Association of Prediabetes and Recurrent Stroke in Atrial Fibrillation Patients: A Population-Based Analysis of Hospitalizations and Outcomes.

Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients, yet, its impact on recurrent stroke in AF patients remains understudied. Using the 2018 National Inpatient Sample, we investigated the link between Prediabetes and recurrent stroke in AF patients with prior stroke or transient ischemic attack (TIA). Among 18,905 non-diabetic AF patients, 480 (2.5%) had prediabetes. The prediabetic group, with a median age of 78, exhibited a two-fold higher risk of recurrent stroke compared to the non-prediabetic cohort (median age 82), as evidenced by both unadjusted (OR 2.14, 95% CI 1.72-2.66) and adjusted (adjusted for socio-demographics/comorbidities, OR 2.09, 95% CI 1.65-2.64, p < 0.001). The prediabetes cohort, comprising more male and Black patients, demonstrated associations with higher Medicaid enrollment, admissions from certain regions, and higher rates of hyperlipidemia, smoking, peripheral vascular disease, obesity, and chronic obstructive pulmonary disease (all p < 0.05). Despite higher rates of home health care and increased hospital costs in the prediabetes group, the adjusted odds of all-cause mortality were not statistically significant (OR 0.55, 95% CI 0.19-1.56, p = 0.260). The findings of this study suggest that clinicians should be vigilant in managing prediabetes in AF patients, and strategies to prevent recurrent stroke in this high-risk population should be considered.

Disparities in the management of non-ST-segment elevation myocardial infarction in the United States.

Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189-0.279, and ≥ 80: OR 0.265, 95% CI 0.195-0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766-0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809-0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491-0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125-1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016.

Clonal Hematopoiesis and the Heart: a Toxic Relationship.

PURPOSE OF REVIEW: Clonal hematopoiesis (CH) refers to the expansion of hematopoietic stem cell clones and their cellular progeny due to somatic mutations, mosaic chromosomal alterations (mCAs), or copy number variants which naturally accumulate with age. CH has been linked to increased risk of blood cancers, but CH has also been linked to adverse cardiovascular outcomes. RECENT FINDINGS: A combination of clinical outcome studies and mouse models have offered strong evidence that CH mutations either correlate with or cause atherosclerosis, diabetes mellitus, chronic kidney disease, heart failure, pulmonary hypertension, aortic aneurysm, myocardial infarction, stroke, aortic stenosis, poor outcomes following transcatheter aortic valve replacement (TAVR) or orthotopic heart transplant, death or need of renal replacement therapy secondary to cardiogenic shock, death from cardiovascular causes at large, and enhance anthracycline cardiac toxicity. Mechanistically, some adverse outcomes are caused by macrophage secretion of IL-1ß and IL-6, neutrophil invasion of injured myocardium, and T-cell skewing towards inflammatory phenotypes. CH mutations lead to harmful inflammation and arterial wall invasion by bone marrow-derived cells resulting in poor cardiovascular health and outcomes. Blockade of IL-1ß or JAK2 signaling are potential avenues for preventing CH-caused cardiovascular morbidity and mortality.

Nationwide Trends in Cardiovascular and Cerebrovascular Diseases and Outcomes Among Young Adults (18-39 years) Hospitalized With Comorbid Depression.

Background Modern-day studies that assess temporal trends in cardiovascular and cerebrovascular events (CCE) and outcomes among the young population in the United States (US) with depression remain limited. Methods We compared baseline demographics, comorbidities, all-cause mortality, acute myocardial infarction (AMI), percutaneous coronary interventions (PCI), arrhythmia, stroke, and venous thromboembolism (VTE) among hospitalized young adults (18-39 years) with vs. without depression using the National Inpatient Sample (NIS) from 2007 to 2014. Results A total of 3,575,275 patients out of 63,020,008 hospitalized young adults had comorbid depression (5.7%; median 31 years, 71.3% females). The depressed cohort more often comprised of older, white, male, and non-electively admitted patients. Higher rates of comorbidities, all-cause mortality, PCI, arrhythmia, VTE, and stroke were observed among the depressed cohort. The rising trend in all-cause mortality was observed among the depressed against a stable trend in the non-depressed. The prevalence of AMI remained stable among depressed with consistent upsurges in arrhythmia and stroke. Those with depression had extended hospital stay, higher hospitalization charges, and were more often transferred to other facilities or discharged against advice. Conclusions Rising trends of inpatient mortality, CCE, and higher resource utilization among young adults with depression are concerning and warrants a multidisciplinary approach to improve quality of life and outcomes.

