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OBJECTIVES: To compare the in-hospital outcomes in cirrhosis patients undergoing transcatheter aortic valve replacement (TAVR) versus those undergoing surgical aortic valve replacement (SAVR). BACKGROUND: Over the last 10 years, TAVR has emerged as a therapeutic option for treating severe aortic stenosis in high-risk patients. Cirrhosis patients have a high risk of operative morbidity and mortality while undergoing cardiac surgery. This study's hypothesis was that TAVR is a safer alternative compared to SAVR in cirrhosis patients. METHODS: The study population was derived from the National Inpatient Sample (NIS) for the years 2011-2012 using ICD-9-CM procedure codes 35.21 and 35.22 for SAVR, and 35.05 and 35.06 for TAVR. Patients <50 years of age and those who concomitantly underwent other valvular procedures were excluded. ICD-9-CM diagnosis codes were used to identify patients with liver cirrhosis, portal hypertension, and esophageal varices. Using propensity score matching, two matched cohorts were derived in which the outcomes were compared using appropriate statistical tests. RESULTS: There were 30 patients in the SAVR and TAVR group each. Compared to the TAVR group, the patients in SAVR group had significantly higher rate of transfusion of whole blood or blood products (p = 0.037), longer mean postprocedural length of stay (p = 0.006), and nonsignificantly higher mean cost of hospitalization (p = 0.2), any complications rate (p = 0.09), and liver complications rate (p = 0.4). In-hospital mortality rate was same in the both the groups. No patients in the TAVR group required open-heart surgery or cardiopulmonary bypass. CONCLUSION: TAVR could be a viable option for aortic valve replacement in cirrhosis patients.
Assuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica/cirurgia , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Cirrose Hepática/complicações , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Transfusão de Sangue , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/economia , Cateterismo Cardíaco/instrumentação , Distribuição de Qui-Quadrado , Estudos Transversais , Bases de Dados Factuais , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/instrumentação , Custos Hospitalares , Humanos , Tempo de Internação , Cirrose Hepática/diagnóstico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVES: We studied the trends and predictors of drug eluting stent (DES) utilization from 2006 to 2011 to further expound the inter-hospital variability in their utilization. BACKGROUND: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) between 2006 and 2011 using ICD-9-CM procedure code, 36.06 (bare metal stent) or 36.07 (drug eluting stents) for Percutaneous Coronary Intervention (PCI). Annual hospital volume was calculated using unique identification numbers and divided into quartiles for analysis. METHODS AND RESULTS: We built a hierarchical two level model adjusted for multiple confounding factors, with hospital ID incorporated as random effects in the model. About 665,804 procedures (weighted n = 3,277,884) were analyzed. Safety concerns arising in 2006 reduced utilization DES from 90% of all PCIs performed in 2006 to a nadir of 69% in 2008 followed by increase (76% of all stents in 2009) and plateau (75% in 2011). Significant between-hospital variation was noted in DES utilization irrespective of patient or hospital characteristics. Independent patient level predictors of DES were (OR, 95% CI, P-value) age (0.99, 0.98-0.99, <0.001), female(1.12, 1.09-1.15, <0.001), acute myocardial infarction(0.75, 0.71-0.79, <0.001), shock (0.53, 0.49-0.58, <0.001), Charlson Co-morbidity index (0.81,0.77-0.86, <0.001), private insurance/HMO (1.27, 1.20-1.34, <0.001), and elective admission (1.16, 1.05-1.29, <0.001). Highest quartile hospital (1.64, 1.25-2.16, <0.001) volume was associated with higher DES placement. CONCLUSION: There is significant between-hospital variation in DES utilization and a higher annual hospital volume is associated with higher utilization rate of DES. © 2015 Wiley Periodicals, Inc.
