Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study.

OBJECTIVE: To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS: Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS: In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. CONCLUSIONS: In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.

Racial and ethnic disparities in the management and outcomes of cardiogenic shock complicating acute myocardial infarction.

BACKGROUND: It remains unclear if there remain racial/ethnic differences in the management and in-hospital outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in contemporary practice. METHODS: We used the National inpatient Sample (2012-2017) to identify a cohort of adult AMI-CS hospitalizations. Race was classified as White, Black and Others (Hispanic, Asian/Pacific Islander, Native Americans). Primary outcome of interest was in-hospital mortality, and secondary outcomes included use of invasive cardiac procedures, length of hospital stay and discharge disposition. RESULTS: Among 203,905 AMI-CS admissions, 70.4% were White, 8.1% were Black and 15.7% belonged to Other races. Black AMI-CS admissions were more often female, with lower socio-economic status, greater comorbidity, and higher rates of non-ST-segment-elevation AMI-CS, cardiac arrest, and multi-organ failure. Compared to White AMI-CS admissions, Black and Other races had lower rates of coronary angiography (75.3% vs 69.3% vs 73.6%), percutaneous coronary intervention (52.7% vs 48.6% vs 54.8%), and mechanical circulatory devices (48.3% vs 42.8% vs 43.7%) (all p < 0.001). Unadjusted in-hospital mortality was comparable between White (33.3%) and Black (33.8%) admissions, but lower for other races (32.1%). Adjusted analysis with White race as the reference identified lower in-hospital mortality for Black (odds ratio [OR] 0.85 [95% confidence interval {CI} 0.82-0.88]; p < 0.001) and Other races (OR 0.97 [95% CI 0.94-1.00]; p = 0.02). Admissions of Black race had longer hospital stay, and less frequent discharges to home. CONCLUSIONS: Contrary to previous studies, we identified Black and Other race AMI-CS admissions had lower in-hospital mortality despite lower rates of cardiac procedures when compared to White admissions.

Reporting of sex as a variable in cardiovascular studies using cultured cells: A systematic review.

Reporting the sex of biological material is critical for transparency and reproducibility in science. This study examined the reporting of the sex of cells used in cardiovascular studies. Articles from 16 cardiovascular journals that publish peer-reviewed studies in cardiovascular physiology and pharmacology in the year 2018 were systematically reviewed using terms "cultured" and "cells." Data were collected on the sex of cells, the species from which the cells were isolated, and the type of cells, and summarized as a systematic review. Sex was reported in 88 (38.6%) of the 228 studies meeting inclusion criteria. Reporting rates varied with Circulation, Cardiovascular Research and American Journal of Physiology: Heart and Circulatory Physiology having the highest rates of sex reporting (>50%). A majority of the studies used cells from male (54.5%) or both male and female animals (32.9%). Humans (31.8%), rats (20.4%), and mice (43.8%) were the most common sources for cells. Cardiac myocytes were the most commonly used cell type (37.0%). Overall reporting of sex of experimental material remains below 50% and is inconsistent among journals. Sex chromosomes in cells have the potential to affect protein expression and molecular signaling pathways and should be consistently reported.

Body Mass Index and In-Hospital Management and Outcomes of Acute Myocardial Infarction.

