In-Hospital Outcomes in Patients With Non-ST Segment Elevation Myocardial Infarction and Concomitant Neurodevelopmental Disorders in the United States: Insights From the National Inpatient Sample 2011-2020.

Patients with neurodevelopmental disorders (NDDs) encounter significant barriers to receiving quality health care, particularly for acute conditions such as non-ST segment elevation myocardial infarction (NSTEMI). This study addresses the critical gap in knowledge regarding in-hospital outcomes and the use of invasive therapies in this demographic. By analyzing data from the National Inpatient Sample database from 2011 to 2020 using the International Classification of Diseases, Ninth Edition (ICD-9) and Tenth Edition (ICD-10) codes, we identified patients with NSTEMI, both with and without NDDs, and compared baseline characteristics, in-hospital outcomes, and the application of invasive treatments. The analysis involved a weighted sample of 7,482,216 NSTEMI hospitalizations, of which 30,168 (0.40%) patients had NDDs. There were significantly higher comorbidity-adjusted odds of in-hospital mortality, cardiac arrest, endotracheal intubation, infectious complications, ventricular arrhythmias, and restraint use among the NDD cohort. Conversely, this group exhibited lower adjusted odds of undergoing left heart catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery. These findings underscore the disparities faced by patients with NDDs in accessing invasive cardiac interventions, highlighting the need for further research to address these barriers and improve care quality for this vulnerable population.

In-hospital outcomes with extracorporeal membrane oxygenation alone versus combined with percutaneous left ventricular assist device.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is associated with increased afterload and hindered myocardial recovery. Adding a percutaneous left ventricular assist device (pLVAD) to ECMO is one strategy to unload the left ventricle. We evaluated in-hospital outcomes in cardiogenic shock patients treated with ECMO alone versus ECMO plus pLVAD. METHODS: We conducted a retrospective study using the National Inpatient Sample database from 2011 to 2019. Logistic regression analysis was performed to adjust for covariates. RESULTS: 20,171 patients were included. 16,064 (79.6 %) patients received ECMO alone and 4107 (20.4 %) patients received ECMO plus pLVAD. The ECMO plus pLVAD group had higher rates of mortality, stroke, acute kidney injury, pericardial complications, and vascular complications. After adjusting for covariates, combined therapy was associated with higher rates of mortality (OR 1.2; 95 % CI [1.1-1.3]) and stroke (OR 1.3; 95 % CI [1.2-1.5]), however lower bleeding (OR 0.7; 95 % CI [0.68-0.81]) (p < 0.001 for all). After adjusting for covariates, a subgroup analysis of 5019 patients with acute coronary syndrome cardiogenic shock (ACS-CS) demonstrated higher rates of mortality (OR 1.3; 95 % CI [1.2-1.5]) and stroke (OR 1.7; 95 % CI [1.4-2.1]; p < 0.001 for all) with combined therapy, however similar rates of bleeding compared to ECMO alone (OR 0.95; 95 % CI [0.8-1.1]; p = 0.54). CONCLUSIONS: In the overall group, ECMO plus pLVAD was associated with increased mortality and stroke, however decreased bleeding. In a sub-group of ACS-CS, ECMO plus pLVAD was associated with increased mortality and stroke, however similar rates of bleeding compared to ECMO alone.

In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019.

BACKGROUND: Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS). HYPOTHESIS: Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients. METHODS: The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05). RESULTS: We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints. CONCLUSIONS: These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.

In-hospital outcomes of septal myectomy vs. alcohol septal ablation for hypertrophic cardiomyopathy with outflow tract obstruction: An update and insights from the national inpatient sample from 2011 to 2019.

