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The coronavirus disease 2019 (COVID-19) pandemic affected many aspects of health care and continues to have an impact as waves of COVID-19 cases re-emerge. Many procedures were negatively impacted by the pandemic, and management was primarily focused on limiting exposure to the virus. We present an analysis of the National Inpatient Sample (NIS) to delineate how COVID-19 affected atrial fibrillation (AF) ablation. The NIS was analyzed from 2017-2020 in order to determine the pre- and intra-pandemic impacts on AF ablation procedures. Admissions were identified using the International Classification of Diseases, 10th Revision, Clinical Modification codes with a primary diagnosis of AF (ICD-10 CM code I48.0, I48.1, I48.2, or I48.91). Admissions were also assessed for the use of cardiac ablation therapy. Comorbidity diagnoses were identified using the Elixhauser comorbidity software (Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Rockville, MD, USA); additional ICD-10 codes for diagnoses and procedures used are also provided. The primary outcome of our study was the trend in ablation therapy during AF admissions. Secondary outcomes included health care disparities, inpatient mortality, and length of stay. Ablation therapy was used in 18,885 admissions in 2020, compared to the preceding 3-year average of 20,103 (adjusted Wald test, P = .002). Multivariate logistic regression revealed a greater likelihood of undergoing ablation therapy (odds ratio, 1.24; 95% confidence interval, 1.10-1.40; P < .001) among 2020 admissions compared to 2017 admissions. Inpatient mortality increased in 2020 compared to the preceding average; however, the difference was not significant. The procedural volume of ablation for AF saw a decrease in 2020; however, surprisingly, more patients were likely to undergo ablation during 2020.
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BACKGROUND: Hypertension is a global health issue associated with increased cardiovascular morbidity and mortality. This study aimed to investigate contemporary hypertension identification and management trends following the 2017 American College of Cardiology/American Heart Association guidelines. METHODS AND RESULTS: Data from the National Health and Nutrition Examination Survey conducted from 2017 to 2020 were analyzed. Participants between 20 and 79 years of age were included. Participants were stratified into different treatment groups based on indication and guideline adherence. Descriptive statistics were used to compare medication use, diagnosis rates, and blood pressure control. A total of 265 402 026 people met the inclusion criteria, of which 19.0% (n=50 349 209) were undergoing guideline antihypertensive management. In the guideline antihypertensive management group, a single antihypertensive class was used to treat 45.7% of participants, and 55.2% had uncontrolled blood pressure. Participants not undergoing guideline antihypertensive management qualified for primary prevention in 11.5% (n=24 741 999) of cases and for secondary prevention in 2.4% (n=5 070 044) of cases; of these, 66.3% (n=19 774 007) did not know they may have hypertension and were not on antihypertensive medication. CONCLUSIONS: Adherence to guidelines for antihypertensive management is suboptimal. Over half of patients undergoing guideline treatment had uncontrolled blood pressure. One-third of qualifying participants may not be receiving treatment. Education and medical management were missing for 2 in 3 qualifying participants. Addressing these deficiencies is crucial for improving blood pressure control and reducing cardiovascular event outcomes.
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Cardiologia , Hipertensão , Estados Unidos/epidemiologia , Humanos , Anti-Hipertensivos/uso terapêutico , Anti-Hipertensivos/farmacologia , Inquéritos Nutricionais , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Pressão Sanguínea , American Heart AssociationRESUMO
With the recent change to value-based care, institutions have struggled with the appropriate management of patients under observation. Observation status can have a huge impact on hospital and patient expenses. Institutions have implemented specialized observation units to provide better care for these patients. Starting in January 2020, coinciding with the initiation of daily multidisciplinary rounds, our study focused on patients aged 18 and older admitted to our hospital under observation status. Efforts were built upon prior initiatives at Jersey Shore University Medical Center (JSUMC) to optimize patient care and length of stay (LOS) reduction. The central intervention revolved around the establishment of daily "Observation Huddles"-succinct rounds led by hospital leaders to harmonize care for patients under observation. The primary aim was to assess the impact of daily multidisciplinary rounds (MDR) on LOS, while our secondary aim involved identifying specific barriers and interventions that contributed to the observed reduction. Our study revealed a 9-h reduction in observation time, resulting in approximately USD 187.50 saved per patient. When accounting for the period spanning 2020 to 2022, potential savings totaled USD 828,187.50 in 2020, USD 1,046,062.50 in 2021, and USD 1,243,562.50 in 2022. MDR for observation patients led to a reduction in LOS from 29 h to 20 h (p < 0.001).
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Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.