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Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/estatística & dados numéricos , Custos Hospitalares/tendências , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Pacientes Internados , Intervenção Coronária Percutânea/estatística & dados numéricos , Idoso , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/economia , Stents Farmacológicos/economia , Feminino , Humanos , Masculino , Desenho de Prótese , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: The aim of our study was to study the impact of glycoprotein IIb/IIIa inhibitors (GPI) on in-hospital outcomes. BACKGROUND: There is paucity of data regarding the impact of GPI on the outcomes following peripheral endovascular interventions. METHODS: The study cohort was derived from Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database between the years 2006 and 2011. Peripheral endovascular interventions and GPI utilization were identified using appropriate ICD-9 Diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The study outcomes were: primary (in-hospital mortality and amputation studied separately) and secondary (composite of in-hospital mortality and postprocedural complications). Hospitalization costs were also assessed. RESULTS: GPI utilization (OR, 95% CI, P-value) was independently predictive of lower amputation rates (0.36, 0.27-0.49, <0.001). There was no significant difference in terms of in-hospital mortality (0.59, 0.31-1.14, P 0.117), although GPI use predicted worse secondary outcomes (1.23, 1.03-1.47, 0.023). Following propensity matching, the amputation rate was lower (3.2% vs. 8%, P < 0.001), while hospitalization costs were higher in the cohort that received GPI ($21,091 ± 404 vs. 19,407 ± 133, P < 0.001). CONCLUSIONS: Multivariate analysis revealed GPI use in peripheral endovascular interventions to be suggestive of an increase in composite end-point of in-hospital mortality and postprocedural complications, no impact on in-hospital mortality alone, significantly lower rate of amputation, and increase in hospitalization costs. © 2016 Wiley Periodicals, Inc.
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Procedimentos Endovasculares , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Estudos Transversais , Bases de Dados Factuais , Custos de Medicamentos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Salvamento de Membro , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/economia , Doença Arterial Periférica/mortalidade , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/economia , Pontuação de Propensão , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
PURPOSE: To examine the impact of intravascular ultrasound (IVUS) utilization during lower limb endovascular interventions as regards postprocedural complications and amputation. METHODS: The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database between the years 2006 and 2011. Peripheral endovascular interventions were identified using appropriate ICD-9 procedure codes. Two-level hierarchical multivariate mixed models were created. The co-primary outcomes were in-hospital mortality and amputation; the secondary outcome was postprocedural complications. Model results are given as the odds ratio (OR) and 95% confidence interval (CI). Hospitalization costs were also assessed. RESULTS: Overall, among the 92,714 patients extracted from the database during the observation period, IVUS was used in 1299 (1.4%) patients. IVUS utilization during lower extremity peripheral vascular procedures was independently predictive of a lower rate of postprocedural complications (OR 0.80, 95% CI 0.66 to 0.99, p=0.037) as well as lower amputation rates (OR 0.59, 95% CI 0.45 to 0.77, p<0.001) without any significant impact on in-hospital mortality. Multivariate analysis also revealed IVUS utilization to be predictive of a nonsignificant increase in hospitalization costs ($1333, 95% CI -$167 to +$2833, p=0.082). CONCLUSION: IVUS use during lower limb endovascular interventions is predictive of lower postprocedural complication and amputation rates with a nonsignificant increase in hospitalization costs.
Assuntos
Procedimentos Endovasculares/estatística & dados numéricos , Extremidade Inferior/irrigação sanguínea , Doenças Vasculares Periféricas/terapia , Padrões de Prática Médica , Ultrassonografia de Intervenção/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Distribuição de Qui-Quadrado , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Salvamento de Membro , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/mortalidade , Doenças Vasculares Periféricas/cirurgia , Padrões de Prática Médica/economia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/economia , Estados Unidos , Adulto JovemRESUMO
Percutaneous coronary intervention (PCI) is an integral treatment modality for acute coronary syndromes (ACS) as well as chronic stable coronary artery disease (CAD) not responsive to optimal medical therapy. This coupled with studies on the feasibility and safety of performing PCI in centers without on-site surgical backup led to widespread growth of PCI centers. However, this has been accompanied by a recent steep decline in the volume of PCIs at both the operator and hospital level, which raises concerns regarding minimal procedural volumes required to maintain necessary skills and favorable clinical outcomes. The 2011 ACC/AHA/SCAI competency statement required PCI be performed by operators with a minimal procedural volume of >75 PCIs annually at high-volume centers with >400 PCIs per year, a number which was relaxed in the 2013 ACC/AHA/SCAI update to >50 PCIs/operator/year in hospitals with >200 PCIs annually to coincide with reduction in national PCI volume. Recent data suggests that many hospitals do not meet these thresholds. We review data on the importance of volume as a vital quality metric at both an operator and hospital level in determining procedural outcomes following PCI.
