Body Mass Index and In-Hospital Management and Outcomes of Pulmonary Embolism: A Nationwide Analysis.

Variations in Management and Outcomes of Pulmonary Embolism in Uninsured Compared With Privately Insured Individuals.

The Reply

Background: While previous studies have noted seasonal variation in acute cardiovascular conditions, such as higher myocardial infarction in the winter, there are limited data on the impact of seasonal variations in pulmonary embolism (PE) outcomes. Methods: All adult (greater than or equal to 18 years) non-elective admissions with a primary diagnosis of PE with available data on the month of admission were identified using the National Inpatient Sample (2016-2020). We stratified the seasons into spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Outcomes of interest included in-hospital mortality, total hospitalization costs, hospital length of stay, and discharge disposition. Results: During 01/01/2016 to 12/31/2020, 903,254 PE admissions with were identified. Spring, summer, fall, and winter had 23.9%, 25.1%, 25.2%, and 25.5% admissions, respectively. Admissions during the four seasons were comparable on sex distribution. Spring had higher admissions of white race (spring 69.6%, summer 68.8%, fall 68.9%, winter 69.2%) whereas summer had highest black race admissions (spring 18.3%, summer 19.0%, fall 19.0%, winter 18.6%) and those in lowest socioeconomic quartile (spring 28.2%, summer 28.7%, fall 28.5%, winter 28.1%) (all p<0.05). Respiratory failure was the highest in winter (spring 26.2%, summer 25.7%, fall 26.4%, winter 26.8%), whereas renal failure (spring 13.4%, summer 13.7%, fall 14.2%, winter 13.9%) bleeding complications (spring 5.7%, summer 5.8%, fall 6.1%, winter 5.9%), were higher in fall (all p<0.05). Mechanical thrombectomy rates were highest in fall (spring 1.0%, summer 1.3%, fall 1.7%, winter 1.2%, p< 0.001), whereas systemic thrombolysis (spring 2.8%, summer 3.2%, fall 3.1%, winter 3.1%, p=0.02) was highest in the summer. Use of catheter directed therapies was comparable. There were no difference in-hospital mortality rates among seasons but winter had highest length of stay, lowest discharges to home, and fall had highest hospitalization costs. Conclusion: In this five-year study duration, despite some differences in organ failure and complication rates, there was no significant seasonal variation in the in-hospital mortality from PE. Winter months had the highest in-hospital resource utilization.

Background and Objectives: Contemporary data on the prevalence, management and outcomes of acute myocardial infarction (AMI) in relation to body mass index (BMI) are limited. Materials and Methods: Using the National Inpatient Sample from 2008 through 2017, we identified adult AMI hospitalizations and categorized them into underweight (BMI < 19.9 kg/m2), normal BMI and overweight/obese (BMI > 24.9 kg/m2) groups. We evaluated in-hospital mortality, utilization of cardiac procedures and resource utilization among these groups. Results: Among 6,089,979 admissions for AMI, 38,070 (0.6%) were underweight, 5,094,721 (83.7%) had normal BMI, and 957,188 (15.7%) were overweight or obese. Over the study period, an increase in the prevalence of AMI was observed in underweight and overweight/obese admissions. Underweight AMI admissions were, on average, older, with higher comorbidity, whereas overweight/obese admissions were younger and had lower comorbidity. In comparison to the normal BMI and overweight/obese categories, significantly lower use of coronary angiography (62.3% vs. 74.6% vs. 37.9%) and PCI (40.8% vs. 47.7% vs. 19.6%) was observed in underweight admissions (all p < 0.001). The underweight category was associated with significantly higher in-hospital mortality (10.0% vs. 5.5%; OR 1.23 (95% CI 1.18–1.27), p < 0.001), whereas being overweight/obese was associated with significantly lower in-hospital mortality compared to normal BMI admissions (3.1% vs. 5.5%; OR 0.73 (95% CI 0.72–0.74), p < 0.001). Underweight AMI admissions had longer lengths of in-hospital stay with frequent discharges to skilled nursing facilities, while overweight/obese admissions had higher hospitalization costs. Conclusions: In-hospital management and outcomes of AMI vary by BMI. Underweight status was associated with worse outcomes, whereas the obesity paradox was apparent, with better outcomes for overweight/obese admissions.

Inferior Vena Cava Filters in Elderly Patients with Stable Acute Pulmonary Embolism

Drs. Kuo and Hofmann respond

There are limited data on seasonal variations and outcomes in pulmonary embolism (PE). To understand the seasonal variations in PE outcomes. All adult (³18 years) non-elective admissions with a primary diagnosis of PE were identified using the National Inpatient Sample (2016-2022) and assessed by the season of admission-spring (March-May), summer (June-August), fall (September-November), and winter (December-February). The primary outcome was in-hospital mortality across the seasons. Secondary outcomes included total hospitalization costs, hospital length of stay, and discharge disposition. During the 7-year period, 1,278,754 PE admissions were identified. Spring, summer, fall, and winter had 24.1%, 25.0%, 25.3%, and 25.6% admissions, respectively (p < 0.001). The baseline and in-hospital characteristics were comparable across cohorts with no significant clinical differences noted. Mechanical thrombectomy rates were highest in fall (spring 2.5%, summer 3.0%, fall 3.5%, winter 2.7%, p < 0.001), whereas systemic thrombolysis (spring 2.9%, summer 3.0%, fall 2.9%, winter 3.1%, p = 0.04) was highest in the summer. Use of other therapies were comparable. There was no statistical difference in adjusted in-hospital mortality rates among seasons. There were slight variations in hospitalization costs, length of stay, and discharge dispositions across the four cohorts but were not clinically relevant. In this study, there was no significant seasonal variation in in-hospital mortality from PE.