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Fragilidade , Insuficiência Cardíaca , Coração Auxiliar , Humanos , Idoso , Fragilidade/epidemiologia , Fragilidade/etiologia , Estudos Retrospectivos , Coração Auxiliar/efeitos adversos , Hospitalização , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/diagnóstico , Readmissão do Paciente , Fatores de RiscoRESUMO
BACKGROUND: Transvenous permanent pacemakers are used frequently to treat cardiac rhythm disorders. Recently, intracardiac leadless pacemakers offer potential treatment using an alternative insertion procedure due to their novel design. Literature comparing outcomes between the two devices is scarce. We aim to assess the impact of intracardiac leadless pacemakers on readmissions and hospitalization trends. METHODS: We analyzed the National Readmissions Database from 2016 to 2019, seeking patients admitted for sick sinus syndrome, second-degree-, or third-degree atrioventricular block who received either a transvenous permanent pacemaker or an intracardiac leadless pacemaker. Patients were stratified by device type and assessed for 30-day readmissions, inpatient mortality, and healthcare utilization. Descriptive statistics, Cox proportional hazards, and multivariate regressions were used to compare the groups. RESULTS: Between 2016 and 2019, 21,782 patients met the inclusion criteria. The mean age was 81.07â¯years, and 45.52â¯% were female. No statistical difference was noted for 30-day readmissions (HR 1.14, 95â¯% CI 0.92-1.41, pâ¯=â¯0.225) and inpatient mortality (HR 1.36, 95â¯% CI 0.71-2.62, pâ¯=â¯0.352) between the transvenous and intracardiac groups. Multivariate linear regression revealed that length of stay was 0.54 (95â¯% CI 0.26-0.83, pâ¯<â¯0.001) days longer for the intracardiac group. CONCLUSION: Hospitalization outcomes associated with intracardiac leadless pacemakers are comparable to traditional transvenous permanent pacemakers. Patients may benefit from using this new device without incurring additional resource utilization. Further studies are needed to compare long-term outcomes between transvenous and intracardiac pacemakers.
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Transcatheter aortic valve replacement (TAVR) procedures have increased since adoption in 2010. Readmission for TAVR patients with underlying chronic congestive heart failure (cCHF) remains challenging. Therefore, we sought to determine the 30-day readmission rate (30-DRr) of patients who undergo TAVR & co-existing cCHF and its impact on mortality & healthcare utilization in the United States. We performed a retrospective study using the national readmission database year 2017 and 2018. The patients studied were discharged with TAVR as a principal diagnosis and underlying cCHF as a secondary diagnosis according to ICD-10 codes. The primary outcome was a 30-day readmission rate and mortality, while secondary outcomes were the most common diagnoses for readmission, and resource utilization. A total of 76,892 index hospitalization for TAVR with coexisting cCHF: mean age was 79.7 years [SD: ± 2], and 54.5% of patients were males. In-hospital mortality rate for index admission was 1.63%. The 30-DRr was 9.5%. Among the group of readmitted patients, in-hospital mortality rate was 3.13%. Readmission mortality showed a statistically significant increase compared to index mortality (3.13% vs 1.63%, adjusted P ≤ 0.001, aOR: 2.1, 95% CI: 1.6-2.9). The total healthcare in-hospital economic spending was $94.4 million, and total patient charge of $412 million. Approximately 1 in 10 patients who underwent TAVR with underlying cCHF had 30-DRr, with subsequent readmissions associated with increased healthcare spending. Readmission mortality showed a statistically significant increase when compared to index mortality. TAVR patients with cCHF are a vulnerable subset requiring additional outpatient care.