Septal Myectomy (SM) and Alcohol Septal Ablation (ASA) improve symptoms in patients with Hypertrophic Cardiomyopathy with outflow tract obstruction (oHCM). However, outcomes data in this population is predominantly from specialized centers. The National Inpatient Database was queried from 2011 to 2019 for relevant international classification of diseases (ICD)-9 and -10 diagnostic and procedural codes. We compared baseline characteristics and in-hospital outcomes of patients with oHCM who underwent SM vs ASA. A p-value < 0.001 was considered statistically significant. We identified 15,119 patients with oHCM who underwent septal reduction therapies, of whom 57.4% underwent SM, and 42.6% underwent ASA. Patients who underwent SM had higher all-cause mortality (OR: 1.8 (1.3-2.5)), post-procedure ischemic stroke (OR: 2.3 (1.7-3.2)), acute kidney injury (OR: 1.4 (1.2-1.7)), vascular complications (OR: 3.6 (2.3-5.3)), ventricular septal defect (OR: 4.4 (3.2-6.1)), cardiogenic shock (OR: 1.7 (1.3-2.3)), sepsis (OR: 3.2 (1.9-5.4)), and left bundle branch block (OR: 3.5 (3-4)), compared to ASA. Patients who underwent ASA had higher post-procedure complete heart block (OR: 1.3 (1.1-1.4)), right bundle branch block (OR: 6.3 (5-7.7)), ventricular tachycardia (OR: 2.2 (1.9-2.6)), supraventricular tachycardia (OR: 1.6 (1.4-2)), and more commonly required pacemaker insertion (OR: 1.4 (1.3-1.7)) (p < 0.001 for all) compared to SM. This nationwide analysis evidenced that patients undergoing SM had higher in-hospital mortality and periprocedural complications than ASA; however, those undergoing ASA had more post-procedure conduction abnormalities and pacemaker implantation. The implications of these findings warrant further investigation regarding patient selection strategies for these therapies.

Trends and In-Hospital Outcomes of Patients With Baseline Right Bundle Branch Block Who Underwent Transcatheter Aortic Valve Implantation.

This study aimed to explore contemporary in-hospital outcomes and trends of transcatheter aortic valve implantation (TAVI) outcomes in patients with baseline right bundle branch block (RBBB) using data collected from a nationwide sample. Using the National Inpatient Sample, we identified patients hospitalized for an index TAVI procedure from 2016 to 2019. Primary outcomes included in-hospital all-cause mortality, complete heart block, and permanent pacemaker (PPM) implantation. A total of 199,895 hospitalizations for TAVI were identified. RBBB was present in 10,495 cases (5.3%). Patients with RBBB were older (median age 81 vs 80 years, p <0.001) and less likely to be female (35% vs 47.4%, p <0.001). After adjusting for differences in baseline characteristics and elective versus nonelective admission, patients with RBBB had a higher incidence of complete heart block (adjusted odds ratio [aOR] 4.77, confidence interval [CI] 4.55 to 5.01, p <0.001) and PPM implantation (aOR 4.15, CI 3.95 to 4.35, p <0.001) and no difference in-hospital mortality rate (aOR 0.85, CI 0.69 to 1.05, p = 0.137). Between 2016 and 2019, there was a 3.5% and 2.9% decrease in in-hospital PPM implantation in patients with and without RBBB, respectively. In conclusion, from 2016 to 2019, the rate of in-hospital PPM implantation decreased during index TAVI hospitalization in both patients with and without RBBB. However, in those with baseline RBBB, complete heart block complication rates requiring PPM implantation remain relatively high. Further research and advances are needed to continue to reduce complication rates and the need for PPM implantation.

The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis.

INTRODUCTION: In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). METHOD: The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. RESULTS: Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend toward increasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. CONCLUSION: In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.

The association of racial differences with in-hospital outcomes of patients admitted for sinus node dysfunction.

Background: The impact of race and its related social determinants of health on cardiovascular disease outcomes has been well documented. However, limited data exist regarding the association of race with in-hospital outcomes in patients admitted for sinus node dysfunction (SND). Objective: To evaluate whether racial disparities exist in outcomes for patients hospitalized with a primary diagnosis of SND. Methods: The National Inpatient Sample was queried from 2011 to 2018 for relevant ICD-9 and ICD-10 diagnosis and procedure codes. Baseline characteristics and in-hospital outcomes in patients with a primary diagnosis of SND were compared among White and non-White patients. A multivariate logistic regression model was used to adjust for potential confounding factors and statistically significant comorbidities between both cohorts. Results: We identified 655,139 persons admitted with a primary diagnosis of SND, 520,926 (79.5%) of whom were White. Non-White patients had significantly higher all-cause mortality, length of stay, and total hospital cost. There were lower odds of pacemaker insertion (adjusted odds ratio [aOR] 1.13 [95% confidence interval (CI) 1.11-1.15]), temporary transvenous pacing (aOR 1.15 [95% CI 1.11-1.22]), and cardioversion (aOR 1.50 [95% CI 1.42-1.58]) in non-White patients. A subgroup analysis was performed and non-Hispanic Black race was predictive of a decreased odds of pacemaker insertion, cardioversion/defibrillation, and temporary transvenous pacing. Conclusion: Significant differences of in-hospital outcomes exist between White and non-White patients with SND. These findings appeared to be primarily driven by disparities in non-Hispanic Black patients. Increased recognition and focused efforts to mitigate these disparities will improve the care of underrepresented populations treated for SND.