Background Pulmonary embolism (PE) results from a blood clot, typically originating in the deep leg and pelvic veins, breaks off and enters the pulmonary circulation to the pulmonary artery. Myasthenia Gravis (MG) is an autoimmune disorder of the neuromuscular junction that causes muscle weakness and fatigue, including respiratory muscles. There is limited data available on the impact of MG on outcomes of patients admitted with PE. Our study goal is to describe in-hospital outcomes among these patients. Methods Using the National Inpatient Sample (NIS) Database from 2019-2022, we conducted a retrospective analysis of patients admitted with PE using respective International Classification of Disease (ICD 10) codes. Our primary population included patients ≥18 years with a primary diagnosis of PE. Patients were divided into two groups, either having MG or not. We excluded patients admitted for myasthenic crisis. Using a univariate and multivariate analysis, we compared the odds of various in hospital outcomes and adjusted for confounders. Results We identified 752300 admissions for PE, out of which 1370 (0.18%) had a concomitant diagnosis of MG. The mean age of MG group was 70 years whereas the mean age of non-MG group was 50 years. The primary outcome of interest was in-hospital mortality. Secondary outcomes included length of stay (LOS), total hospitalization charges (TOTCHG), cardiac arrest (CA), cardiogenic shock (CS), acute heart failure (AHF), and mechanical ventilation (MV) during the same admission. On adjusted analysis, there was no significant difference in mortality (adjusted odds ratio (aOR): 0.59, CI: 0.22-1.56, p &amp;lt; 0.29) and regarding secondary outcomes, there was also no difference in TOTCHG (Coefficient $2805, CI: -$8822- $14432, p &amp;lt; 0.64), mean LOS (Coefficient 0.32 days, CI: -0.28 – 0.86, p &amp;lt; 0.32), AHF (aOR:0.99, CI:0.29-2.84, p&amp;lt;0.86), CA(aOR 0.58, CI; 0.14-2.36, p&amp;lt;0.45), CS (aOR:0.34, CI:0.05-2.32, P&amp;lt;0.27) and MV(aOR:0.96, CI:0.42-2.18, P&amp;lt;0.92). Conclusions Although Myasthenia Gravis can cause respiratory muscle weakness, our study demonstrates that patients with and without MG have comparable results when admitted with pulmonary embolism.

Contemporary National Trends and Outcomes of Pulmonary Embolism in the United States

Acute pulmonary embolism (PE) is one of the most common causes of cardiovascular mortality in the United States. Significant variations in the management of various cardiovascular conditions have previously been reported, but this has been poorly elucidated for pulmonary embolism. During 2016-2020, adult (≥ 18 years) nonelective admissions with PE, admitted to Northeast, Midwest, South, and West geographic regions were identified using the National Inpatient Sample. Outcomes of interest included in-hospital mortality, utilization of PE therapies, non-cardiac organ support, total hospitalization costs, and hospitalization duration. In this 5-year duration, 904,260 admissions were identified - Northeast, Midwest, South, and West had 166,050 (18.3%), 225,680 (24.9%), 350,160 (38.7%), and 162,370 (17.9%) admissions, respectively. On average, admissions to the Northeast were less comorbid, from a higher socioeconomic status, privately insured, and more commonly admitted to urban teaching and medium-sized hospitals (all p < 0.001). The Northeast region also had the lowest rates of definitive PE therapies except surgical thrombectomy. In comparison to the Northeast, the in-hospital mortality was higher in the South and West and lower in the Midwest region (3.1% vs 2.8% vs 3.2% vs 3.3%, p < 0.001). However, on adjusted analysis with Northeast as a reference, in-hospital mortality was noted to be lower in the Midwest (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.67-0.84; p < 0.001), South (aOR 0.89, 95% CI 0.80-0.98; p < 0.05), and the West (aOR 0.88, 95% CI 0.78-0.99; p < 0.05). In this study, we noted significant heterogeneity in the management and outcome of pulmonary embolism across various regions of the United States.

Risk Stratification for Acute Pulmonary Embolism

SURGICAL EMBOLECTOMY FOR ACUTE PULMONARY EMBOLISM: A MULTICENTER ANALYSIS OF OVER 58,000 CASES

Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE. This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not. A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

There are limited and conflicting data on sex and urban-rural disparities in outcomes of patients with pulmonary embolism (PE) in the reproductive age group. Our object was to assess sex disparities in the reproductive age group cohort. All adult non-elective admissions in the reproductive age group (18-49 years) with a primary diagnosis of PE and with no missing sex/age data were identified using the National Inpatient Sample. Females and males were stratified into rural and urban location based on hospital information. Outcomes of interest included in-hospital mortality, complication rates, variations in management, total hospitalization costs, and length of stay. During 01/01/2016 to 12/31/2020, 180,898 PE admissions aged 18-49 years were identified (rural-12,319 [6.8%]). Females comprised 54.8% and 55.1% of the rural and urban cohorts, respectively. Overall, compared to males, females in urban and rural regions had largely comparable rates of definitive PE interventions, except lower rates of catheter directed therapy (4.7 vs. 3.6%, p < 0.001) in females admitted to urban hospitals. Despite younger age, higher comorbidity, and lower utilization of PE interventions, females in both regions had similar unadjusted in-hospital mortality (rural 1.1% vs. 1.0%; p = 0.93 and urban 1.8% vs. 1.7%; p = 0.78) and hospitalization costs compared to males. In conclusion, females of reproductive age group had comparable in-hospital outcomes to males in both urban and rural areas. Females in urban areas had lower utilization of advanced PE interventions, potentially indicating selective management strategies in different settings.