Background and Objectives: Contemporary data on the prevalence, management and outcomes of acute myocardial infarction (AMI) in relation to body mass index (BMI) are limited. Materials and Methods: Using the National Inpatient Sample from 2008 through 2017, we identified adult AMI hospitalizations and categorized them into underweight (BMI < 19.9 kg/m2), normal BMI and overweight/obese (BMI > 24.9 kg/m2) groups. We evaluated in-hospital mortality, utilization of cardiac procedures and resource utilization among these groups. Results: Among 6,089,979 admissions for AMI, 38,070 (0.6%) were underweight, 5,094,721 (83.7%) had normal BMI, and 957,188 (15.7%) were overweight or obese. Over the study period, an increase in the prevalence of AMI was observed in underweight and overweight/obese admissions. Underweight AMI admissions were, on average, older, with higher comorbidity, whereas overweight/obese admissions were younger and had lower comorbidity. In comparison to the normal BMI and overweight/obese categories, significantly lower use of coronary angiography (62.3% vs. 74.6% vs. 37.9%) and PCI (40.8% vs. 47.7% vs. 19.6%) was observed in underweight admissions (all p < 0.001). The underweight category was associated with significantly higher in-hospital mortality (10.0% vs. 5.5%; OR 1.23 (95% CI 1.18-1.27), p < 0.001), whereas being overweight/obese was associated with significantly lower in-hospital mortality compared to normal BMI admissions (3.1% vs. 5.5%; OR 0.73 (95% CI 0.72-0.74), p < 0.001). Underweight AMI admissions had longer lengths of in-hospital stay with frequent discharges to skilled nursing facilities, while overweight/obese admissions had higher hospitalization costs. Conclusions: In-hospital management and outcomes of AMI vary by BMI. Underweight status was associated with worse outcomes, whereas the obesity paradox was apparent, with better outcomes for overweight/obese admissions.

Epidemiology of in-hospital cardiac arrest complicating non-ST-segment elevation myocardial infarction receiving early coronary angiography.

In the period between 2000 and 2014, 584,704 admissions with non-ST-segment elevation myocardial infarction that received early coronary angiography (day zero) were identified from the National Inpatient Sample. In-hospital cardiac arrest was noted in 4349 (0.8%), of which ~47% were from ventricular arrhythmias and ~90% of occurred within ≤4 days. Non-ST-segment elevation myocardial infarction admissions with in-hospital cardiac arrest had higher in-hospital mortality compared to those without (61% vs. 1.6%) with an unchanged temporal trend of in-hospital cardiac arrest rates (adjusted odds ratio 1.29 [95% confidence interval 0.73-2.28]) in 2014 compared to 2000).

Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis.

BACKGROUND: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

Boerhaave Syndrome Presenting as Tension Pneumothorax: First Reported North American Case.

Tension pneumothorax is a rare and potentially life-threatening clinical complication. A 43-year-old Caucasian woman with type 1 diabetes mellitus presented with nausea and retching and examination revealed dehydration. Laboratory parameters were consistent with a diagnosis of diabetic ketoacidosis, which responded to therapy. Suddenly, 30 hours later, she developed cardiorespiratory compromise due to a tension pneumothorax. After emergent decompression and catheter placement, computerized tomographic scan of the chest demonstrated esophageal-pleural fistula confirming Boerhaave syndrome as the etiology for the pneumothorax. The patient underwent emergent esophagectomy with pleural washout with a subsequent gastric pull-up surgery. Boerhaave syndrome frequently presents atypically with chest pain, dyspnea, and nausea. It communicates with the left pleural space in 80% to 90% of cases, but <5% of cases involve the right pleural cavity. Unexplained and rapidly progressive pleural effusions have been associated with this entity. Only 4 cases of Boerhaave syndrome causing tension pneumothorax have been reported in the literature so far.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Left ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008-2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.

Sex differences in acute cardiovascular care: a review and needs assessment.

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in Patients With Current and Historical Cancer: An 18-Year United States Cohort Study.

BACKGROUND: Data regarding cardiac arrest (CA) complicating acute myocardial infarction (AMI) in patients with cancers are limited. METHODS: Using the HCUP-NIS database (2000-2017), we identified adult admissions with AMI-CA and current or historical cancers to evaluate in-hospital mortality, utilization of coronary angiography, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), mechanical circulatory support (MCS), palliative care consultation, do-not-resuscitate status use, among those with current, historical and without cancer. RESULTS: Of 11,622,528 AMI admissions, CA was noted in 584,263 (5.0%). Current and historical cancers were identified in 14,790 (2.5%) and 26,939 (4.6%), respectively. Both current and historical cancer groups were on average older, of white race, had greater comorbidity, and received care at small/medium-sized hospitals compared to those without. The current cancer cohort had the lowest rates of coronary angiography (45.2% vs. 59.2% vs. 63.3%), PCI (32.4% vs. 42.3% vs. 47.0%), MCS (13.5% vs. 16.5% vs. 20.9%) and CABG (4.1% vs. 7.6% vs. 10.2%) compared to the historical cancer and no cancer cohorts (all p < 0.001). Compared to those without, the current (61.1% vs. 44.0%; adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.20-1.31], p < 0.001) and historical cancer cohorts (52.2% vs. 44.0%; adjusted OR 1.05 [95% CI 1.01-1.08], p = 0.003) had higher in-hospital mortality. Cancer admissions had higher rates of palliative care consultations and do-not-resuscitate status. CONCLUSION: AMI-CA admissions with cancer were older, had lower utilization of cardiac procedures, and higher rates of palliative care and do-not-resuscitate status and in-hospital mortality compared to those without cancer.

