Prevalence, trends, and outcomes of cardiovascular diseases in pregnant patients in the USA: 2010-19.

AIMS: Contemporary data on the prevalence, trends, and outcomes of cardiovascular diseases (CVDs) in pregnant patients are limited. This study aimed to analyse the prevalence, trends, and outcomes of CVD and their subtypes in hospitalized pregnant patients in the USA. METHODS AND RESULTS: This retrospective population-based cohort study used the Nationwide Readmission Database to identify all hospitalized pregnant patients from 1 January 2010, to 31 December 2019. Data analyses were conducted from January to February 2022. Pregnancy-associated hospitalizations were identified. The main outcomes were the prevalence and trend of CVD in pregnant patients. 39 212 104 hospitalized pregnant patients were identified: 4 409 924 with CVD (11.3%) and 34 802 180 without CVD (88.8%). The annual age-adjusted CVD prevalence increased from 9.2% in 2010 to 14.8% in 2019 (P < 0.001). Hypertensive disorder of pregnancy (1069/10 000) was the most common, and aortic dissection (0.1/10 000) was the least common CVD. The trends of all CVD subtypes increased; however, the trend of valvular heart disease decreased. Age-adjusted in-hospital all-cause mortality was 8.2/10 000 in CVD, but its trend decreased from 8.1/10 000 in 2010 to 6.5/10 000 in 2019 (P < 0.001). CVD was associated with 15.51 times higher odds of in-hospital all-cause mortality compared with non-CVD patients [odds ratio (OR): 15.51, 95% confidence interval (CI)13.22-18.20, P < 0.001]. CVD was associated with higher 6-week postpartum readmission (OR: 1.97, 95% CI: 1.95-1.99), myocardial infarction (OR: 3.04, 95% CI: 2.57-3.59), and stroke (OR: 2.66, 95% CI: 2.41-2.94)(P < 0.001 for all). CONCLUSION: There is an increasing age-adjusted trend in overall CVD and its subtypes among pregnant patients in the USA from 2010 to 2019. Pregnant patients with CVD had higher odds of in-hospital mortality than those without CVD. However, in-hospital all-cause mortality among patients with and without CVD has decreased over the past 10 years. CVD was associated with higher 6-week postpartum all-cause readmission, myocardial infarction, and stroke rates.

Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study.

OBJECTIVE: To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS: Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS: In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. CONCLUSIONS: In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.

Contemporary Trends of Clinical Outcomes in Primary Left Ventricular Assist Device Implantation and Postprocedure High-Risk Categories.

OBJECTIVE: We aimed to analyze trends of 30-day readmission and find high-risk patients associated with increased risk of mortality, resource use, and readmission after primary left ventricular assist device (LVAD) implantation. Limited data exist on the contemporary trends of readmission rates and patients at a higher risk of worse outcomes after LVAD implantation. METHODS AND RESULTS: This is a retrospective study of adults from the Nationwide Readmission Database who underwent primary durable LVAD implantation from 2010 to 2018. The main outcomes were 30-day readmission rates and their trends in patients with primary durable LVAD implantation from 2010 to 2018. This study also sought to identify patients at the highest risk for readmission, in-hospital mortality, and resource use. A total of 31,002 adults with primary durable LVAD implantation were included in the present analysis. Overall, 3808 patients (12.3%) died and 27,168 (87.6%) were discharged alive. Of those discharged alive, 8303 patients (30.6%) were readmitted within 30 days. The trend of 30-day all-cause readmission among LVAD implantation patients remained similar from 2010 to 2018 (P = .809). The in-hospital mortality rate during the index hospitalization decreased significantly (P = .014), and the mean cost of an index hospitalization increased (P = .031) during the study period. The patients with post-LVAD in-hospital cardiac, vascular, and thromboembolic complications (ie, high-risk patients) had the highest mortality, resource use, and readmission rates compared with patients without major complications. CONCLUSIONS: This study found that the readmission rates associated with LVAD implantation did not change from 2010 to 2018 and identified high-risk patients who may benefit from closer monitoring after primary LVAD implantation.

Impact of Chronic Kidney Disease on In-Hospital Outcomes of Hospitalizations With Acute Limb Ischemia Undergoing Endovascular Therapy.

PURPOSE: Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited. METHODS: The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality. RESULTS: A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 - 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74-3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages. CONCLUSION: Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT. CLINICAL IMPACT: Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.

Racial and ethnic disparities in the management and outcomes of cardiogenic shock complicating acute myocardial infarction.