Nationwide Trends in Prevalent Cardiovascular Risk Factors and Diseases in Young Adults: Differences by Sex and Race and In-Hospital Outcomes.

OBJECTIVES: Prevalence and trends in all cardiovascular disease (CVD) risk factors among young adults (18-39 years) have not been evaluated on a large scale stratified by sex and race. The aim of this study was to establish the prevalence and temporal trend of CVD risk factors in US inpatients younger than 40 years of age from 2007 through 2014 with racial and sex-based distinctions. In addition, the impact of these risk factors on inpatient outcomes and healthcare resource utilization was explored. METHODS: A cross-sectional nationwide analysis of all hospitalizations, comorbidities, and complications among young adults from 2007 to 2014 was performed. The primary outcomes were frequency, trends, and race- and sex-based differences in coexisting CVD risk factors. Coprimary outcomes were trends in all-cause mortality, acute myocardial infarction, arrhythmia, stroke, and venous thromboembolism in young adults with CVD risk factors. Secondary outcomes were demographics and resource utilization in young adults with versus without CVD risk factors. RESULTS: Of 63 million hospitalizations (mean 30.5 [standard deviation 5.9] years), 27% had at least one coexisting CVD risk factor. From 2007 to 2014, admission frequency with CVD risk factors increased from 42.8% to 55.1% in males and from 16.2% to 24.6% in females. Admissions with CVD risk were higher in male (41.4% vs 15.9%) and white (58.4% vs 53.8%) or African American (22.6% vs 15.9%) patients compared with those without CVD risk. Young adults in the Midwest (23.9% vs 21.1%) and South (40.8% vs 37.9%) documented comparatively higher hospitalizations rates with CVD risk. Young adults with CVD risk had higher all-cause in-hospital mortality (0.4% vs. 0.3%) with a higher average length of stay (4.3 vs 3.2 days) and charges per admission ($30,074 vs $20,124). CONCLUSIONS: Despite modern advances in screening, management, and interventional measures for CVD, rising trends in CVD risk factors across all sex and race/ethnic groups call for attention by preventive cardiologists.

Nationwide Frequency, Sequential Trends, and Impact of Co-morbid Mental Health Disorders on Hospitalizations, Outcomes, and Healthcare Resource Utilization in Adult Congenital Heart Disease.

Despite the growing prevalence of adult congenital heart disease (ACHD), data on trends in prevalence of mental health disorders (MHD) among patients with ACHD remain limited. The National Inpatient Sample (2007 to 2014) was queried to identify the frequency and trends of MHD among ACHD hospitalizations (stratification by age, sex, and race); demographics and co-morbidities for ACHD cohorts, with (MHD+) versus without MHD (MHD-); the rate and trends of all-cause in-hospital mortality, disposition, mean length of stay, and hospitalization charges among both cohorts. A total of 11,709 (13.8%, mean age: 49.1 years, 56.0% females, 78.7% white) out of 85,029 ACHD patient encounters had a coexistent MHD (anxiety, depression, mood disorder, or psychosis). ACHD-MHD+ cohort was more often admitted nonelectively (38.1% vs 32.8%, p <0.001) and had a higher frequency of cardiac/extra-cardiac co-morbidities. The trends in prevalence of coexistent MHD increased from 10.3% to 17.5% (70% relative increase) from 2007 to 2014 with a consistently higher prevalence among females (from 13% to 20.3%) compared to males (from 7.6% to 15.5%) (ptrend <0.001). The hospitalization trends with MHD increased in whites (12.1% to 19.8%) and Hispanics (5.9% to 12.7%). All-cause mortality was lower (0.7% vs 1.1%, p = 0.002) in ACHD-MHD+; however, mean length of stay (∼5.7 vs 4.9 days, p <0.001) was higher without significant difference in charges ($97,710 vs $96,058, p = 0.137). ACHD-MHD+ cohort was less often discharged routinely (declining trend) and more frequently transferred to other facilities and required home healthcare (rising trends). In conclusion, this study reveals increasing trends of MHD, healthcare resource utilization and a higher frequency of co-morbidities in patients with ACHD.