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Estenose da Valva Aórtica , Insuficiência Cardíaca , Vírus da Febre Hemorrágica da Crimeia-Congo , Febre Hemorrágica da Crimeia , Substituição da Valva Aórtica Transcateter , Masculino , Humanos , Estados Unidos/epidemiologia , Idoso , Feminino , Substituição da Valva Aórtica Transcateter/efeitos adversos , Readmissão do Paciente , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estudos Retrospectivos , Febre Hemorrágica da Crimeia/complicações , Febre Hemorrágica da Crimeia/cirurgia , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/complicações , Resultado do Tratamento , Fatores de Risco , Valva Aórtica/cirurgiaRESUMO
BACKGROUND: Acute kidney injury (AKI) is a common complication in patients with severe COVID-19. METHODS: We retrospectively reviewed 249 patients admitted to an intensive care unit (ICU) during the first wave of the pandemic to determine risk factors for AKI. Demographics, comorbidities, and clinical and outcome variables were obtained from electronic medical records. RESULTS: Univariate analysis revealed older age, higher admission serum creatinine, elevated Sequential Organ Failure Assessment (SOFA) score, elevated admission D-Dimer, elevated CRP on day 2, mechanical ventilation, vasopressor requirement, and azithromycin usage as significant risk factors for AKI. Multivariate analysis demonstrated that higher admission creatinine (p = 0.0001, OR = 2.41, 95% CI = 1.56-3.70), vasopressor requirement (p = 0.0001, OR = 3.20, 95% CI = 1.69-5.98), elevated admission D-Dimer (p = 0.008, OR = 1.0001, 95% CI = 1.000-1.001), and elevated C-reactive protein (CRP) on day 2 (p = 0.033, OR = 1.0001, 95% CI = 1.004-1.009) were independent risk factors. Conversely, the combined use of Tocilizumab and corticosteroids was independently associated with reduced AKI risk (p = 0.0009, OR = 0.437, 95% CI = 0.23-0.81). CONCLUSION: This study confirms the high rate of AKI and associated mortality among COVID-19 patients admitted to ICUs and suggests a role for inflammation and/or coagulopathy in AKI development. One should consider the possibility that early administration of anti-inflammatory agents, as is now routinely conducted in the management of COVID-19-associated acute respiratory distress syndrome, may improve clinical outcomes in patients with AKI.
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BACKGROUND: Degeneration of the cardiac conduction system resulting in complete heart block (CHB), ventricular arrhythmias (VA), and sudden cardiac death (SCD) is recognized in patients with Kearns-Sayre syndrome (KSS) and is potentially preventable with permanent pacemaker (PPM) implantation. However, other mechanisms for SCD have been proposed, and the efficacy of implanting a defibrillator instead of PPM remains to be investigated. METHODS: We utilized the National Inpatient Sample (NIS) database 2016-2019 to investigate the risk of VA or dysrhythmic cardiac arrest (dCA) in KSS patients. We compared the outcomes of KSS to myotonic dystrophy (MD), a more common genetic disorder with similar clinical cardiac features and course. RESULTS: We identified 640 admissions for KSS. VA or dCA were lower in admissions for KSS than MD patients (2.3% vs. 4.5%, p = .009). Device implantation differed between study groups. Approximately, 70% of cases with KSS and conduction abnormalities had pacemaker (± defibrillator) on hospital discharge, compared to 35% in MD. Conduction abnormalities were associated with higher rates of VA or dCA in both study groups. None of the admissions for KSS patients who developed VA or dCA had a pacemaker, and all of them had conduction abnormalities. One-third of admissions for MD patients who developed VA or dCA had a device already implanted prior to the event. CONCLUSION: Despite its effectiveness in preventing VA, PPM remains underutilized in patients with KSS or MD who have conduction abnormalities. PPM alone do not fully prevent VA in MD patients; therefore, addition of defibrillator capacity might be necessary.
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Síndrome de Kearns-Sayre , Humanos , Estudos de CoortesRESUMO
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a predominantly autosomal dominant genetic condition in which fibrous and fatty tissue infiltrate and replace healthy myocardial tissue. This uncommon yet debilitating condition can cause ventricular arrhythmias, cardiac failure, and sudden cardiac death. Management focuses primarily on prevention of syndrome sequelae in order to prevent morbidity and mortality. Genetic testing and screening in affected families, although utilized clinically, has not yet been incorporated in guidelines due to lack of larger studies and data. We aim herein to identify causative gene mutations, present advancements in diagnosis and management, and describe the role of genetic screening and counseling in patients with ARVC. With the advancement of genetic testing and therapy, diseases such as ARVC may become more accurately diagnosed and more effectively managed, ultimately significantly reducing morbidity and mortality.
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PURPOSE: Coagulopathy is common in patients with COVID-19. The ideal approach to anticoagulation remains under debate. There is a significant variability in existing protocols for anticoagulation, and these are mostly based on sporadic reports, small studies, and expert opinion. MATERIALS AND METHODS: This multicenter retrospective cohort study evaluated the association between anticoagulation dose and inpatient mortality among critically ill COVID-19 patients admitted to the intensive care units (ICUs) or step-down units (SDUs) of eight Beaumont Healthcare hospitals in Michigan, USA from March 10th to April 15th, 2020. RESULTS: Included were 578 patients with a median age of 64 years; among whom, 57.8% were males. Most patients (n = 447, 77.3%) received high dose and one in four (n = 131, 22.7%) received low dose anticoagulation. Overall mortality rate was 41.9% (n = 242). After adjusting for potential confounders (age, sex, race, BMI, ferritin level at hospital admission, intubation, comorbidities, mSOFA, and Padua score), administration of high anticoagulation doses at the time of ICU/SDU admission was associated with decreased inpatient mortality (OR 0.564, 95% CI 0.333-0.953, p = 0.032) compared to low dose. CONCLUSION: Treatment with high dose anticoagulation at the time of ICU/SDU admission was associated with decreased adjusted mortality among critically ill adult patients with COVID-19.