Assuntos
Síndrome Coronariana Aguda/cirurgia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/tendências , Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Mortalidade Hospitalar , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Since elective transcatheter aortic valve replacements (TAVRs) can be performed on the day of admission, i.e., Day 0, or on the next day of admission, i.e., Day 1, we sought to investigate if there is an advantage to either approach. METHODS: We performed a retrospective cohort study, using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012 and identified subjects undergoing endovascular (Transfemoral/Transaortic) TAVRs using the ICD-9-CM procedure code of 35.05. The cohort was divided based on the day of the TAVR performed, i.e., Day 0 or 1. The cost of the hospitalization and length of stay were the primary outcomes, with in-hospital mortality and procedural complications as the secondary outcomes. We identified a total of 843 TAVRs. Propensity matched models were created. The mean age of the study cohort was 82 years. RESULTS: In a propensity-matched dataset, TAVRs performed on Day 0 were associated with a lower cost ($51,126 ± 1184 vs $57,703 ± 1508, p < 0.0001) and length of stay (mean days, standard error: 5.87 ± 0.25 vs 7.20 ± 0.29, p < 0.001) compared to Day 1. In-hospital mortality plus complication rates were relatively similar with no difference between Days 0 and 1 (31.5% vs 34.1%, p = 0.47, respectively). CONCLUSIONS: Endovascular TAVRs performed on the same day of admission are associated with lower hospitalization costs and length of stay, and similar mortality and complication rates compared to those performed on the next day of admission.
Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/métodos , Admissão do Paciente , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Cateterismo Cardíaco/economia , Feminino , Seguimentos , Custos Hospitalares/tendências , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/tendências , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/economia , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The aim of the study was to assess the utilization of catheter-directed thrombolysis (CDT) and its comparative effectiveness against systemic thrombolysis in acute pulmonary embolism (PE). BACKGROUND: Contemporary real world data regarding utilization and outcomes comparing systemic thrombolysis with CDT for PE is sparse. METHODS: We queried the Nationwide Inpatient Sample from 2010 to 2012 using the ICD-9-CM diagnosis code 415.11, 415.13, and 415.19 for acute PE. We used propensity score analysis to compare outcomes between systemic thrombolysis and CDT. Primary outcome was in-hospital mortality. Secondary outcome was combined in-hospital mortality and intracranial hemorrhage (ICH). RESULTS: Out of 110,731 patients hospitalized with PE, we identified 1,521 patients treated with thrombolysis, of which 1,169 patients received systemic thrombolysis and 352 patients received CDT. After propensity-matched comparison, primary and secondary outcomes were significantly lower in the CDT group compared to systemic thrombolysis (21.81% vs. 13.36%, OR 0.55, 95% CI 0.36-0.85, P value = 0.007) and (22.89% vs. 13.36%, OR 0.52, 95% CI 0.34-0.80, P value = 0.003), respectively. The median length of stay [7 days, interquartile range (IQR) (5-9 days) vs. 7 days, IQR (5-10 days), P = 0.17] was not significant between the two groups. The CDT group had higher cost of hospitalization [$17,218, IQR ($12,272-$23,906) vs. $23,799, IQR ($17,892-$35,338), P < 0.001]. Multivariate analysis identified increasing age, saddle PE, cardiopulmonary arrest, and Medicaid insurance as independent predictors of in-hospital mortality. CONCLUSIONS: CDT was associated with lower in-hospital mortality and combined in-hospital mortality and ICH.