BACKGROUND: It remains unclear if there remain racial/ethnic differences in the management and in-hospital outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in contemporary practice. METHODS: We used the National inpatient Sample (2012-2017) to identify a cohort of adult AMI-CS hospitalizations. Race was classified as White, Black and Others (Hispanic, Asian/Pacific Islander, Native Americans). Primary outcome of interest was in-hospital mortality, and secondary outcomes included use of invasive cardiac procedures, length of hospital stay and discharge disposition. RESULTS: Among 203,905 AMI-CS admissions, 70.4% were White, 8.1% were Black and 15.7% belonged to Other races. Black AMI-CS admissions were more often female, with lower socio-economic status, greater comorbidity, and higher rates of non-ST-segment-elevation AMI-CS, cardiac arrest, and multi-organ failure. Compared to White AMI-CS admissions, Black and Other races had lower rates of coronary angiography (75.3% vs 69.3% vs 73.6%), percutaneous coronary intervention (52.7% vs 48.6% vs 54.8%), and mechanical circulatory devices (48.3% vs 42.8% vs 43.7%) (all p < 0.001). Unadjusted in-hospital mortality was comparable between White (33.3%) and Black (33.8%) admissions, but lower for other races (32.1%). Adjusted analysis with White race as the reference identified lower in-hospital mortality for Black (odds ratio [OR] 0.85 [95% confidence interval {CI} 0.82-0.88]; p < 0.001) and Other races (OR 0.97 [95% CI 0.94-1.00]; p = 0.02). Admissions of Black race had longer hospital stay, and less frequent discharges to home. CONCLUSIONS: Contrary to previous studies, we identified Black and Other race AMI-CS admissions had lower in-hospital mortality despite lower rates of cardiac procedures when compared to White admissions.

Northwell intracoronary brachytherapy for the treatment of recurrent drug eluting stent in-stent restenosis (NITDI study group).

OBJECTIVE: The purpose of this study is to report on safety, short-term and long-term clinical efficacy following intracoronary brachytherapy (ICBT) for restenosis (ISR) in patients with drug eluting stents (DES). BACKGROUND: ICBT is an effective treatment for ISR of bare metal stents (BMS) but its utilization has waned due to the advent of DES. ISR following DES occurs at a frequency of 8% or greater. METHOD: A retrospective analysis was performed on patients treated on an institutional review board (IRB) approved protocol using ICBT for DES ISR between January 2011 and October 2016. All patients were followed for 24 months for procedural complications, mortality, clinical ISR/target lesion revascularization (TLR) and stroke. RESULTS: A total of 290 patients were identified with a mean age of 66.6 years. All of them had high rates of typical coronary artery disease risk factors. Our primary outcome, composite of in-hospital mortality, myocardial infarction (MI), safety outcomes and procedural failure was noted in 1(0.3%) patient who had a MI. No other secondary outcome was noted in-hospital. At 1-year follow up, 12.4% patients had ISR, 1.7% patients died, and 1 (0.3%) had ischemic stroke. At 2-year, 14.7% had ISR, and total 6 (2.1%) patients had MI. CONCLUSION: ICBT demonstrates excellent technical success rates for treatment, safety, and reasonable efficacy over 2-years to be free from recurrent clinical ISR. This study represents the largest ICBT data for DES ISR to date among very complex lesion subsets, however, more prospective data will be needed to determine the optimal patient for treatment.

Short term outcomes of rotational atherectomy versus orbital atherectomy in patients undergoing complex percutaneous coronary intervention: a systematic review and meta-analysis.

OBJECTIVE: Coronary artery calcification (CAC) is one of the paramount hurdles for percutaneous coronary intervention (PCI) since it impedes stent delivery and complete expansion. This study intended to evaluate the short-term clinical and procedural outcomes comparing rotational atherectomy (RA) and orbital atherectomy (OA) in patients with heavily calcified coronary lesions undergoing PCI. Design: This systematic review and meta-analysis included all head-to-head published comparisons of coronary RA versus OA. Procedural endpoints and post-procedural clinical outcomes (30 days/in-hospital), were compared. RevMan 5.3 software was used for data analysis. Results: Seven retrospective observational investigations with a total of 4623 patients, including 3203 patients in the RA group and 1420 patients in the OA group, were incorporated. Compared with OA, the RA group was associated with a higher incidence of myocardial infarction at short-term follow-up (OR: 1.56, 95% CI: 1.07-2.29, p = .02, I2 = 0%). No difference was noted among other short-term post-procedural clinical outcomes including all-cause mortality, target vessel revascularization, or major adverse cardiac events. Among procedural complications, RA was associated with reduced coronary artery dissection and arterial perforation. Increased fluoroscopy time was observed in the RA cohort as compared with OA (MD: 4.78, 95% CI: 2.25-7.30, p = .0002, I2 = 80%). Conclusion: RA was associated with fewer vascular complications, but at a cost of higher incidence of myocardial infarction and higher fluoroscopy time compared with OA, at short term follow-up. OA is a safe and effective alternative for the management of CAC.