Acute myocardial infarction in heart transplant recipients: An 18-year national study.

Among 11,622,528 acute myocardial infarction (AMI) hospitalizations, 892 had a history of heart transplantation (HT). In comparison to AMI admissions without HT, those with prior HT were more frequently complicated with cardiac arrest (8.3 % vs 5.0 %, p < 0.001), acute non-cardiac organ failure (17.4 % vs 9.4 %) (p < 0.001), lower rates of coronary angiography (55.4 % vs 63.6 %, p < 0.001), comparable rates of percutaneous coronary intervention (38.8 % vs 41.5 %, p = 0.10), higher rates of pulmonary artery catheterization (2.7 % vs 1.1 %, p < 0.001), invasive mechanical ventilation and acute hemodialysis compared to AMI admissions without HT. Compared to AMI admissions without HT, prior HT recipients had higher in-hospital mortality (11.8 % vs 6.2 %, adjusted odds ratio 2.87 [95 % CI 2.23-3.70]; p < 0.001).

Hospital-Level Disparities in the Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction.

There are limited contemporary data evaluating the relation between hospital characteristics and outcomes of patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). As such, we used the National Inpatient Sample database (2000 to 2017), to identify adult admissions with primary diagnosis of AMI and concomitant CA. Interhospital transfers were excluded, and hospitals were classified based on location and teaching status (rural, urban nonteaching, and urban teaching) and bed size (small, medium, and large). Among 494,083 AMI-CA admissions, 9.3% received care at rural hospitals, 43.4% at urban nonteaching hospitals, and 47.3% at urban teaching hospitals. Compared with urban nonteaching and teaching hospitals, AMI-CA admissions at rural hospitals received lower rates of cardiac and noncardiac procedures. Admissions to urban teaching hospitals had higher rates of acute organ failure, concomitant cardiogenic shock, and cardiac and noncardiac procedures. When hospitals were stratified by bed size, 9.8% of AMI-CA admissions were admitted to small capacity hospitals, 26.0% to medium capacity, and 64.2% to large capacity hospitals. The use of cardiac and noncardiac procedures was lower in small hospitals with higher rates of use in medium and large hospitals. In-hospital mortality was higher in urban nonteaching (adjusted odds ratio [OR] 1.17; 95% confidence interval [CI]1.14 to 1.20; p <0.001) and urban teaching hospitals (adjusted OR 1.36; 95% CI 1.32 to 1.39; p <0.001) compared with rural hospitals. Compared with small hospitals, medium (adjusted OR 1.11; 95% CI 1.08 to 1.14; p <0.001) and large hospitals (adjusted OR 1.22; 95% CI 1.19 to 1.25; p <0.001) were associated with higher in-hospital mortality. In conclusion, AMI-CA admissions to large and urban hospitals had higher in-hospital mortality compared with small and rural hospitals potentially owing to greater acuity.

Temporal Trends, Predictors and Outcomes of Inpatient Palliative Care Use in Cardiac Arrest Complicating Acute Myocardial Infarction.

