Comparison of phase 2 cardiac rehabilitation outcomes between patients after transcatheter versus surgical aortic valve replacement.

Background Referral rates and outcomes of cardiac rehabilitation have not been evaluated in patients with transcatheter aortic valve replacement or compared with surgical aortic valve replacement. Method A retrospective cohort study was conducted in 488 patients who underwent transcatheter aortic valve replacement ( n = 199) and surgical aortic valve replacement ( n = 289) from a university-based statewide transcatheter aortic valve replacement/surgical aortic valve replacement program during 2015-2017. Cardiac rehabilitation consisted of supervised exercise, diet education, and stress and depression management. We compared changes from baseline in exercise duration and intensity during cardiac rehabilitation sessions, quality-of-life (36-Item Short-Form Health Survey), and psychosocial measures (anxiety, depression, mood, social support, and diet) between transcatheter aortic valve replacement and surgical aortic valve replacement patients using t-test and chi-square analyses. Results Of 488 patients, cardiac rehabilitation referral rates were similar at 41% (transcatheter aortic valve replacement 81/199 versus surgical aortic valve replacement 117/289), but enrollment rates were lower in transcatheter aortic valve replacement (27/199, 14%) versus surgical aortic valve replacement (102/289, 35%, p < 0.01). Among eligible patients, cardiac rehabilitation completion rates were lower in transcatheter aortic valve replacement (12%) than surgical aortic valve replacement (32%). Exercise intensity during cardiac rehabilitation improved in both groups in a similar fashion (transcatheter aortic valve replacement 1.03 ± 1.09 versus surgical aortic valve replacement 1.34 ± 1.15 metabolic equivalents), but increase in exercise duration was higher in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients (14.52 ± 6.42 versus 10.67 ± 8.38 min, p = 0.02). Improvement in physical composite score was higher in surgical aortic valve replacement versus transcatheter aortic valve replacement (8.72 ± 7.87 versus 2.36 ± 7.6, p = 0.02) while improvement in mental composite score was higher in transcatheter aortic valve replacement (8.19 ± 8.50) versus surgical aortic valve replacement (1.18 ± 7.23, p = 0.02). There was no significant difference between the two groups in improvement in psychosocial measures. Conclusion Cardiac rehabilitation enrollment was low in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients despite similar referral rates. Improvement in functional and quality-of-life performance was achieved in both transcatheter aortic valve replacement and surgical aortic valve replacement. Future studies should address obstacles for enrollment of transcatheter aortic valve replacement patients.

Smoker's Paradox in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Prior studies have found that smokers undergoing thrombolytic therapy for ST-segment elevation myocardial infarction have lower in-hospital mortality than nonsmokers, a phenomenon called the "smoker's paradox." Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention. METHODS AND RESULTS: We used the 2003-2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Multivariable logistic regression was used to compare in-hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in-hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31-0.33, P<0.001). Although the association between smoking and lower in-hospital mortality was partly attenuated after baseline risk adjustment, a significant residual association remained (adjusted odds ratio 0.60, 95% CI 0.58-0.62, P<0.001). This association largely persisted in age-stratified analyses. Smoking status was also associated with shorter average length of stay (3.5 versus 4.5 days, P<0.001) and lower incidence of postprocedure hemorrhage (4.2% versus 6.1%; adjusted odds ratio 0.81, 95% CI 0.80-0.83, P<0.001) and in-hospital cardiac arrest (1.3% versus 2.1%; adjusted OR 0.78, 95% CI 0.76-0.81, P<0.001). CONCLUSIONS: In this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, we observed significantly lower risk-adjusted in-hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Association Between Opioid Abuse/Dependence and Outcomes in Hospitalized Heart Failure Patients.