Differences in risk factors and resource utilization for women undergoing percutaneous coronary intervention and lower extremity peripheral vascular intervention.

OBJECTIVE: To investigate the differences in risk factors and in-hospital outcomes for women undergoing percutaneous coronary intervention (PCI) and peripheral vascular intervention (PVI). BACKGROUND: The clinical impact of coronary artery disease (CAD) and peripheral artery disease (PAD) is well characterized and is associated with high morbidity and mortality. There is lack of data comparing risk factors and in-hospital outcomes for PCI and PVI, particularly in women. METHODS: Only female hospitalizations (age ≥ 18 years) who underwent PCI or PVI from 2005 to 2014 were identified using appropriate International Classification of Diseases-Ninth Revision, Clinical Modification codes from the National Inpatient Sample database. Charlson's Comorbidity Index (CCI) was selected as the primary endpoint of the study. Coprimary endpoint was the cost of hospitalizations associated with PCI or PVI. RESULTS: Of the 2,461,328 female hospitalizations that were included, 85.6% (N = 2,105,236) underwent PCI and 14.4% (N = 356,092) received PVI. Compared to PCI, PVI hospitalizations were 3.2 years older (p < .001) and consisted of significantly more hospitalizations above 80 years of age (26.5% vs. 18.6%; p < .001). Hospitalizations with CCI ≥3 were significantly higher in the PVI cohort (29.1% vs. 24%; p < .001). CCI in women increased during the study period for both groups. PVI hospitalizations had a significantly longer length of stay (3 days vs. 2 days; p < .001) and cost of hospitalization ($23,610 vs. $20,571; p < .001), compared to PCI. Finally, the mean cost of hospitalizations increased during the study period for PCI and PVI. CONCLUSION: Women hospitalized for PVI had a greater risk-profile and resource utilization as demonstrated by the longer length of stay and higher cost compared to PCI.

Nationwide Analysis of Resource Utilization and In-Hospital Outcomes in the Obese Patients With Lower Gastrointestinal Hemorrhage.

GOALS: The goal of this study was to evaluate the impact of obesity on the outcomes of patients with lower gastrointestinal hemorrhage (LGIH). BACKGROUND: Obesity is considered as an independent risk factor for LGIH. We sought to analyze in-hospital outcomes and characteristics of nonobese and obese patients who presented with LGIH, and further, identify resource utilization during their hospital stay. MATERIALS AND METHODS: With the use of National Inpatient Sample from January 2005 through December 2014, LGIH-related hospitalizations (age≥18 y) were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Patients were stratified into the nonobese and obese groups depending on their body mass index (>30 kg/m). The statistical analyses were performed using SAS 9.4. RESULTS: Of the total 482,711 patients with LGIH-related hospitalizations, 38,592 patients were found to be obese. In a propensity-matched analysis, the in-hospital mortality was higher in the nonobese patients (4.2% vs. 3.8%, P=0.004), however, the mean length of hospital stay and mean cost was higher in the obese group which could be due to a higher number of comorbidities in the obese group. Secondary outcomes such as the need for mechanical ventilation vasopressor use and colonoscopy was significantly higher in the obese group. CONCLUSIONS: The study results demonstrate that 'obesity paradox' do exist for LGIH-related hospitalizations for mortality. LGIH hospitalizations in the obese patients are associated with higher resource utilization as evidenced by the longer length of stay and higher cost of hospitalizations as compared with the nonobese patients.

Index of microvascular resistance and outcomes following intra-coronary thrombolysis with percutaneous intervention in STEMI: a meta-analysis of randomized control trials.