A novel temporary atrioventricular sequential pacing catheter-Characteristics and first-in-human application.

BACKGROUND: Sequential synchronized atrioventricular (AV) pacing provides enhanced electrophysiologic parameters which contribute to improved hemodynamic parameters and increased cardiac performance to subsequently confer a clinical advantage over traditional ventricular pacing. Current temporary transvenous pacemaker catheters are limited to only one electrode which paces solely the right ventricle, thus lacking the capability to provide the optimal pacing mode. A new multilead pacemaker device was developed in response to the need for improved temporary pacing through the utilization of sequential synchronized atrioventricular pacing (TAVSP). It consists of seven preformed, preshaped nitinol wires electrodes, of which four are for intra-atrial and three for intraventricular positioning and endocardial contact, respectively. Each wire carries a ball tip designed to minimize tissue trauma and provide a high current density for adequate myocardial capture. The device is not yet Food and Drug Administration approved. OBJECTIVE: To present the unique structural components and mechanical properties of a novel sequential synchronized AV pacing device for temporary insertion and to report its first-in-human application with an analysis of the early clinical experience. METHODS: Following a process of development and proof of concept of the novel pacing modality in an animal model which demonstrated feasibility and safety, a series of patients who were candidates for the device application was identified. During left and right heart catheterization, the novel temporary pacing catheter was inserted transvenously and delivered in most patients under fluoroscopy or echocardiography. The catheter was deployed to its target right heart anatomic sites and then activated in an AV sequential mode. The technical aspects, the corresponding clinical utilization, and device performance were documented and analyzed. RESULTS: The series included 10 enrolled subjects. During planned left and right heart catheterization, the novel TAVSP device was inserted transvenously and then delivered and deployed successfully in a timely fashion in all patients. The pacing catheter achieved proper threshold and impedance in all (100%) patients. The performance of all ventricular leads was adequate; however, in 1 (10%) patient poor performance of the atrial leads was detected. The device was successfully retrieved in all patients. No adverse arrhythmia, impaired hemodynamics, or clinical adverse events occurred. No technical difficulties, component failure, or wires thrombosis were detected. All patients sustained the device application without sequala and were discharged home. CONCLUSION: Initial clinical experience with the utilization of a novel TAVSP demonstrates feasibility and safety in humans. The TAVSP modality potentially offers improved pacing capability and subsequent hemodynamic benefits over the current temporary pacing catheters. Further experience with the clinical application of this pacing catheter is warranted.

Comparison of In-Hospital Outcomes and Readmission Rates of Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease Versus Pure Aortic Stenosis.

Recently, transcatheter aortic valve implantation (TAVI) has been performed in patients with combined aortic stenosis (AS) and aortic regurgitation. We sought to evaluate in-hospital outcomes and readmission rates after TAVI in patients with mixed aortic valve disease (MAVD). A total of 100,573 TAVI procedures were identified between 2011 and 2017 using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes the from Nationwide Readmissions Database. We separated patients into 2 cohorts, those with MAVD and those with pure AS. The primary outcome was all-cause inpatient mortality after TAVI, and secondary outcomes included rates of 30- and 90-day readmissions and postprocedural complications. A total of 3,260 patients had MAVD (median age 83 years, 43.5% women). In-hospital mortality (2.5% vs 2.6%, p = 0.531) and rates of paravalvular leak (1.0% vs 1.3%, p = 0.056) were similar between the MAVD and pure AS groups. Major bleeding (7.4% vs 9.6%, p <0.001), 30-day readmission (0.5% vs 8.8%, p <0.001) and 90-day readmission rates (0.8% vs 16.0%, p <0.001), acute kidney injury (12.9% vs 15.1%, p <0.001), postoperative ischemic stroke (2.0% vs 5.7%, p <0.001), and mechanic circulatory support use (1.9% vs 4.5%, p <0.001) were less prevalent in the MAVD cohort. Using a multivariate logistic regression model to adjust for confounding factors, MAVD was not predictive of mortality in patients who underwent TAVI (adjusted odds ratio [adjOR] 1.25, 95% confidence interval [CI] 0.99 to 1.57, p = 0.056); however, MAVD was associated with: decreased odds of 30-day readmission (adjOR 0.05, 95% CI 0.03 to 0.08, p <0.001), 90-day readmission rates (adjOR 0.04, 95% CI 0.03 to 0.06, p <0.001), and higher odds of pacemaker implantation (adjOR 1.46, 95% CI 1.29 to 1.65, p <0.001). In conclusion, despite differences in the aortic valve and left ventricular anatomy (pressure vs volume-related adaptive changes) in patients with MAVD and pure AS, TAVI appears safe and feasible. However, patients with MAVD were more likely to have permanent pacemakers implanted. The results of our study warrant further randomized controlled studies to confirm these findings.