Opioid use is associated with unintentional and intentional overdose and is one of the leading causes of emergency room visits and accidental deaths. However, the association between opioid abuse/dependence and outcomes in hospitalized patients has not been well studied. Congestive heart failure (HF) is the fourth most common cause of hospitalization in the United States. The purpose of this study was to examine the effect of opioid abuse/dependence on outcomes in patients hospitalized with HF. We queried the 2002-2010 Nationwide Inpatient Sample databases to identify all patients aged 18 years and older admitted with the primary diagnosis of HF. Multivariate logistic regression analysis was used to compare the frequency of hospital-acquired conditions (HACs) and in-hospital mortality between patients with and without a history of opioid abuse/dependence. Of 9,993,240 patients with HF, 29,014 had a history of opioid abuse or dependence. Opioid abusers/dependents were likely to be younger men of poor socioeconomic background with self pay or Medicaid as their primary payer. They had a lower prevalence of dyslipidemia, diabetes mellitus, coronary artery disease, prior myocardial infarction, and peripheral vascular disease (P < 0.001 for all). They were more likely to be smokers and have chronic pulmonary disease, depression, liver disease, and obesity (P < 0.001 for all). Patients with a history of opioid abuse/dependence had lower incidence of HACs (14.8% vs. 16.5%, adjusted odds ratio: 0.71, P < 0.001) and lower in-hospital mortality (1.3% vs. 3.6%, adjusted odds ratio: 0.64, P < 0.001) as compared with patients without prior opioid abuse/dependence. In conclusion, among adult patients aged 18 years and older hospitalized with HF, opioid abuse/dependence was associated with lower frequency of HACs and lower in-hospital mortality.

Advances in our understanding of the influence of gender on patient outcomes with peripheral arterial disease co-occurring with diabetes.

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

Association of chronic renal insufficiency with in-hospital outcomes after percutaneous coronary intervention.

BACKGROUND: The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized. METHODS AND RESULTS: We queried the 2007-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% versus 6.0%, respectively; adjusted odds ratio for CKD 1.21, 95% CI 1.18 to 1.23, P<0.001; adjusted odds ratio for ESRD 1.27, 95% CI 1.23 to 1.32, P<0.001), longer average length of stay (2.9 days versus 5.0 days versus 6.4 days, respectively; P<0.001), and higher average total hospital charges ($60 526 versus $77 324 versus $97 102, respectively; P<0.001). Similar results were seen in subgroups of patients undergoing PCI for acute coronary syndrome or stable ischemic heart disease. CONCLUSIONS: In patients undergoing PCI, chronic renal insufficiency is associated with higher in-hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.

Risk of Heart Failure and Death After Prolonged Smoking Cessation: Role of Amount and Duration of Prior Smoking.

BACKGROUND: According to the 2004 Surgeon General's Report on Health Consequences of Smoking, after >15 years of abstinence, the cardiovascular risk of former smokers becomes similar to that of never-smokers. Whether this health benefit of smoking cessation varies by amount and duration of prior smoking remains unclear. METHODS AND RESULTS: Of the 4482 adults ≥65 years without prevalent heart failure (HF) in the Cardiovascular Health Study, 2556 were never-smokers, 629 current smokers, and 1297 former smokers with >15 years of cessation, of whom 312 were heavy smokers (highest quartile; ≥32 pack-years). Age-sex-race-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for centrally adjudicated incident HF and mortality during 13 years of follow-up were estimated using Cox regression models. Compared with never-smokers, former smokers as a group had similar risk for incident HF (aHR, 0.99; 95% CI, 0.85-1.16) and all-cause mortality (aHR, 1.08; 95% CI, 0.96-1.20), but former heavy smokers had higher risk for both HF (aHR, 1.45; 95% CI, 1.15-1.83) and mortality (aHR, 1.38; 95% CI, 1.17-1.64). However, when compared with current smokers, former heavy smokers had lower risk of death (aHR, 0.64; 95% CI, 0.53-0.77), but not of HF (aHR, 0.97; 95% CI, 0.74-1.28). CONCLUSIONS: After >15 years of smoking cessation, the risk of HF and death for most former smokers becomes similar to that of never-smokers. Although this benefit of smoking cessation is not extended to those with ≥32 pack-years of prior smoking, they have lower risk of death relative to current smokers.

Outcomes of acute myocardial infarction in patients with hypertrophic cardiomyopathy.

BACKGROUND: Acute myocardial infarction is a recognized complication in patients with hypertrophic cardiomyopathy. However, limited data are available on outcomes of patients with hypertrophic cardiomyopathy and acute myocardial infarction. METHODS: We analyzed the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years with a principal diagnosis of acute myocardial infarction. Patients with a concomitant diagnosis of hypertrophic cardiomyopathy were then identified and analyzed as a separate cohort. Multivariate logistic regression was used to compare outcomes in patients with acute myocardial infarction with and without hypertrophic cardiomyopathy. RESULTS: Of 5,901,827 patients with acute myocardial infarction, 5688 (0.1%) had a diagnosis of hypertrophic cardiomyopathy. Patients with hypertrophic cardiomyopathy were older, more likely to be female, and less likely to have traditional cardiovascular risk factors. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy were less likely to present with ST-elevation myocardial infarction and more likely to present with non-ST-elevation myocardial infarction. Patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction were less likely to receive revascularization. In the overall population with acute myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.84-1.11; P = .59). In the population with ST-elevation myocardial infarction, patients with hypertrophic cardiomyopathy had lower risk-adjusted in-hospital mortality than those without hypertrophic cardiomyopathy (OR, 0.75; 95% CI, 0.63-0.91; P = .003), whereas in the population with non-ST-elevation myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (OR, 0.97; 95% CI, 0.84-1.11; P = .63). CONCLUSIONS: Patients with hypertrophic cardiomyopathy represent a small proportion of patients with acute myocardial infarction and are less likely to receive revascularization. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction have lower risk-adjusted in-hospital mortality.

Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States.

BACKGROUND: Regional variation in the incidence and outcomes of in-hospital cardiac arrest (IHCA) is not well studied and may have important health and policy implications. METHODS AND RESULTS: We used the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients≥18 years of age who underwent cardiopulmonary resuscitation (International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes 99.60 and 99.63) for IHCA. Regional differences in IHCA incidence, survival to hospital discharge, and resource use (total hospital cost and discharge disposition among survivors) were analyzed. Of 838,465 patients with IHCA, 162,270 (19.4%) were in the Northeast, 159,581 (19.0%) were in the Midwest, 316,201 (37.7%) were in the South, and 200,413 (23.9%) were in the West. Overall IHCA incidence in the United States was 2.85 per 1000 hospital admissions. IHCA incidence was lowest in the Midwest and highest in the West (2.33 and 3.73 per 1000 hospital admissions, respectively). Compared with the Northeast, risk-adjusted survival to discharge was significantly higher in the Midwest (odds ratio, 1.33; 95% confidence interval, 1.31-1.36), South (odds ratio, 1.21; 95% confidence interval, 1.19-1.23), and West (odds ratio, 1.25; 95% confidence interval, 1.23-1.27). IHCA survival increased significantly from 2003 to 2011 in the United States and in all regions (all Ptrend<0.001). Total hospital cost was highest in the West, whereas discharge to skilled nursing facility and use of home health care among survivors was highest in the Northeast. CONCLUSIONS: We observed significant regional variation in IHCA incidence, survival, and resource use in the United States. This variation was explained only partially by differences in patient and hospital characteristics. Further studies are needed to identify other potential factors responsible for these regional differences to improve outcomes after IHCA.

Trends in management and outcomes of ST-elevation myocardial infarction in patients with end-stage renal disease in the United States.

Acute myocardial infarction in patients with end-stage renal disease (ESRD) is associated with increased risk of morbidity and mortality. Limited data are available on the contemporary trends in management and outcomes of ST-elevation myocardial infarction (STEMI) in patients with ESRD. We analyzed the 2003 to 2011 Nationwide Inpatient Sample databases to examine the temporal trends in STEMI, use of mechanical revascularization for STEMI, and in-hospital outcomes in patients with ESRD aged ≥18 years in the United States. From 2003 to 2011, whereas the number of patients with ESRD admitted with the primary diagnosis of acute myocardial infarction increased from 13,322 to 20,552, there was a decrease in the number of STEMI hospitalizations from 3,169 to 2,558 (ptrend <0.001). The overall incidence rate of cardiogenic shock in patients with ESRD and STEMI increased from 6.6% to 18.3% (ptrend <0.001). The use of percutaneous coronary intervention for STEMI increased from 18.6% to 37.8% (ptrend <0.001), whereas there was no significant change in the use of coronary artery bypass grafting (ptrend = 0.32). During the study period, in-hospital mortality increased from 22.3% to 25.3% (adjusted odds ratio [per year] 1.09; 95% confidence interval 1.08 to 1.11; ptrend <0.001). The average hospital charges increased from $60,410 to $97,794 (ptrend <0.001), whereas the average length of stay decreased from 8.2 to 6.5 days (ptrend <0.001). In conclusion, although there have been favorable trends in the utilization of percutaneous coronary intervention and length of stay in patients with ESRD and STEMI, the incidence of cardiogenic shock has increased threefold, with an increase in risk-adjusted in-hospital mortality, likely because of the presence of greater co-morbidities.

Pretransplant coagulopathy and in-hospital outcomes among heart transplant recipients: a propensity-matched nationwide inpatient sample study.