BACKGROUND: Utilization of inpatient palliative care services (PCS) has been infrequently studied in patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). METHODS: Adult AMI-CA admissions were identified from the National Inpatient Sample (2000-2017). Outcomes of interest included temporal trends and predictors of PCS use and in-hospital mortality, length of stay, hospitalization costs and discharge disposition in AMI-CA admissions with and without PCS use. Multivariable logistic regression and propensity matching were used to adjust for confounding. RESULTS: Among 584,263 AMI-CA admissions, 26,919 (4.6%) received inpatient PCS. From 2000 to 2017 PCS use increased from <1% to 11.5%. AMI-CA admissions that received PCS were on average older, had greater comorbidity, higher rates of cardiogenic shock, acute organ failure, lower rates of coronary angiography (48.6% vs 63.3%), percutaneous coronary intervention (37.4% vs 46.9%), and coronary artery bypass grafting (all p < 0.001). Older age, greater comorbidity burden and acute non-cardiac organ failure were predictive of PCS use. In-hospital mortality was significantly higher in the PCS cohort (multivariable logistic regression: 84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; propensity-matched analysis: 84.7% vs. 66.2%, p < 0.001). The PCS cohort received a do- not-resuscitate status more often (47.6% vs. 3.7%), had shorter hospital stays (4 vs 5 days), and were discharged more frequently to skilled nursing facilities (73.6% vs. 20.4%); all p < 0.001. These results were consistent in the propensity-matched analysis. CONCLUSIONS: Despite an increase in PCS use in AMI-CA, it remains significantly underutilized highlighting the role for further integrating of these specialists in AMI-CA care.

Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction: An 18-Year Analysis of Temporal Trends, Epidemiology, Management, and Outcomes.

BACKGROUND: There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS). METHODS: Adult (>18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS: In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P < 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P < 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P < 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P < 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P > 0.05). CONCLUSIONS: In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals.

BACKGROUND: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. METHODS: Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. RESULTS: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization. CONCLUSIONS: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

Impact of Active and Historical Cancers on the Management and Outcomes of Acute Myocardial Infarction Complicating Cardiogenic Shock.

BACKGROUND: There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with concomitant cancer. METHODS: A retrospective cohort of adult AMI-CS admissions was identified from the National Inpatient Sample (2000-2017) and stratified by active cancer, historical cancer, and no cancer. Outcomes of interest included in-hospital mortality, use of coronary angiography, use of percutaneous coronary intervention, do-not-resuscitate status, palliative care use, hospitalization costs, and hospital length of stay. RESULTS: Of the 557,974 AMI-CS admissions during this 18-year period, active and historical cancers were noted in 14,826 (2.6%) and 27,073 (4.8%), respectively. From 2000 to 2017, there was a decline in active cancers (adjusted odds ratio, 0.70 [95% CI, 0.63-0.79]; P < .001) and an increase in historical cancer (adjusted odds ratio, 2.06 [95% CI, 1.89-2.25]; P < .001). Compared with patients with no cancer, patients with active and historical cancer received less-frequent coronary angiography (57%, 67%, and 70%, respectively) and percutaneous coronary intervention (40%, 47%, and 49%%, respectively) and had higher do-not-resuscitate status (13%, 15%, 7%%, respectively) and palliative care use (12%, 10%, 6%%, respectively) (P < .001). Compared with those without cancer, higher in-hospital mortality was found in admissions with active cancer (45.9% vs 37.0%; adjusted odds ratio, 1.29 [95% CI, 1.24-1.34]; P < .001) but not historical cancer (40.1% vs 37.0%; adjusted odds ratio, 1.01 [95% CI, 0.98-1.04]; P = .39). AMI-CS admissions with cancer had a shorter hospitalization duration and lower costs (all P < .001). CONCLUSION: Concomitant cancer was associated with less use of guideline-directed procedures. Active, but not historical, cancer was associated with higher mortality in patients with AMI-CS.

Influence of Body Mass Index on the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in the United States, 2008-2017.