Assuntos
Cateterismo de Swan-Ganz , Fibrinolíticos/administração & dosagem , Padrões de Prática Médica , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Adulto , Idoso , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/mortalidade , Cateterismo de Swan-Ganz/estatística & dados numéricos , Cateterismo de Swan-Ganz/tendências , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Mortalidade Hospitalar , Humanos , Hemorragias Intracranianas/induzido quimicamente , Modelos Logísticos , Masculino , Medicaid , Medicare , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Padrões de Prática Médica/tendências , Pontuação de Propensão , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Terapia Trombolítica/estatística & dados numéricos , Terapia Trombolítica/tendências , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVES: To compare the utilization and outcomes in patients who had percutaneous coronary interventions (PCIs) performed with intra-aortic balloon pump (IABP) versus percutaneous ventricular assist devices (PVADs) such as Impella and TandemHeart and identify a sub-group of patient population who may derive the most benefit from the use of PVADs over IABP. BACKGROUND: Despite the lack of clear benefit, the use of PVADs has increased substantially in the last decade when compared to IABP. METHODS: We performed a cross sectional study including using the Nationwide Inpatient Sample. Procedures performed with hemodynamic support were identified through appropriate ICD-9-CM codes. RESULTS: We identified 18,094 PCIs performed with hemodynamic support. IABP was the most commonly utilized hemodynamic support device (93%, n = 16, 803) whereas 6% (n = 1069) were performed with PVADs and 1% (n = 222) utilized both IABP and PVAD. Patients in the PVAD group were older in age and had greater burden of co-morbidities whereas IABP group had higher percentage of patients with cardiac arrest. On multivariable analysis, the use of PVAD was a significant predictor of reduced mortality (OR 0.55, 0.36-0.83, P = 0.004). This was particularly evident in sub-group of patients without acute MI or cardiogenic shock. The propensity score matched analysis also showed a significantly lower mortality (9.9% vs 15.1%; OR 0.62, 0.55-0.71, P < 0.001) rate associated with PVADs when compared to IABP. CONCLUSION: This largest and the most contemporary study on the use of hemodynamic support demonstrates significantly reduced mortality with PVADs when compared to IABP in patients undergoing PCI. The results are largely driven by the improved outcomes in non-AMI and non-cardiogenic shock patients.
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Coração Auxiliar/estatística & dados numéricos , Balão Intra-Aórtico/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Choque Cardiogênico/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/mortalidade , Estados Unidos/epidemiologia , Adulto JovemRESUMO
A magnetic nanoadsorbent with a cross-linked ß-Cyclodextrin maleic anhydride polymer capable of simultaneous removal of hydrophilic and hydrophobic dyes was developed with high efficacy and desorption/recycling efficiency. The effect of various parameters (concentration, adsorbent dosage, contact time, pH, and temperature) was evaluated to assess the optimum adsorption conditions. The superparamagnetic nanoadsorbent (SPNA) could be easily separated by magnetic decantation and showed maximum removal of malachite green with 97.2% adsorption efficiency. Studies on simultaneous adsorption of dyes from a mixture were performed and the adsorption capacity was calculated. Interestingly, the phenomenon of competitive adsorption was observed. The adsorption process can be fitted well into the Langmuir isotherm model and follows pseudo-second-order kinetics. SPNA could be effectively regenerated and recycled at least five times without any significant loss in removal efficiency. SPNA could be an ideal adsorbent for water remediation because of excellent dye removal efficiency in addition to chemical stability, ease of synthesis, and better reusability.
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INTRODUCTION: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients with colon cancer. We assessed nationwide population-based trends in rates of hospitalization and mortality from VTE among patients with colon cancer to determine its impact. METHODS: We queried the Nationwide Inpatient Sample (NIS) database entries from 2003 to 2011 to identify patients with colon cancer. Bivariate group comparisons between hospitalized patients with colon cancer with VTE to those without VTE were made. Multivariate logistic regression analysis was used to obtain adjusted odds ratios. The Cochrane-Armitage test for linear trend was used to assess occurrences of VTE and mortality rates among patients with colon cancer. RESULTS: The total number patients with colon cancer was 1,502,743, of which 41,394 (2.75%) had VTE. The median age of the study population was 69 years; 51.5% were women. After adjusting for potential confounders, compared with those without VTE, patients with colon cancer with VTE had significantly higher inpatient mortality (6.26% vs. 5.52%, OR 1.15, P < .001) and greater disability at discharge (OR 1.38, P < .001), but were not associated with longer length of stay (LOS) or cost of hospitalization. From 2003 to 2011, despite an increase in hospitalization rate with VTE in patients with colon cancer, their mortality steadily declined. CONCLUSION: VTE in hospitalized patients with colon cancer is associated with a significantly higher inpatient mortality and greater disability, but not with longer LOS or cost of hospitalization. Furthermore, even though there has been a trend toward more frequent hospitalizations in this patient population, their mortality continues to decline.