Early trends in leadless pacemaker implantation: Evaluating nationwide in-hospital outcomes.

BACKGROUND: Single-chamber leadless intracardiac pacemaker (LICP) implantation was approved in 2016 in the United States. However, little is known regarding trends in real-world utilization and complication rates. OBJECTIVE: The purpose of this study was to assess nationwide demographics, trends, and outcomes among hospitalizations with LICP implantation in the United States. METHODS: Using the National Inpatient Sample, we identified all hospitalizations with LICP or transvenous pacemaker implantation as a comparator between 2017 and 2019. We evaluated baseline patient characteristics, admitting diagnoses, procedural complications, lengths of stay, discharge dispositions, and all-cause mortality. RESULTS: The majority of LICP recipients were elderly (75.4 ± 12.8 years), male (55.2%), and White (76.8%) compared to Black (9.8%), or Hispanic (7.3%). Between 2017 and 2019, the average age increased along with the prevalence of heart failure, atrial fibrillation, and malignancy among recipients. Most hospitalizations were emergent (84.5%). Between 2017 and 2019, pooled procedural complications decreased significantly (10.8% vs 7.9%; P <.001), primarily due to declining infection and device retrieval rates. In-hospital mortality also decreased significantly (8.2% vs 4.2%; P <.001). History of cardiogenic shock or cardiac device infection was associated with the greatest mortality or complication risk. Compared to transvenous pacemaker, LICP implantation was associated with lower complication rates (8.6% vs 11.2%) but greater mortality (5.2% vs 1.3%; P <.001). CONCLUSION: Nationwide LICP implantations were performed in patients of increasing age, comorbidities, and acuity of illness. In-hospital mortality and procedure-related complications declined in the first 3 years after approval of LICP implantation and may reflect improving operator experience. Increased mortality compared with transvenous pacemaker implant remains a concern.

Comparison of in-hospital outcomes of patients undergoing catheter ablation for typical versus atypical atrial flutter.

BACKGROUND: Catheter ablation (CA) is indicated as definitive therapy for patients with either typical or atypical atrial flutter (TAFlutter and AAFlutter, respectively) which is unresponsive to medical therapy. There is a paucity of data regarding in-hospital outcomes of patients undergoing CA. METHODS: Retrospective study using the NIS to identify patients ≥18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAFlutter, AAFlutter, and CA. RESULTS: A total of 17,390 patients underwent CA for Aflutter (33% AAFlutter and 67% TAFlutter). The TAFlutter group was younger (mean 65.9 years vs. 67.2 years), with less females (30% vs. 43%, p ≤ 0.001 for both) compared to the AAFlutter group. The TAFlutter group had a higher rate of diabetes, tobacco use, obesity, and chronic obstructive pulmonary disease (p ≤ 0.001 for all). The AAFlutter cohort had increased prior strokes and atrial fibrillation (p ≤ 0.001 for both). The mean CHA2DS2-VASc score was found to be 2.3 in AAFlutter compared to 2.1 in TAFlutter (p ≤ 0.001). There were significantly higher proportions of thromboembolic events, transfusions, and longer length of stay in the TAFlutter group (p ≤ 0.001 for all) with the AAFlutter group having significantly higher rates of cardioversion, implantation of cardiac devices, and increased hospital charges (p ≤ 0.001 for all); no significant difference was found in mortality after controlling for comorbidities. CONCLUSIONS: We found higher complication rates in CA for patients with TAFlutter, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AFlutter may underlie these differences, and warrant further study.