Microvascular obstruction following percutaneous coronary intervention (PCI) is highly prevalent and independently associated with adverse clinical outcomes. Microvascular obstruction is determined by index of the microvascular resistance. We performed a systematic review with meta-analysis of all published randomized clinical trials (RCTs) studying the effect of intra-coronary thrombolysis with PCI as compared to standard treatment among patients with ST-segment elevated myocardial infarction. We included 6 RCTs summing up to 947 patients in the final analysis. Intra-coronary thrombolysis resulted in significantly lower index of microvascular resistance [standardized mean difference: - 13.74, 95% confidence interval (CI): - 16.74 to - 10.73, P value < 0.001, I2 = 0%]. There was no difference noted in the occurrence of major adverse cardiac events with intra-coronary thrombolysis as compared to standard treatment [Odds ratio: 0.71, 95% CI: 0.46-1.08, P value = 0.11,  I2 = 0%]. The absence of heterogeneity deferred us from using dose-response analysis to account for altering dose used across studies. The results of the present meta-analysis highlights the role of intra-coronary thrombolysis in reducing microvascular obstruction. No effect of intra-coronary thrombolysis was noted on the occurrence of major adverse cardiac events.

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

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

The outcomes of Clostridioides difficile infection in patients with diverticular disease: a nationwide analysis.

Background: Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections. It contributes to significant morbidity and mortality among hospitalized patients in the United States. Prior studies suggest worse outcomes of CDI in patients with diverticulitis and increased risk for recurrent CDI. We conducted this study to evaluate the outcomes of CDI in patients with diverticular disease from a nationwide data sample (2012-2015).Methods: The National Inpatient Sample (NIS) database between January 2012 and September 2015 was queried for CDI admissions using the International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 008.45, 562.11, 562.10, 562.12, and 562.13 for diagnoses of CDI and diverticular disease.Results: The study included 1,327,595 patients who were admitted between 2012 and 2105 for CDI. Out of all of the patients, 84,170 (6.34%) had a concurrent diagnosis of diverticular disease. After adjusting for confounding variables, the in-hospital mortality was lower [odd ratio (OR): 0.48, 95% CI: 0.44-0.52, p < .001] for patients with diverticular disease. The length of stay (LOS) was longer [10.5 versus 9.3 days, p < .001] and mean cost of hospitalization was significantly higher in patients without a history of diverticular disease.Discussion: In a nationwide population study, admissions with CDI, patients with a concurrent diagnosis of diverticular disease had lower in-hospital mortality. The observed results are different from prior studies and might be attributed to a higher burden of normal flora in those patients and increased use of antibiotic stewardship program across many hospitals nationwide.

Modern-Day Nationwide Utilization of Intravascular Ultrasound and Its Impact on the Outcomes of Percutaneous Coronary Intervention With Coronary Atherectomy in the United States.

OBJECTIVES: Intravascular ultrasonography (IVUS) and coronary atherectomy (CA) are useful modalities in managing calcified coronary lesions. Considering an inadequacy of data, we aimed to compare the outcomes with versus without IVUS assistance in percutaneous coronary interventions (PCIs) with CA. METHODS: From the National (Nationwide) Inpatient Sample data set for the years 2012 to 2014, we identified adult patients undergoing PCI and CA with or without IVUS assistance using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We assessed the impact of IVUS on procedural outcomes, length of stay, total hospital charges, and predictors of IVUS utilization by multivariable analyses. Discharge weights were used to calculate national estimates. RESULTS: A total of 46,095 PCIs with CA procedures were performed from 2012 to 2014, of these, 4800 (10.4%) procedures were IVUS-assisted. IVUS-assisted procedures showed lower odds of in-hospital mortality (odds ratio, 0.57; P = .024) but higher odds of any cardiac complication (odds ratio, 1.25; P = .025). Total hospital charges were higher in IVUS-assisted procedures without any substantial difference in the length of stay between the groups. Cardiac complication rates declined (from 16.2% to 14.8%) from 2012 to 2014, whereas inpatient mortality increased (1.1%-4.4%) in IVUS-assisted procedures during the same period. The odds of IVUS utilization were higher in Asian/Pacific Islander and urban teaching and western region hospitals. Comorbidities, including hypertension, obesity, and chronic pulmonary disease, raised odds of IVUS utilization. CONCLUSIONS: IVUS-assisted procedures showed lower in-hospital mortality and higher iatrogenic and overall cardiac complications. The mortality rate in patients undergoing IVUS-assisted PCI with CA was on the rise, with declining cardiac complication rates from 2012 to 2014.

Trends in the Utilisation and In-Hospital Mortality Associated With Short-Term Mechanical Circulatory Support for Heart Failure With Reduced Ejection Fraction.