Assuntos
Neoplasias do Colo/complicações , Neoplasias do Colo/mortalidade , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Adulto , Idoso , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologiaRESUMO
Hospital volume is regarded amongst many in the medical community as an important quality metric. This is especially true in more complicated and less commonly performed procedures such as structural heart disease interventions. Seminal work on hospital volume relationships was done by Luft et al more than 4 decades ago, when they demonstrated that hospitals performing > 200 surgical procedures a year had 25%-41% lower mortality than those performing fewer procedures. Numerous volume-outcome studies have since been done for varied surgical procedures. An old adage "practice makes perfect" indicating superior operator and institutional experience at higher volume hospitals is believed to primarily contribute to the volume outcome relationship. Compelling evidence from a slew of recent publications has also highlighted the role of hospital volume in predicting superior post-procedural outcomes following structural heart disease interventions. These included transcatheter aortic valve repair, transcatheter mitral valve repair, septal ablation and septal myectomy for hypertrophic obstructive cardiomyopathy, left atrial appendage closure and atrial septal defect/patent foramen ovale closure. This is especially important since these structural heart interventions are relatively complex with evolving technology and a steep learning curve. The benefit was demonstrated both in lower mortality and complications as well as better economics in terms of lower length of stay and hospitalization costs seen at high volume centers. We present an overview of the available literature that underscores the importance of hospital volume in complex structural heart disease interventions.
RESUMO
The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.
Assuntos
Procedimentos Endovasculares/métodos , Avaliação de Resultados em Cuidados de Saúde , Doenças Vasculares Periféricas/cirurgia , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Doenças Vasculares Periféricas/mortalidade , Qualidade de VidaRESUMO
Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.
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Fibrinolíticos/administração & dosagem , Infarto do Miocárdio/terapia , Transferência de Pacientes , Terapia Trombolítica , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Distribuição de Qui-Quadrado , Angiografia Coronária , Análise Custo-Benefício , Bases de Dados Factuais , Custos de Medicamentos , Feminino , Fibrinolíticos/efeitos adversos , Fibrinolíticos/economia , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/terapia , Disparidades em Assistência à Saúde , Parada Cardíaca/terapia , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/economia , Infarto do Miocárdio/mortalidade , Revascularização Miocárdica , Fatores de Risco , Choque Cardiogênico/terapia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/economia , Terapia Trombolítica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
Atrial fibrillation (AF) is one of the commonest arrhythmias in clinical practice and has major healthcare and economic implications. It is a growing epidemic with prevalence all set to double to 12 million by 2050. After adjusting for other associated conditions, hypertension confers a 1.5- and 1.4-fold risk of developing AF, for men and women respectively. Furthermore, in patients with AF, the presence of hypertension has a cumulative effect on the risk of stroke. Growing evidence suggests reversal or attenuation of various structural and functional changes predisposing to AF with the use of antihypertensive medications. Randomized trials have shown major reduction in the risk of stroke and heart failure with blood pressure reduction. However, such trials are lacking in AF patients specifically. The Joint National Committee-8 guidelines have not addressed the threshold or goal BP for patients with known AF. Furthermore, "J-shaped" or "U-shaped" curves have been noted during hypertension management in patients with AF with published data demonstrating worse outcomes in patients with strict BP control to <110/60 mmhg similar to coronary artery disease. In this review, we outline the available literature on management of hypertension in patients with AF as well as the role of individual anti-hypertensive medications in reducing the incidence of AF Fig. 1.