Effect of Gender on Prognosis in Patients With Takotsubo Syndrome (from a Nationwide Perspective).

Takotsubo syndrome (TTS) largely affects postmenopausal women but has been shown to carry increased mortality risk in men. We sought to evaluate nationwide in-hospital outcomes between men and women admitted with TTS to better characterize these disparities. Using the National Inpatient Sample database from 2011 to 2018, we identified a total of 48,300 hospitalizations with the primary diagnosis of TTS. The primary end point was in-hospital all-cause mortality. Secondary end points included in-hospital complications, length of stay, and discharge disposition. Men with TTS accounted for 8.9% of hospitalizations, were younger in age (62.0 ± 15.1 vs 66.8 ± 12.1 years, p <0.001), and were more frequently Black (9.7% vs 5.8%, p <0.001). Nationwide TTS mortality rates were 1.1% overall and may be improving, but remained higher in men than in women (2.2% vs 1.0%, p <0.001). Male gender was associated with increased all-cause mortality (adjusted odds ratios 2.41, 95% confidence interval 1.88 to 3.10, p <0.001), greater length of stay, and discharge complexity. Men carried increased co-morbidity burden associated with increased cardiogenic shock or mortality, including atrial fibrillation, thrombocytopenia, chronic kidney disease, and chronic obstructive pulmonary disease. Men more frequently developed acute kidney injury, ventricular arrhythmias, cardiac arrest, and respiratory failure. Male gender remains associated with nearly 2.5-fold increase in in-hospital mortality risk. In conclusion, early identification of patients with high-risk co-morbidities and close monitoring for arrhythmias, renal injury, or cardiogenic shock may reduce morbidity and mortality.

Comparison of household income in in-hospital outcomes after implantation of left ventricular assist device.

INTRODUCTION: Due to the inability to keep up with the demand for heart transplantation, there is an increased utilization of left ventricular assist devices (LVAD). However, paucity of data exists regarding the association of household income with in-hospital outcomes after LVAD implantation. METHODS: Retrospective cohort study using the NIS to identify all patients ⩾18 years who underwent LVAD implantation from 2011 to 2017. Statistical analysis was performed comparing low household income (⩽50th percentile) and high income (>50th percentile). RESULTS: A total of 25,503 patients underwent LVAD implantation. The low-income group represented 53% and the high-income group corresponded to 47% of the entire cohort. The low-income group was found to be younger (mean age 55 ± 14 vs 58 ± 14 years), higher proportion of females (24% vs 22%), and higher proportion of blacks (32% vs 16%, p < 0.001 for all). The low-income group was found to have higher prevalence of hypertension, chronic pulmonary disease, smoking, dyslipidemia, obesity, and pulmonary hypertension (p < 0.001 for all). However, the high-income cohort had higher rate of atrial tachyarrhythmias and end-stage renal disease (p < 0.001). During hospitalization, patients in the high-income group had increased rates of ischemic stroke, acute kidney injury, acute coronary syndrome, bleeding, and need of extracorporeal membrane oxygenation (p < 0.001 for all). We found that the unadjusted mortality had an OR 1.30 (CI 1.21-1.41, p < 0.001) and adjusted mortality of OR 1.14 (CI 1.05-1.23, p = 0.002). CONCLUSION: In patients undergoing LVAD implantation nationwide, low-income was associated with increased comorbidity burden, younger age, and fewer in-hospital complications and all-cause mortality.

Trends, Predictors and In-Hospital Outcomes of the Next Day Discharge Approach After Transcatheter Mitral Valve Repair.