Heart failure with reduced ejection fraction (HFrEF) is a systolic dysfunction with an ejection fraction below 40% and the prevalence of it is substantially increasing in the United States. Mechanical circulatory support (MCS) devices have increasingly been used for the management of HFrEF and are associated with improved outcomes. The National Inpatient Sample database was used to identify hospitalisations with mechanical circulatory support for HFrEF from 2005 to 2014. This study observed a reduction in the utilisation of intra-aortic balloon pump (IABP), which is partially replaced by percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) for the management of HFrEF. In-hospital mortality in IABP and ECMO recipients decreased during the study period while mortality with pLVAD did not change. Finally, technology for the short-term MCS in HFrEF hospitalisations continues to improve, however, there is still some space for updated technology in future.

Clinical outcomes of atherectomy prior to percutaneous coronary intervention: A comparison of outcomes following rotational versus orbital atherectomy (COAP-PCI study).

BACKGROUND: Because of the challenges in treating calcified coronary artery disease (CAD), lesion preparation has become increasingly important prior to percutaneous coronary intervention (PCI). Despite growing data for both rotational atherectomy (RA) and orbital atherectomy (OA), there have been no multicenter studies comparing the safety and efficacy of both. We sought to examine the clinical outcomes of patients with calcified CAD who underwent atherectomy. METHODS: A total of 39 870 patients from five tertiary care hospitals who had PCI from January 2011 to January 2017 were identified. 907 patients who had RA or OA were included. This multicenter, prospectively collected observational analysis compared OA and RA. The primary end-point was myocardial infarction and safety outcomes including significant dissection, perforation, cardiac tamponade, and vascular complications. Propensity score matching (1:1) was performed to reduce selection bias. RESULTS: After matching, 546 patients were included in the final analysis. The primary endpoint, myocardial infarction occurred less frequently with OA compared to RA (6.7% vs 13.8%, P ≤ 0.01) in propensity score matched cohorts. Procedural safety outcomes were comparable between the groups. The secondary outcome of death on discharge occurred less in the OA group as compared with RA (0% vs 2.2%, P = 0.01). Fluoroscopy time was less in patients who were treated with OA (21.9 vs 25.6 min, P ≤ 0.01). Additional secondary outcomes were comparable between groups. CONCLUSION: In this non-randomized, multicenter comparison of contemporary atherectomy devices, OA was associated with significantly decreased in-hospital myocardial infarction and mortality after propensity score matching with decreased fluoroscopy time.

Targeted Temperature Management After Cardiac Arrest: Systematic Review and Meta-analyses.

BACKGROUND: Targeted temperature management (TTM) with therapeutic hypothermia is an integral component of postarrest care for survivors. However, recent randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. We sought to determine if the pooled data from available RCTs support the use of prehospital and/or in-hospital TTM after cardiac arrest. METHODS: A comprehensive search of SCOPUS, Elsevier's abstract and citation database of peer-reviewed literature, from 1966 to November 2016 was performed using predefined criteria. Therapeutic hypothermia was defined as any strategy that aimed to cool post-cardiac arrest survivors to a temperature ≤34°C. Normothermia was temperature of ≥36°C. We compared mortality and neurologic outcomes in patients by categorizing the studies into 2 groups: (1) hypothermia versus normothermia and (2) prehospital hypothermia versus in-hospital hypothermia using standard meta-analytic methods. A random effects modeling was utilized to estimate comparative risk ratios (RR) and 95% confidence intervals (CIs). RESULTS: The hypothermia and normothermia strategies were compared in 5 RCTs with 1389 patients, whereas prehospital hypothermia and in-hospital hypothermia were compared in 6 RCTs with 3393 patients. We observed no difference in mortality (RR, 0.88; 95% CI, 0.73-1.05) or neurologic outcomes (RR, 1.26; 95% CI, 0.92-1.72) between the hypothermia and normothermia strategies. Similarly, no difference was observed in mortality (RR, 1.00; 95% CI, 0.97-1.03) or neurologic outcome (RR, 0.96; 95% CI, 0.85-1.08) between the prehospital hypothermia versus in-hospital hypothermia strategies. CONCLUSIONS: Our results suggest that TTM with therapeutic hypothermia may not improve mortality or neurologic outcomes in postarrest survivors. Using therapeutic hypothermia as a standard of care strategy of postarrest care in survivors may need to be reevaluated.

Utilization and in-hospital outcomes associated with atherectomy in the treatment of peripheral vascular disease: An observational analysis from the National Inpatient Sample.