Frequency of takotsubo cardiomyopathy in epilepsy-related hospitalizations among adults and its impact on in-hospital outcomes: A national standpoint.

BACKGROUND: Literature remains constrained to case reports with respect to epilepsy-associated takotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy and its impact on in-hospital outcomes remains largely obscure. METHODS: The National Inpatient Sample databases (2010-2014) were queried to identify and compare baseline characteristics and outcomes in adult hospitalizations for epilepsy with and without secondary TC using ICD-9-CM codes and propensity-matching. Primary outcomes were the frequency of TC, ensuing all-cause mortality, and complications. Secondary outcome was healthcare resource utilization. RESULTS: Of 981,571 epilepsy-related hospitalizations, 854 (0.1%, 1 in 1000) admissions (unspecified, 49.1%; grand mal/status epilepticus, 28.1% and generalized convulsive 11.7%) revealed associated in-hospital TC. Of the propensity-matched cohorts of epilepsy (TC = 793; mean 61.1 ±â€¯15.0 yrs. & 82.4% females vs. non-TC = 795; mean 60.7 ±â€¯14.2 yrs. & 84.2% females), the TC group consisted more often white (83.7% vs. 78.0%, p < 0.02) patients with higher cardiovascular risk factors. The all-cause inpatient mortality (3.7% vs <11; p = 0.002), arrhythmia (22.7% vs. 18.7%, p = 0.05), cardiac arrest (3.9% vs <11; p = 0.001), cardiogenic shock (3.2% vs <11, p < 0.001), stroke (3.5% vs 1.9%, p = 0.04), venous thromboembolism (4.4% vs. 1.9%, p = 0.004), and respiratory failure (29.4% vs. 14.8%, p < 0.001) were significantly higher in the TC cohort. The mean LOS (6.3 ±â€¯5.6 vs. 5.1 ±â€¯7.1 days), hospital charges ($77,908 vs. $45,881), transfers to other facilities (3.8% vs. 3.2%), and need of home healthcare (19.4% vs. 9.9%) were higher in the TC group (p < 0.001). CONCLUSION: In this nationwide population-based study, 1 in every 1000 epilepsy-related hospitalizations was associated with secondary TC which resulted in poor inpatient outcomes and higher healthcare resource utilization.

Rising Trends in Medication Non-compliance and Associated Worsening Cardiovascular and Cerebrovascular Outcomes Among Hospitalized Adults Across the United States.

Introduction Small-scale studies have described concerning rates of non-compliance/nonadherence towards groups of medications for primary and secondary prevention. Trends in cardiovascular and cerebrovascular events (CCE) among hospitalized patients with a non-compliant behavior towards medication, on the whole, remains unexplored on a large scale. Methods Using the National Inpatient Sample databases (2007-2014), we sought to assess the prevalence and trends in all-cause mortality and CCE in adult patients hospitalized with medication non-compliance. We compared baseline characteristics and comorbidities in the non-compliant patients with and without concomitant in-hospital CCE. Results We identified 7,453,831 adult hospitalizations with medication non-compliance from 2007 to 2014, of which 867,997 (11.6%) patients demonstrated in-hospital CCE. Non-compliant patients with CCE consisted of a higher number of older, white, male patients having greater comorbid risk factors. Non-compliant patients with CCE had higher all-cause in-hospital mortality (3% vs. 0.7%), frequent transfers [4.4% vs. 1.8% transfers to short-term hospitals, and 17.6% vs. 11.6% other transfers (skilled nursing or intermediate care facilities)], lower routine discharges (59.4% vs. 71.1%), and higher mean hospital charges ($52,740 vs. $30,748) compared to non-compliant patients without CCE. Remarkably, this study demonstrates the rising trend in medication non-compliance across all age, sex, and race groups, and related in-hospital mortality, CCE, transfers to other facilities, and the health care cost from 2007 to 2014. Conclusions We observed rising trends in the prevalence of medication non-compliance and subsequent in-hospital mortality in hospitalizations among adults from 2007 to 2014. Non-compliant patients with inpatient CCE demonstrated rising trends in all-cause mortality, complications, health care utilization, and cost from 2007 to 2014.