Early discharge strategies are associated with lower cost and resource utilization during hospitalization, as such we sought to evaluate trends, predictors and outcomes of the next day discharge (NDD) approach after transcatheter mitral valve repair (TMVR) procedures with the MitraClip device. The National Inpatient Sample (NIS) was queried between 2013 and 2018 for patients undergoing TMVR using the International Classification of Diseases (ICD) 9 procedure code '3597' and ICD-10 procedure code '02UG3JZ'. Patients undergoing TMVR were stratified into two groups, determined by hospital length of stay (LOS) [≤1 day, NDD versus >1-day, non-NDD]. Overall, 22,035 patients underwent TMVR with 35.7% (n  = 7,870) belonging to the NDD group (mean age 78.1 ± 9.7 years, women 45%). From 2013 to 2018, the proportion of patients being discharged using the NDD approach trended upward from 18.3% to 46.0%. Amongst demographic and social factors, female sex, black race, and low median household income were predictive of non-NDD (p <0.05 for all). Amongst clinical factors, anemia, iron deficiency anemia, major depressive disorder, thrombocytopenia, obesity and end stage renal disease were some predictors of non-NDD (p <0.05 for all). In the non-NDD group there was a downward trend of pooled post-procedure complications, post procedure cardiogenic shock, vascular complications, acute kidney injury, mechanical circulatory support use, acute respiratory distress and postoperative ischemic stroke and (p for trend <0.001 for all). Despite the overall downward trend, complications began increasing in 2017-18. In conclusion, these trends may reflect improving operator experience, advancement in vascular access device closures and techniques, and prioritization of decreasing length of stay. Ideally, the feasibility and safety of this approach should be confirmed in larger-sized multicenter, randomized trials.

Cardiovascular disease and prevention among people living with HIV in South Florida.

ABSTRACT: Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25-0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.

Assessing in-hospital cardiovascular, thrombotic and bleeding outcomes in patients with chronic liver disease undergoing left ventricular assist device implantation.

INTRODUCTION: Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD. METHODS: The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation. RESULTS: A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010). CONCLUSION: LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.

Cardiac Catheterization Procedures in Patients with HIV: A Retrospective Analysis.

With the advent of effective antiretroviral therapies, there has been a decrease in HIV-related mortality, but an increase in non-AIDS-related comorbidities including cardiovascular disease (CVD). We sought to investigate current status of cardiac catheterization (CC) procedures in people with HIV (PWH). This is a retrospective study done at a University Hospital in South Florida between 2017 and 2019. Medical records from 985 PWH indicated that CC was performed in 1.9% of the cases. Of the PWH who underwent CC, 68% were found to have obstructive coronary artery disease (CAD). Among obstructive CAD cases, PCI was performed in 77% and CABG in 21% of cases; 26% had a repeat procedure and 11% died from non-cardiac causes. When comparing PWH who had CC to those who did not, there was a significantly higher rate of statin use (63% vs. 25%, p < 0.015) and a higher prevalence of low ejection fraction (38% vs. 11%, p = 0.004) among those patients who underwent CC. However, there was no significant difference in the prevalence of hypertension (p = 0.13), HbA1c levels (p = 0.32), CD4 count (p = 0.45) nor in undetectable viral load status (p = 0.75) after controlling for age, sex and BMI. Despite the finding of traditional CVD risk factors among PWH, there were no differences in HIV-related factors among patients requiring CC, supporting the importance of optimization of traditional CVD risk factors in this population.

In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support.

Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.

Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation.

BACKGROUND: Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC). OBJECTIVE: The purpose of this study was to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC. METHODS: We identified 16,830 hospitalizations for pLAAC between 2015 and 2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay, and discharge disposition were assessed between White and Black/African American (AA) populations. RESULTS: Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease, and prior stroke history (P <.001 for all). Black/AA patients had significantly increased length of stay and nonroutine discharge (P <.001 for both) but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater postoperative stroke (0.7% vs 0.2%), acute kidney injury (4.5% vs 2.1%), bleeding requiring transfusion (4.5% vs 1.4%), and venous thromboembolism (0.7% vs 0.1%; P <.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and nonroutine discharge. CONCLUSION: Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC.

Epigenetics, HIV, and Cardiovascular Disease Risk.

Human immunodeficiency virus (HIV) is currently considered a risk factor for cardiovascular disease (CVD). With the advent of antiretroviral treatment and prevention, HIV-related morbidity and mortality rates have decreased significantly. Prolonged life expectancy heralded higher prevalence of diseases of aging, including CVD-associated morbidity and mortality, having an earlier onset in people living with HIV (PLHIV) compared to their noninfected counterparts. Several epigenetic biomarkers are now available as predictors of health and disease, with DNA methylation being one of the most widely studied. Epigenetic biomarkers are changes in gene expression without alterations to the intrinsic DNA sequence, with the potential to predict risk of future CVD, as well as the outcome and response to therapy among PLHIV. We sought to review the available literature referencing epigenetic markers to determine underlying biomechanism predisposing high-risk PLHIV to CVD, elucidating areas of possible intervention.