BACKGROUND: The prevalence and contemporary trends of pre-heart transplantation (HT) coagulopathy and associated clinical outcomes have not been studied from a national database. HYPOTHESIS: Pre-HT coagulopathy is associated with increased in-hospital mortality. METHODS: Among 2454 adult HT recipients from the 2003 to 2010 Nationwide Inpatient Sample databases, 707 (29%) had pre-HT coagulopathy (defined as a comorbidity variable, based on International Classification of Diseases, Ninthe Revision, Clinical Modification and Diagnosis Related Group codes). We used propensity scores for coagulopathy to assemble a matched cohort of 664 pairs of patients with and without coagulopathy balanced in 54 baseline characteristics. RESULTS: The prevalence of pre-HT coagulopathy increased from 17% in 2003 to 44% in 2010 (P for trend <0.001). In-hospital mortality occurred in 8.6% and 4.7% of matched HT recipients with and without coagulopathy, respectively (hazard ratio: 1.81; 95% confidence interval [CI]: 1.17-2.80; P = 0.008). Coagulopathy was not significantly associated with post-HT graft complications (odds ratio [OR]: 1.20; 95% CI: 0.95-1.52; P = 0.131) but was associated with increased blood transfusions (OR: 1.92; 95% CI, 1.54-2.41; P < 0.001). Coagulopathy and no-coagulopathy groups had no difference in median length of stay (22 days in each group, P = 0.746), but median total hospital charges were higher among patients with coagulopathy compared to those without (US$425 643 vs US$389 656; P = 0.008). CONCLUSIONS: In this national study of HT recipients, pretransplant coagulopathy was common, increased over time, and was not significantly associated with post-HT graft complications or increased hospital stay. However, it was associated with increased bleeding risk, in-hospital mortality, and total hospital charges. These findings may have implications for the selection of patients for HT.

Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction: Temporal Trends and Association With In-Hospital Outcomes.

OBJECTIVES: The purpose of this study was to determine the association of complete heart block (CHB) with outcomes and to examine temporal trends in the incidence and outcomes of CHB complicating ST-segment elevation myocardial infarction (STEMI). BACKGROUND: There are limited data available on the incidence and outcomes of CHB in STEMI patients who undergo contemporary management. METHODS: We used the 2003 to 2012 National Inpatient Sample databases to identify all patients age ≥18 years hospitalized with STEMI. Patients with a concomitant diagnosis of CHB were then identified. Multivariable logistic regression was used to analyze the association of CHB with outcomes and to examine the temporal trends in incidence and outcomes of CHB complicating STEMI. RESULTS: Of 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB. The incidence of CHB increased from 2.1% in 2003 to 2.3% in 2012 (adjusted odds ratio [OR] per year: 1.02; 95% confidence interval [CI]: 1.02 to 1.03). STEMI patients with CHB had higher in-hospital mortality than those without CHB (20.4% vs. 8.7%; adjusted OR: 2.47; 95% CI: 2.41 to 2.53). The higher mortality associated with CHB was independent of the location of STEMI; however, the magnitude of this association was greatest in patients with anterior STEMI. In patients with CHB complicating STEMI, although permanent pacemaker implantation rates declined (adjusted OR per year: 0.96; 95% CI: 0.95 to 0.97), in-hospital mortality remained unchanged during the study period (adjusted OR per year: 1.00; 95% CI: 0.99 to 1.01). CONCLUSIONS: The incidence of CHB complicating STEMI has increased slightly over the last decade, although the absolute incidence remains quite low. CHB remains associated with higher in-hospital mortality in STEMI patients even in the current era of prompt reperfusion therapy. In patients with CHB complicating STEMI, there was no change in risk-adjusted in-hospital mortality during the study period.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes.

BACKGROUND: There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States. METHODS AND RESULTS: We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978). CONCLUSIONS: There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay.

Catheter ablation of postinfarction ventricular tachycardia: ten-year trends in utilization, in-hospital complications, and in-hospital mortality in the United States.