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COVID-19 , Estado Terminal , Adulto , Anticoagulantes/uso terapêutico , Cuidados Críticos , Atenção à Saúde , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SARS-CoV-2RESUMO
BACKGROUND: Patients with sickle cell disease can experience various crises including sequestration crisis, haemolytic crisis and aplastic crisis. Due to alloantibody formation, transfusion alloantibodies can cause a haemolytic crisis. Treatment involves avoiding packed red blood cell transfusions, as well as intravenous immunoglobulin, steroids and eculizumab to decrease the chances of haemolysis. CASE DESCRIPTION: We report the case of a 42-year-old man who was found to have worsening anaemia after packed red blood cell transfusion with evidence suggestive of haemolytic crisis. Due to reticulocytopenia, aplastic crisis was also suspected and later confirmed via parvovirus IgG and IgM titres. The patient did not improve with steroid and intravenous immunoglobulin therapy and was treated with eculizumab as a salvage therapy. CONCLUSION: Concurrent hyper-haemolytic crisis and aplastic crisis should be suspected in patients with features of haemolysis and reticulocytopenia. Prompt recognition and treatment with eculizumab are paramount in those who fail steroid and intravenous immunoglobulin treatment. LEARNING POINTS: Treatment of hyper-haemolytic and aplastic crisis in sickle cell disease with eculizumab offers therapeutic benefit.A high index of suspicion for hyper-haemolytic crisis and aplastic crisis should be maintained in those with haemolytic features as well as reticulocytopenia in the setting of sickle cell disease.
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Cardiac lymphoma is a rare neoplasm involving heart, pericardium or both, usually seen in immunocompromised patients. We report a 61-year-old male presenting with worsening shortness of breath and 20-pound weight loss. Investigations showed right-sided tumor with interatrial septal wall perforation and left atrial expansion. The diagnosis was confirmed with mediastinal mass biopsy. After receiving the appropriate treatment, there was a steady improvement clinically and on the transesophageal echocardiography.
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Coronary sinus thrombosis (CST) is a rare but life-threatening condition that involves clot formation within the vessel responsible for draining all of the venous blood from the myocardium itself. The coronary sinus is situated in the right atrium approximately half-way between the tricuspid value and the inferior vena cava. The coronary sinus is rarely cited in medical literature due to limited knowledge as well as rarity in clinical encounters. CST can be a rapidly progressive life-threatening emergency as the interruption of vascular drainage can result in pericardial effusions, tamponade and cardiogenic shock. A major clinical challenge in diagnosing and treating this condition is due to relative rarity as well as the non-specificity of presenting symptoms that are often associated with more commonly encountered cardiopulmonary diseases. CST is most commonly induced by endothelial damage, such as post intracardiac instrumentation with catheter guidewires, or any of the criteria outlined by Virchow's triad. Our team described the finding of a thrombus 1.8 cm in diameter in a patient with underlying hepatobiliary cancer as well as underlying bacteremia from infected ascitic fluid. Though our patient remained hemodynamically stable without cardiopulmonary complications, we hope to spark a discussion within the medical community to increase awareness as well as to highlight the need for more research on this potentially life-threatening condition.
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Traumatic amputations are partial or complete dismemberment of part of the human body (usually one limb) due to an injury that involves a component of blunt force trauma. It is usually caused by accidental events and only very rarely due to suicidal events. A 37-year-old female with major depressive disorder attempted suicide by placing her forearms on a railroad track, resulting in traumatic bilateral upper extremity amputations. Emergency Department resuscitation was initiated as the patient was taken immediately to the operating room; however, restoration of the limbs was unfeasible, and the patient had successful debriding and fashioning a flap to the distal ends of the upper extremities after hemostasis was achieved. Depression may still be an undertreated clinical entity in our society, and many preventable causes of suicide are attempted each year. Evidence exists that suggests severe suicide attempts occur generally in men and minor suicide attempts, or so-called suicidal gestures, occur generally in women. This case questions this notion.