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Anti-Hipertensivos/uso terapêutico , Fibrilação Atrial/prevenção & controle , Hipertensão/tratamento farmacológico , Fibrilação Atrial/etiologia , Feminino , Humanos , Hipertensão/complicações , Masculino , Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Multivessel coronary artery disease carries significant mortality risk. Comprehensive data on inhospital outcomes following multivessel percutaneous coronary intervention (MVPCI) are sparse. METHODS: We queried the Healthcare Cost and Utilization Project's nationwide inpatient sample (NIS) between 2006 and 2011 using different International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. The primary outcome was inhospital all-cause mortality, and the secondary outcome was a composite of inhospital mortality and periprocedural complications. RESULTS: The overall mortality was low at 0.73% following MVPCI. Multivariate analysis revealed that (odds ratio, 95% confidence interval, P value) age (1.63, 1.48-1.79; <.001), female sex (1.19, 1.00-1.42; P = .05), acute myocardial infarction (AMI; 2.97, 2.35-3.74; <.001), shock (17.24, 13.61-21.85; <.001), a higher burden of comorbidities (2.09, 1.32-3.29; .002), and emergent/urgent procedure status (1.67, 1.30-2.16; <.001) are important predictors of primary and secondary outcomes. MVPCI was associated with higher mortality, length of stay (LOS), and cost of care as compared to single vessel single stent PCI. CONCLUSION: MVPCI is associated with higher inhospital mortality, LOS, and hospitalization costs compared to single vessel, single stent PCI. Higher volume hospitals had lower overall postprocedural mortality rate along with shorter LOS and lower hospitalization costs following MVPCI.
Assuntos
Doença da Artéria Coronariana/mortalidade , Pacientes Internados/estatística & dados numéricos , Intervenção Coronária Percutânea/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Stents/efeitos adversos , Estados Unidos , Adulto JovemRESUMO
Contemporary real-world data on clinical outcomes after utilization of coronary atherectomy are sparse. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from year 2012. Percutaneous coronary interventions including atherectomy were identified using appropriate International Classification of Diseases, 9th Revision diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The primary outcome was a composite of in-hospital mortality and periprocedural complications; the secondary outcome was in-hospital mortality. Hospitalization costs were also assessed. A total of 107,131 procedures were identified in 2012. Multivariate analysis revealed that atherectomy utilization was independently predictive of greater primary composite outcome of in-hospital mortality and complications (odds ratio 1.34, 95% confidence interval 1.22 to 1.47, p <0.001) but was not associated with any significant difference in terms of in-hospital mortality alone (odds ratio 1.22, 95% confidence interval 0.99 to 1.52, p 0.063). In the propensity-matched cohort, atherectomy utilization was again associated with a higher rate of complications (12.88% vs 10.99%, p = 0.001), in-hospital mortality +a ny complication (13.69% vs 11.91%, p = 0.003) with a nonsignificant difference in terms of in-hospital mortality alone (3.45% vs 2.88%, p = 0.063) and higher hospitalization costs ($25,341 ± 353 vs $21,984 ± 87, p <0.001). Atherectomy utilization during percutaneous coronary intervention is associated with a higher rate of postprocedural complications without any significant impact on in-hospital mortality.
Assuntos
Aterectomia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/cirurgia , Custos de Cuidados de Saúde , Pacientes Internados/estatística & dados numéricos , Sistema de Registros , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aterectomia Coronária/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
Prior studies have highlighted disparities in cardiac lifesaving procedure utilization, particularly among women and in minorities. Although there has been a significant increase in implantable cardioverter-defibrillator (ICD) insertion, socioeconomic disparities still exist in the trend of ICD utilization. With the use of the Nationwide Inpatient Sample from 2003 through 2011, we identified subjects with ICD insertion (procedure code 37.94) and cardiac resynchronization defibrillator (procedure code 00.50, 00.51) as codified by the International Classification of Diseases, Ninth Revision, Clinical Modification. Overall, 1 020 076 ICDs were implanted in the United States from 2003 to 2011. We observed an initial increase in ICD utilization by 51%, from 95 062 in 2003 to 143 262 in 2006, followed by a more recent decline. The majority of ICDs were implanted in men age ≥65 years. Implantation of ICDs was 2.5× more common in men than in women (402 per million vs 163 per million). Approximately 95% of the ICDs were implanted in insured patients, and 5% were used in the uninsured population. There has been a significant increase in ICD implantation in blacks, from 162 per million in 2003 to 291 per million in 2011. We found a significant difference in the volume of ICD implants between the insured and the uninsured patient populations. Racial disparities have narrowed significantly in comparison with those noted in earlier studies and are now more reflective of the population demographics at large. On the other hand, significant gender disparities continue to exist.