BACKGROUND: There is a paucity of data regarding the complications and in-hospital mortality after catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease. OBJECTIVE: The purpose of this study was to determine the temporal trends in utilization, in-hospital mortality, and complications of catheter ablation of postinfarction VT in the United States. METHODS: We used the 2002-2011 Nationwide Inpatient Sample (NIS) database to identify all patients ≥18 years of age with a primary diagnosis of VT (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 427.1) and who also had a secondary diagnosis of prior history of myocardial infarction (ICD-9-CM 412). Patients with supraventricular arrhythmias were excluded. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Temporal trends in catheter ablation, in-hospital complications, and in-hospital mortality were analyzed. RESULTS: Of 81,539 patients with postinfarct VT, 4653 (5.7%) underwent catheter ablation. Utilization of catheter ablation increased significantly from 2.8% in 2002 to 10.8% in 2011 (Ptrend < .001). The overall rate of any in-hospital complication was 11.2% (523/4653), with vascular complications in 6.9%, cardiac in 4.3%, and neurologic in 0.5%. In-hospital mortality was 1.6% (75/4653). From 2002 to 2011, there was no significant change in the overall complication rates (8.4% to 10.2%, Ptrend = .101; adjusted odds ratio [per year] 1.02, 95% confidence interval 0.98-1.06) or in-hospital mortality (1.3% to 1.8%, Ptrend = .266; adjusted odds ratio [per year] 1.03, 95% confidence interval 0.92-1.15). CONCLUSION: The utilization rate of catheter ablation as therapy for postinfarct VT has steadily increased over the past decade. However, procedural complication rates and in-hospital mortality have not changed significantly during this period.

Relation of smoking status to outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest.

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p<0.001) and ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (24.3% vs 20.5%, p<0.001). Smokers had a higher rate of survival to hospital discharge compared with nonsmokers (28.2% vs 24.1%, adjusted odds ratio 1.06, 95% confidence interval 1.05 to 1.08, p<0.001). Smokers were less likely to have a poor neurologic status after IHCA compared with nonsmokers (3.5% vs 3.9%, adjusted odds ratio 0.92, 95% confidence interval 0.89 to 0.95, p<0.001). In conclusion, among patients aged ≥18 years who underwent CPR for IHCA, we observed a higher rate of survival in smokers than nonsmokers-consistent with the "smoker's paradox." Smokers were also less likely to have a poor neurologic status after IHCA.

Management and outcomes of ST-elevation myocardial infarction in nursing home versus community-dwelling older patients: a propensity matched study.

OBJECTIVES: The influence of admission source (nursing home [NH] versus community-dwelling) on treatment strategies and outcomes among elderly patients with ST-elevation myocardial infarction (STEMI) has not been investigated. PARTICIPANTS: Nationwide Inpatient Sample databases from 2003 to 2010 were used to identify 270,117 community-dwelling and 4082 NH patients 75 years of age or older with STEMI. DESIGN: Retrospective observational study. MEASUREMENTS: Propensity scores for admission source were used to assemble a matched cohort of 3081 community-dwelling and 3132 NH patients, who were balanced on baseline demographic and clinical characteristics. Bivariate logistic regression models were then used to determine the associations of NH with in-hospital outcomes among matched patients. RESULTS: In-hospital mortality was significantly higher in patients with STEMI presenting from a NH as compared with community-dwelling patients (30.5% versus 27.6%; odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03-1.29; P = .012). Overall, NH patients were less likely to receive reperfusion (thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting) (11.5% versus 13.4%; OR 0.84, 95% CI 0.72-0.98; P = .022). However, rates of percutaneous coronary intervention alone were similar in both groups (9.9% in NH versus 9.1% in community-dwelling; OR 1.10, 95% CI 0.93-1.30; P = .276). Mean length of stay was also similar in both groups (5.68 ± 5.40 days in NH versus 5.69 ± 4.98 days in community-dwelling, P = .974). CONCLUSION: Compared with their community-dwelling counterparts, older NH patients are less likely to receive reperfusion therapy for STEMI and have higher in-hospital mortality.

Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: a nationwide population-based study.

BACKGROUND: The reported incidence of peripartum cardiomyopathy (PPCM) in the United States varies widely. Furthermore, limited information is available on the temporal trends in incidence and outcomes of PPCM. METHODS AND RESULTS: We queried the 2004-2011 Nationwide Inpatient Sample databases to identify all women aged 15 to 54 years with the diagnosis of PPCM. Temporal trends in incidence (per 10 000 live births), maternal major adverse events (MAE; defined as in-hospital mortality, cardiac arrest, heart transplant, mechanical circulatory support, acute pulmonary edema, thromboembolism, or implantable cardioverter defibrillator/permanent pacemaker implantation), cardiogenic shock, and mean length of stay were analyzed. From 2004 to 2011, we identified 34 219 women aged 15 to 54 years with PPCM. The overall PPCM rate was 10.3 per 10 000 (or 1 in 968) live births. PPCM incidence increased from 8.5 to 11.8 per 10 000 live births (Ptrend<0.001) over the past 8 years. MAE occurred in 13.5% of patients. There was no temporal change in MAE rate, except a small increase in in-hospital mortality and mechanical circulatory support (Ptrend<0.05). Cardiogenic shock increased from 1.0% in 2004 to 4.0% in 2011 (Ptrend<0.001). Mean length of stay decreased during the study period. CONCLUSION: From 2004 to 2011, the incidence of PPCM has increased in the United States. Maternal MAE rates overall have remained unchanged while cardiogenic shock, utilization of mechanical circulatory support, and in-hospital mortality have increased during the study period. Further study of the mechanisms underlying these adverse trends in the incidence and outcomes of PPCM are warranted.