Objective Percutaneous revascularization for patients with peripheral arterial disease has become a treatment of choice for many symptomatic patients. The presence of severe arterial calcification presents many challenges for successful revascularization. Atherectomy is an adjunctive treatment option for patients with severe calcification undergoing percutaneous intervention. We sought to analyze the impact of atherectomy on in-hospital outcomes, length of stay, and cost in the percutaneous treatment of peripheral arterial disease. Methods Patients with lower extremity peripheral arterial disease undergoing percutaneous revascularization were assessed, utilizing the National Inpatient Sample (2012-2014) and appropriate International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes. Patients who were not treated with atherectomy ( n = 51,037) were compared to those treated with atherectomy ( n = 11,408). Propensity score-matched analysis was performed to address baseline differences. Results After performing propensity score-matched analysis, 11,037 patients were included in each group. Utilization of atherectomy was associated with lower in-hospital mortality (2% vs. 1.4% p = 0.0006). All secondary outcomes were lower when using atherectomy except acute renal failure. Length of stay was slightly lower when using atherectomy (7.2 vs. 7.0 days, p = 0.0494). However, median cost was higher in patients treated with atherectomy ($21,589 vs. $24,060, p = <0.0001). Conclusion The use of atherectomy was associated with significantly decreased in-hospital mortality, adverse events, and length of stay. Though, cost associated with atherectomy use is increased, this is offset by decreased in-hospital adverse outcomes. Appropriate use of atherectomy devices is an important tool in revascularization of peripheral arterial disease in select patients.

Gender disparities among patients with peripheral arterial disease treated via endovascular approach: A propensity score matched analysis.

BACKGROUND: Remarkable improvement in the treatment of Peripheral Arterial Disease (PAD) has led to changes in revascularization strategies from traditional open surgery to less invasive endovascular management. However, few studies are available on gender disparities in patients with PAD treated via an endovascular approach. This study was designed to analyze gender related differences with respect to in-hospital outcomes in PAD patients. METHODS: Our data was obtained from National Inpatient Sample (NIS) 2012 through 2014. We used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes appropriate for PAD and endovascular treatment. Endovascular treatment included drug eluting stent, bare metal stent, atherectomy or angioplasty of lower extremity arteries. A propensity score matching was performed to adjust for imbalances between variables. RESULTS: Females presented late with more comorbidities and underwent more emergent/urgent procedures. After performing propensity score matched analysis, 25 758 patients were included in each group. There was no difference in in-hospital mortality between males and females in matched cohorts (2.3% vs 2.4%, P = 0.25). Acute renal failure, gangrene, infection, and composite of all complications were higher in males. Only blood transfusion was noted higher in females. CONCLUSION: This study revealed no difference in in-hospital mortality between males and females undergoing endovascular peripheral intervention. Males have a higher rate of complications compared to females which explains the higher cost of care in males. Further research with long-term follow up is needed to see if there is any difference with regards to long-term outcomes and re-admission.

Impella 2.5 initiated prior to unprotected left main PCI in acute myocardial infarction complicated by cardiogenic shock improves early survival.

OBJECTIVES: To assess post-procedural outcomes when Impella 2.5 percutaneous left ventricular assist device (pLVAD) support is initiated either prior to or after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULMCA) culprit lesion in the context of acute myocardial infarction cardiogenic shock (AMICS). BACKGROUND: Initiation of Impella 2.5 pLVAD prior to PCI is associated with significant survival benefit in the setting of AMICS. Outcomes of those presenting with a ULMCA culprit lesion in this setting have not been well characterized. METHODS: Thirty-six consecutive patients in the cVAD Registry supported with Impella 2.5 pLVAD for AMICS who underwent PCI on ULMCA culprit lesion were included in our multicenter study. RESULTS: The average age was 69.8 ± 14.2 years, 77.8% were male, 72.7% were in CS at admission, 44.4% sustained one or multiple cardiac arrests, and 30.6% had anoxic brain injury. Baseline characteristics were comparable between the Pre-PCI group (n = 20) and Post-PCI group (n = 16). Non-ST segment elevation myocardial infarction and greater coronary disease burden were significantly more frequent in the Pre-PCI group but they had significantly better survival to discharge (55.0% vs 18.8%, P = 0.041). Kaplan-Meier 30-day survival analysis showed very poor survival in Post-PCI group (48.1% vs 12.5%, Log-Rank P = 0.004). CONCLUSIONS: Initiation of Impella 2.5 pLVAD prior to as compared with after PCI of ULMCA for AMICS culprit lesion is associated with significant early survival. As previously described, patients supported after PCI appear to have very poor survival at 30 days.