Assuntos
Desfibriladores Implantáveis/tendências , Cardioversão Elétrica/tendências , Disparidades em Assistência à Saúde/tendências , Insuficiência Cardíaca/terapia , Seguro Saúde/tendências , Padrões de Prática Médica/tendências , Negro ou Afro-Americano , Idoso , Bases de Dados Factuais , Desfibriladores Implantáveis/estatística & dados numéricos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/etnologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etnologia , Hispânico ou Latino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Pessoa de Meia-Idade , Fatores Sexuais , Fatores de Tempo , Estados Unidos , População BrancaRESUMO
Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p <0.001). Atherectomy use in conjunction with angioplasty (with or without stenting) was associated with improved in-hospital outcomes in terms of lower amputation rates, mortality, and postprocedural complications.
Assuntos
Aterectomia/métodos , Procedimentos Endovasculares/métodos , Pacientes Internados , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
High-risk surgical patients undergoing transcatheter aortic valve implantation (TAVI) represent an emerging population, which may benefit from short-term use of mechanical circulatory support (MCS) devices. The aim of this study was to determine the practice and inhospital outcomes of MCS utilization in patients undergoing TAVI. We analyzed data from Nationwide Inpatient Sample (2011 and 2012) using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. A total of 1,794 TAVI procedures (375 hospitals in the United States) were identified of which 190 (10.6%) used an MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVI was associated with significant increase in the inhospital mortality (14.9% vs 3.5%, p <0.01). The mean length (11.8 ± 0.8 vs 8.1 ± 0.2 days, p <0.01) and cost ($68,997 ± 3,656 vs $55,878 ± 653, p = 0.03) of hospitalization were also significantly greater in the MCS group. Ventricular fibrillation arrest, transapical access for TAVI, and cardiogenic shock were the most significant predictors of MCS use during TAVI. In the multivariate model, use of any MCS device was found to be an independent predictor of increased mortality (odds ratio 3.5, 95% confidence interval 2.6 to 4.6, p <0.0001) and complications (odds ratio 3.3, 95% confidence interval 2.8 to 3.9, p <0.0001). The propensity score-matched analysis also showed a similar result. In conclusion, the unacceptably high rates of mortality and complications coupled with a significant increase in the length and cost of hospitalization should raise concerns about utility of MCS devices during TAVI in this prohibitive surgical risk population.
Assuntos
Estenose da Valva Aórtica/cirurgia , Coração Auxiliar , Pacientes Internados/estatística & dados numéricos , Medição de Risco , Substituição da Valva Aórtica Transcateter , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: Prior studies have described a negative relationship between influenza vaccination and recurrence of cardiovascular (CV) events. However, due to lack of any prior studies, we evaluated and attempted to define the relationship between non-influenza vaccines and CV mortality. METHODS: We used the National Health and Nutrition Examination Survey III (NHANES III-1988-1994, n = 19,215) and Continuous NHANES (1999-2004, n > 17,000), which includes oral surveys and general examination. It was designed to assess the demographic, socioeconomic, dietary, and overall health status of a nationally representative sample in non-institutionalized patients from all 50 states in the USA. Cox proportional hazard regression modeling was used to calculate the hazard ratio of CV mortality, and multivariate models were built for the individual seropositive vaccination titers as well as after creating a combined vaccination variable. RESULTS: A total of >35,000 subjects (>18 years old) have been identified for analysis. Multivariate analysis from NHANES III and continuous NHANES did not show any influence of individual seroprotective titers of routine vaccinations on CV mortality. The combined effect of vaccination in NHANES III data did not show any protective effect of three or more positive vaccination titers (odds ratio = 0.94, p = 0.6) or all four positive vaccination titers (odds ratio = 0.93, p = 0.6) with two or less positive vaccination titers as the referent group. CONCLUSION: Effect on non-influenza vaccinations in preventing CV mortality seems to be unclear.