reports, and case series. Clinical characteristics, outcomes and the usage of IVUS-guided mechanical thrombectomy during the treatment of acute high and intermediate-risk PE were examined in a descriptive analysis. RESULTS: In this systematic review, we included one prospective study, two case series, and two case reports from July 2019 to May 2023. A total of 39 patients were evaluated; most were female (53.8%). The main presenting symptoms were dyspnea and chest pain (79.5%); three patients (7.9%) presented with syncope, one with shock and one with cardiac arrest. Biomarkers (troponin and BNP) were elevated in 94.6% of patients. Most patients (87.2%) had intermediate-risk PE, and 12.8% had high-risk PE. All patients presented with right-heart strain (RV/LV ratio ≥ 0.9, n = 39). Most patients (56.4%) had bilateral PE. Mechanical thrombectomy was performed using IVUS without contrast utilization in 39.4% of the patients. After the initial learning curve, contrast usage decreased gradually over time. There was a significant decrease in the composite mean arterial pressure immediately following IVUS-guided thrombectomy from 35.1 ± 7.2 to 25.2 ± 8.3 mmHg (p < 0.001). Post-procedure, there was no reported (0%) CI-AKI, no all-cause mortality, no major bleeding, or other adverse events. There was a significant improvement in symptoms and RV function at the mean follow-up. CONCLUSIONS: New evidence suggests that IVUS-guided mechanical thrombectomy is safe, with visualization of the thrombus for optimal intervention, and reduces contrast exposure.

Cardiovascular Disease Risk Factors and Outcomes of Acute Myocardial Infarction in Young Adults: Evidence From 2 Nationwide Cohorts in the United States a Decade Apart.

The purpose of this study was to evaluate 2 national in-patient cohorts of young adults (18-44 years) hospitalized with acute myocardial infarction (AMI) a decade apart to highlight its prevalence, associated comorbidities, and in-hospital outcomes. We identified hospitalizations for AMI in young adults in 2007 and 2017 using the weighted data from the National Inpatient Sample. We compared admission rates, sociodemographic characteristics, in-hospital morbidity, complications, mortality, rate of coronary interventions, and healthcare utilization between the 2 cohorts. We found that the admission rate of AMI increased among young adults in 2017 vs 2007. The overall admission rate was higher in males, although with a decline (77.1% vs 66.1%), whereas it rose from 28.9% to 33.9% in females. Hypertension (47.8% vs 60.7%), smoking (49.7% vs 55.8%), obesity (14.8% vs 26.8%), and diabetes mellitus (22.0% vs 25.6%) increased in the 2017 cohort. Post-AMI complications: cardiogenic shock (aOR = 1.16 [1.06-1.27]) and fatal arrhythmias heightened with comparable all-cause mortality (aOR = 1.01 [0.93-1.10], P = 0.749). Reperfusion interventions, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) decreased in the 2017 cohort (PCI; aOR = 0.95 [0.91-0.98], CABG; aOR = 0.66 [0.61-0.71], P < 0.001). Our study highlights the rise in AMI hospitalizations, plateauing of mortality, sex-based and racial disparities, the surge in post-MI complications, and a reassuring decline in the requirement of reperfusion interventions in young AMI patients over the decade.

Rising Burden of Cardiovascular Disease Risk Factors and Acute Cardiac Events in Young Adults With Comorbid Depression: A Comparison Nationwide US Cohorts Hospitalized 10-years Apart.

Depression and coronary artery disease are leading causes of mortality in adults in high-income countries. Due to the paucity of data on the young, we aimed to investigate the prevalence of cardiovascular disease (CVD) risk factors and associated major adverse cardiac and cerebrovascular events (MACCE) in young adults hospitalized with comorbid depression a decade apart. We conducted a retrospective analysis of the National Inpatient Sample Database for the years 2007 and 2017. Young adults (18-44 years) hospitalized with comorbid depression were identified using ICD-9 CM/ICD-10 codes. Frequency and trends in demographics, comorbidities including CVD risk factors, and MACCE have been compared between the 2017 vs 2007 cohorts. A total of 1,274,118 admissions with a median age of 34 years and 68.7% of females were recorded with comorbid depression. When the 2007 cohort was compared with the 2017 cohort, a rising trend in depression was observed (5.5% vs 8.2%, P < 0.001). The 2017 cohort of young adults with depression more often consisted of male, non-white patients. The burden of CVD risk factors such as hypertension, diabetes with chronic complications, smoking, and obesity was also greater in the 2017 cohort. Although the all-cause mortality remained comparable (0.3%) in both cohorts, there was a significantly higher rate and risk of MACCE including acute myocardial infarction (aOR 1.18, 95%CI:1.10-1.26), atrial fibrillation or flutter (aOR 1.47, 95%CI:1.40-1.54) and stroke (aOR 1.33, 95%CI: 1.26-1.40) (P < 0.001) in the 2017 cohort. In conclusion, this nationwide study reveals an alarmingly increased prevalence of CVD risk factors and an increase in the rate and risk of MACCE in 2 cohorts of young adults with comorbid depression studied a decade apart. The burden of mental disorders in young adults has been rising in the last decade and warrants extra vigilance by clinicians to recognize and manage depression to curtail CVD risk and improve MACE-associated outcomes.