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Cardiovascular conduction delay makes up part of the triad associated with Kearns-Sayre syndrome (KSS). Although there have been a few reported cases of prolonged Qtc and polymorphic ventricular tachycardia associated with this disease, despite the use of automatic implantable cardioverter defibrillators (AICD) for secondary prevention, some cases have been reported where the use of AICD did not help. We present a case of a 62-year-old male with KSS who came to the emergency department (ED) after two episodes of syncope. He already had an automatic AICD placed at the age of 34. Our patient had Qtc prolongation which is an unusual finding in KSS. He also had recurrent ventricular tachycardia (VT) refractory to medications and multiple shocks from his AICD, which progressed to a VT storm. He eventually passed away after the withdrawal of care, as his prognosis worsened. We recommend that a more clear guideline will help manage this devastating disease, resulting in mortality reduction.
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Small bowel obstruction is a common cause of abdominal pain and accounts for approximately 20% of surgical admissions related to abdominal pain. In the United States alone, there are over 300,000 admissions annually for small bowel obstruction and account for every 15 out of 100 admissions for abdominal pain. If treated appropriately with medical management, over 80% of cases resolve without life-threatening, long-term complications or the need for surgical intervention. The three most common causes including adhesions, tumors, and hernias account for the majority of cases. Less frequently reported causes include infections. We present the case of a 26-year-old male with a history of AIDS who was found to have a small bowel obstruction in the setting of active Cryptosporidium infection. Cryptosporidium is an opportunistic infection that more commonly affects immunocompromised hosts, especially those noncompliant with antiretroviral therapy. Our patient had an uncomplicated hospital course and made a full recovery due to early diagnosis and immediate intervention. We hope to make the medical community more aware of this rare and potentially life-threatening association given the rarity of such a presentation. Early diagnosis and intervention are critical to preventing morbidity and mortality.
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Hydatid liver disease (HLD) is the most common form of hydatid disease, and it is caused by a zoonotic infection with a tape worm. It is endemic mostly in sheep-farming countries and rare in the United States. Liver involvement is usually asymptomatic, but symptoms develop upon growth of the cyst leading to many complications, most common of which is intra-biliary rupture, and less likely biliary obstruction. Diagnosis is clinical, serologic and radiologic. Therapeutic approaches to HLD include surgery, anthelminthic medications and medico-surgical procedures. Here we present a case of HLD that presented in advanced stage leading to grave consequences, complicated course and difficult therapeutic options. Given the rarity of hydatid disease in Northern America, physicians have to keep high index of suspicion especially in a patient with history of travel to endemic areas, as early diagnosis and treatment is important to avoid high morbidity and mortality.
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Novel coronavirus 2019 (COVID-19) has been the focus of the medical community since its emergence in December 2019 and has already infected more than 100 million patients globally. Primarily described to cause a respiratory illness, COVID-19 has been found to affect almost every organ system. Bradycardia is a newly recognized ramification of COVID-19 that still has unknown prognostic value. Studies have shown an increase in the incidence of arrhythmias, cardiomyopathies, myocarditis, acute coronary syndromes, and coagulopathies in infected patients as well as an increased risk of mortality in patients with preexisting cardiovascular disease. While the pathogenesis of bradycardia in COVID-19 may be multifactorial, clinicians should be aware of the mechanism by which COVID-19 affects the cardiovascular system and the medication side effects which are used in the treatment algorithm of this deadly virus. There has yet to be a comprehensive review analyzing bradyarrhythmia and relative bradycardia in COVID-19 infected patients. We aim to provide a literature review including the epidemiology, pathogenesis, and management of COVID-19 induced bradyarrhythmia.
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Multiple myeloma (MM) is a rare plasma cell neoplasm characterized by monoclonal cell infiltration in the bone marrow, which can cause anemia, bone pain, and recurrent infections. Extramedullary myeloma (EM) is a rare clinical presentation with a poor prognosis. It involves the accumulation of clonal plasma cells in soft tissues with a tumor-like appearance, either presenting as a primary (initial) or secondary (relapse) malignancy. We present a case of a 65-year-old male who experienced an abrupt onset of chest pain associated with a localized sternal mass while exercising the day prior to arrival. Chest computed tomography (CT) scan with contrast revealed an expansile lytic lesion around the sternal area. Due to high suspicion for malignancy, a CT-guided core needle biopsy was done, which showed plasma cells with rare Dutcher bodies consistent with MM. Bone marrow smear showed the presence of 70% plasma cells confirming a diagnosis of MM. Early detection of this devastating disease may help improve survival. Therefore, physicians should have a high index of suspicion for MM in older patients with similar clinical presentations.