Dual antiplatelet therapy (clopidogrel and aspirin) is associated with increased all-cause mortality after carotid revascularization for asymptomatic carotid disease.

OBJECTIVE: Despite the established guidelines, there is not a clear consensus about how to manage antiplatelet therapy after carotid surgery. It is a common practice in vascular surgery to use the combination of aspirin and clopidogrel in the treatment of such patients. In this work, we analyzed the impact on long-term survival of antiplatelet therapy in patients treated for carotid stenosis at a single institution over a 10-year period. METHODS: Outcomes of 471 patients who underwent carotid intervention (1999-2008) were analyzed. Discharge prescription summaries were retrieved, and patients were divided into two groups according to their antiplatelet regimen: aspirin-only group and aspirin plus clopidogrel group. Only patients with a minimum of 30 days of confirmed antiplatelet therapy were included. All-cause mortality during follow-up represented the primary outcome, whereas stroke and bleeding at 30 days and during follow-up represented secondary end points. When local records were sparse, the Social Security Death Index was queried to confirm mortality. The International Classification of Diseases, 9th Revision (ICD-9 codes), was reviewed for treatment related to a bleeding condition. RESULTS: When divided by indication, there was an increased mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs 40%; P = .05). Patients with symptomatic carotid disease had a nonsignificant decrease in all-cause mortality if they received dual antiplatelet therapy (38% vs 39%; P = .53). In a subgroup analysis, there was a significant increase in the rate of all-cause mortality among patients older than 75 years receiving dual antiplatelet therapy for asymptomatic carotid disease (82% vs 56%; P = .001), whereas there was a nonsignificant decrease in mortality in patients older than 75 years receiving dual antiplatelet therapy for symptomatic carotid disease (47% vs 63%; P = .50). There was no difference in secondary outcomes (stroke and bleeding) regardless of the indication or the antiplatelet therapy. CONCLUSIONS: In this retrospective, single-institution study, the use of dual antiplatelet therapy (aspirin plus clopidogrel) in patients intervened for asymptomatic carotid disease was related to increased all-cause mortality, whereas it did not significantly influence the outcome in patients with symptomatic carotid disease.

Regional variation across the United States in management and outcomes of ST-elevation myocardial infarction: analysis of the 2003 to 2010 nationwide inpatient sample database.

BACKGROUND: Regional differences in the treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI) within the United States remain poorly understood. HYPOTHESIS: Treatment choice and outcomes in patients with STEMI differ between regions within the United States. METHODS: We used the 2003 to 2010 Nationwide Inpatient Sample databases to identify all patients age ≥ 40 years hospitalized with STEMI. Patients were divided into 4 groups according to region: Northeast, Midwest, South, and West. Multivariable logistic regression was used to identify differences in treatment choice and outcomes (in-hospital mortality, acute stroke, and cardiogenic shock) among the 4 regions. RESULTS: Of 1,990,486 patients age ≥ 40 years with STEMI, 350,073 (17.6%) were hospitalized in the Northeast, 483,323 (24.3%) in the Midwest, 784,869 (39.4%) in the South, and 372,222 (18.7%) in the West. Compared with the Northeast, patients in the Midwest, South, and West were less likely to receive medical therapy alone and more likely to receive percutaneous coronary intervention and coronary artery bypass grafting. Risk-adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.05-1.09, P <0.001), South (OR: 1.03, 95% CI: 1.01-1.05, P = 0.001), and West (OR: 1.06, 95% CI: 1.04-1.08, P <0.001), as compared with the Northeast. When adjusted further for regional variation in treatment selection, risk-adjusted in-hospital mortality was even higher in the Midwest, West, and South. CONCLUSIONS: Despite higher reperfusion and revascularization rates, STEMI patients in the Midwest, West, and South have paradoxically higher risk-adjusted in-hospital mortality as compared with patients in the Northeast.

Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.

BACKGROUND: Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group. CONCLUSIONS: The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.