Outcomes and Predictors of Mortality in Hospitalized Frail Patients Undergoing Percutaneous Coronary Intervention.

Objective To study the impact of frailty on inpatient outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods The National Inpatient Sample data of all PCI-related hospitalizations throughout the United States (US) from 2010 through 2014 was utilized. Patients were divided into two groups: frailty and no-frailty. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to stratify groups and outcomes. In order to address the substantial difference in the total number of valid observations between the two groups, a propensity-matched analysis was performed at a 1:1 ratio and caliper width of 0.01. Results A total of 2,612,661 PCI-related hospitalizations throughout the US from 2010 through 2014 were identified, out of which 16,517 admissions (0.6%) had coexisting frailty. Only 1:1 propensity-matched data was utilized for the study. Propensity-matched frailty group (n=14,717) as compared to no-frailty (n=14,755) was frequently older, white, and Medicare enrollee (p<0.05). The frailty group had significantly higher rates of comorbidities and complications (p<0.05). All-cause in-hospital mortality was higher in the no-frailty group (p<0.05). Age, white race, non-elective admission, urban hospitals, and comorbidities predicted in-hospital mortality in frailty group (p<0.05). Rheumatoid arthritis, depression, hypertension, obesity, dyslipidemia, and history of previous PCI decreased odds of in-hospital mortality in frailty group (p<0.05). Frailty group had prolonged hospital stay and higher hospital charges (p<0.05). Conclusions Frailty has a significant effect on PCI-related outcomes. We present a previously unknown protective effect of cardiovascular disease risk factors and other health risk factors on frail patients undergoing PCI. Frailty's inclusion in risk stratification will help in predicting the post-procedure complications and improve resource utilization.

Heart failure: Same-hospital vs. different-hospital readmission outcomes.

BACKGROUND: Heart Failure (HF) is a major driver of the readmissions/penalties in the US. Although extensive literature on rehospitalization attributed to HF, studies to compare outcomes for same-hospital vs. different-hospital readmissions are sparse. METHODS: Nationwide Readmission Database from 2010 to 14 utilized for HF-related hospitalization using appropriate ICD-9-CM diagnostic codes. 30-day readmissions were classified into two groups: same-hospital and different-hospital. A comparative analysis was conducted focusing on: in-hospital mortality, length of stay (LOS) and hospitalization cost. Hierarchical two-level modeling and propensity score matching utilized to adjust confounders. RESULTS: 715,993 HF readmissions were identified, of which 21.3% were readmitted to different-hospital. Elderly, females, patients with higher co-morbidities and higher median household income were less likely to be readmitted to different-hospital. Index hospitalizations in a teaching hospital and/or larger hospital were associated with reduced different-hospital readmissions. Readmissions to the different hospital were associated with higher in-hospital mortality (7.7% vs. 6.6%, p < 0.001), higher resource utilization (LOS:7.5 days vs. 6.1 days, p < 0.001 and Cost: $22,602 vs. $13,740, p < 0.001) after adjusting for propensity score match. Similar results were observed with propensity score matching of multiple high-risk subgroups. CONCLUSION: Resources should be directed towards minimizing different-hospital HF readmissions to improve patient outcomes by identifying the vulnerable subgroup and further tailoring in-hospital and post-discharge care.