BACKGROUND: There are limited data on influence of body mass index (BMI) on outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS: Adult AMI-CS admissions from 2008 to 2017 were identified from the National Inpatient Sample and stratified by BMI into underweight (<19.9 kg/m2), normal-BMI (19.9-24.9 kg/m2) and overweight/obese (>24.9 kg/m2). Outcomes of interest included in-hospital mortality, invasive cardiac procedures use, hospitalization costs, and discharge disposition. RESULTS: Of 339,364 AMI-CS admissions, underweight and overweight/obese constitute 2356 (0.7%) and 46,675 (13.8%), respectively. In 2017, compared to 2008, there was an increase in underweight (adjusted odds ratio [aOR] 6.40 [95% confidence interval {CI} 4.91-8.31]; p < 0.001) and overweight/obese admissions (aOR 2.93 [95% CI 2.78-3.10]; p < 0.001). Underweight admissions were on average older, female, with non-ST-segment-elevation AMI-CS, and higher comorbidity. Compared to normal and overweight/obese admissions, underweight admissions had lower rates of coronary angiography (57% vs 72% vs 78%), percutaneous coronary intervention (40% vs 54% vs 54%), and mechanical circulatory support (28% vs 46% vs 49%) (p < 0.001). In-hospital mortality was lower in underweight (32.9% vs 34.1%, aOR 0.64 [95% CI 0.57-0.71], p < 0.001) and overweight/obese (27.6% vs 38.4%, aOR 0.89 [95% CI 0.87-0.92], p < 0.001) admissions. Higher hospitalization costs were seen in overweight/obese admissions while underweight admissions were discharged more often to skilled nursing facilities. CONCLUSION: Underweight patients received less frequent cardiac procedures and were discharged more often to skilled nursing facilities. Underweight and overweight/obese AMI-CS admissions had lower in-hospital mortality compared to normal BMI.

Impact of concomitant respiratory infections in the management and outcomes acute myocardial infarction-cardiogenic shock.

OBJECTIVE: To evaluate the prevalence and impact of respiratory infections in cardiogenic shock complicating acute myocardial infarction (AMI-CS). METHODS: Using the National Inpatient Sample (2000-2017), this study identified adult (≥18 years) admitted with AMI-CS complicated by respiratory infections. Outcomes of interest included in-hospital mortality of AMI-CS admissions with and without respiratory infections, hospitalization costs, hospital length of stay, and discharge disposition. Temporal trends of prevalence, in-hospital mortality and cardiac procedures were evaluated. RESULTS: Among 557,974 AMI-CS admissions, concomitant respiratory infections were identified in 84,684 (15.2%). Temporal trends revealed a relatively stable trend in prevalence of respiratory infections over the 18-year period. Admissions with respiratory infections were on average older, less likely to be female, with greater comorbidity, had significantly higher rates of NSTEMI presentation, and acute non-cardiac organ failure compared to those without respiratory infections (all p < 0.001). These admissions received lower rates of coronary angiography (66.8% vs 69.4%, p < 0.001) and percutaneous coronary interventions (44.8% vs 49.5%, p < 0.001), with higher rates of mechanical circulatory support, pulmonary artery catheterization, and invasive mechanical ventilation compared to AMI-CS admissions without respiratory infections (all p < 0.001). The in-hospital mortality was lower among AMI-CS admissions with respiratory infections (31.6% vs 38.4%, adjusted OR 0.58 [95% CI 0.57-0.59], p < 0.001). Admissions with respiratory infections had longer lengths of hospital stay (127-20 vs 63-11 days, p < 0.001), higher hospitalization costs and less frequent discharges to home (27.1% vs 44.7%, p < 0.001). CONCLUSIONS: Respiratory infections in AMI-CS admissions were associated with higher resource utilization but lower in-hospital mortality.

Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes.

BACKGROUND: The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era. METHODS: From the National Inpatient Sample, adult NSTEMI admissions were identified [2000-2017]. Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition. RESULTS: Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53-60 years), more likely to be female (48% vs. 25-44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9-3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11-1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92-0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75-0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94-1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65-74%; early 15% vs. 22-27%) and PCI (27% vs. 35-44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges. CONCLUSIONS: Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Acute Kidney Injury in Cardiogenic Shock: An Updated Narrative Review.

Acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with high mortality and morbidity despite advancements in cardiovascular care. AMI-CS is associated with multiorgan failure of non-cardiac organ systems. Acute kidney injury (AKI) is frequently seen in patients with AMI-CS and is associated with worse mortality and outcomes compared to those without. The pathogenesis of AMI-CS associated with AKI may involve more factors than previously understood. Early use of renal replacement therapies, management of comorbid conditions and judicious fluid administration may help improve outcomes. In this review, we seek to address the etiology, pathophysiology, management, and outcomes of AKI complicating AMI-CS.