Higher In-hospital Mortality In Patients Research Articles

Higher Mortality in Patients Undergoing Nighttime Surgical Procedures for Acute Type A Aortic Dissection

The aim of this study was to investigate whether nighttime surgical procedures contribute to higher in-hospital mortality in patients with acute type A aortic dissection. All patients with acute type A aortic dissection who underwent surgical procedures at Fuwai Hospital in Beijing, China from 2010 to 2015 were included in the present study. Depending on the start and end time of the surgical procedures, patients were divided in daytime and nighttime groups. Propensity-matching analysis was used to compare in-hospital mortality and postoperative complications between these groups. A total of 698 patients with acute type A aortic dissection underwent operation. Of these, 321 (45.98%) patients underwent nighttime surgical procedures, whereas 377 (54.02%) patients underwent daytime procedures. The operation time, cardiopulmonary bypass time, and aortic cross-clamp time showed statistical differences between the two groups (p < 0.01). There was a significant difference between the daytime and nighttime groups in in-hospital mortality (6.42% vs 12.08%; p< 0.05). The nighttime group had a higher incidence rate of reintubation and continuous renal replacement therapy compared with the daytime group (p < 0.05). Furthermore, patients who underwent nighttime operations had significantly higher adjusted in-hospital mortality than patients who underwent daytime operations (odds ratio, 2.13; 95% confidence interval, 1.19 to 3.81; p= 0.01). Patients with acute type A aortic dissection and certain serious medical conditions were more likely to die in the hospital if they underwent emergency nighttime surgical procedures.

Left ventricular hypertrophy assessed by electrocardiogram is associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke

Background and aimsLeft ventricular hypertrophy (LVH), assessed by electrocardiogram (ECG), is associated with increased risk for stroke. However, few studies that evaluated whether ECG-detected LVH predicts ischemic stroke severity and outcome. We aimed to evaluate these associations. MethodsWe prospectively studied 922 patients consecutively admitted with acute ischemic stroke (age 79.6 ± 6.9 years). Stroke severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS≥5. LVH was evaluated with the Sokolow-Lyon index and the Cornell voltage-duration product criteria in an ECG obtained at admission. The outcome was assessed with dependency at discharge (modified Rankin scale 2–5) and in-hospital mortality. ResultsIndependent predictors of severe stroke were age (relative risk (RR) per year 1.07, 95% confidence interval (CI) 1.03–1.11, p<0.001), female gender (RR 0.36, 95% CI 0.17–0.76, p<0.01), atrial fibrillation (RR 2.07, 95% CI 1.30–3.29, p<0.005), chronic kidney disease (RR 2.38, 95% CI 1.04–5.44, p<0.05), heart rate (RR per 1/min 1.02, 95% CI 1.01–1.04, p<0.005), glucose levels (RR 1.012, 95% CI 1.006–1.018, p<0.001), high-density lipoprotein cholesterol levels (RR 0.976, 95% CI 0.960–0.993, p<0.005) and LVH defined according to the Cornell voltage-duration product criteria (RR 2.08, 95% CI 1.12–3.86, p<0.05). Independent predictors of dependency at discharge were age (RR per year 1.08, 95% CI 1.03–1.13, p<0.001), past smoking (RR versus no smoking 0.42, 95% 0.19–0.89, p<0.05), history of ischemic stroke (RR 2.13, 95% CI 1.23–3.71, p<0.01) and NIHSS at admission (RR 1.48, 95% CI 1.35–1.63, p<0.001). Independent predictors of in-hospital mortality were glucose levels (RR 1.014, 95% CI 1.003–1.025, p<0.05), NIHSS at admission (RR 1.29, 95% CI 1.19–1.41, p<0.001) and LVH according to the Cornell voltage-duration product criteria (RR 4.95, 95% CI 1.09–22.37, p<0.05). ConclusionsLVH according to the Cornell voltage-duration product criteria appears to be associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke.

Diabetes Mellitus and Cardiogenic Shock Complicating Acute Myocardial Infarction

BackgroundDiabetes mellitus (diabetes) increases the risk of acute myocardial infarction, which can result in cardiogenic shock. Data on the relation of diabetes and the occurrence and prognosis of cardiogenic shock postacute myocardial infarction are scant. MethodsAmong the National Inpatient Sample patients aged ≥18 years and hospitalized for acute myocardial infarction during the 2012-2014 period, we examined the association between diabetes and the incidence and outcomes of cardiogenic shock complicating acute myocardial infarction, using multivariable logistic and linear regression models. ResultsOf 1,332,530 hospitalizations for acute myocardial infarction, 72,765 (5.5%) were complicated by cardiogenic shock. In acute myocardial infarction patients, cardiogenic shock incidence was higher among those with vs without diabetes (5.8% vs 5.2%; adjusted odds ratio [aOR] 1.14; 95% confidence interval [CI], 1.11-1.19; P < .001), with 42.8% (n = 31,135) of patients with acute myocardial infarction and cardiogenic shock having diabetes. Diabetic patients were less likely to undergo revascularization (percutaneous coronary intervention or coronary artery bypass grafting) (67.1% vs 68.7%; aOR 0.88; 95% CI, 0.80-0.96; P = .003). Diabetes was associated with higher in-hospital mortality in patients with acute myocardial infarction and cardiogenic shock (37.9% vs 36.8%; aOR 1.18; 95% CI, 1.09-1.28; P < .001). Among survivors, patients with diabetes had a longer hospital stay (mean ± SEM: 11.6 ± 0.16 vs 10.9 ± 0.16 days; adjusted estimate 1.12; 95% CI, 1.06-1.18; P < .001) and were more likely to be discharged to a skilled nursing home or with home health care (56.0% vs 50.5%; aOR 1.19; 95% CI, 1.07-1.33; P = .001). ConclusionsIn a large cohort of acute myocardial infarction patients, preexisting diabetes was associated with an increased risk of cardiogenic shock and worse outcomes in those with cardiogenic shock.

Major Adipokines and the −420C>G Resistin Gene Polymorphism as Predictors of Acute Ischemic Stroke Severity and In-Hospital Outcome

The role of adiponectin, leptin, and resistin and the -420C>G polymorphism of the resistin gene promoter in the pathogenesis of ischemic stroke are controversial. We aimed to evaluate whether serum levels of these adipokines and the -420C>G polymorphism are associated with ischemic stroke severity and in-hospital outcome. We prospectively studied 93 patients who were consecutively hospitalized for acute ischemic stroke (39.8% males, age 79.7 ± 6.3 years). Stroke severity was evaluated at admission by the National Institutes of Health Stroke Scale (NIHSS). In-hospital outcome was evaluated by dependency rates at discharge and in-hospital mortality. The G allele was more prevalent in patients with severe stroke (P < .05). Independent predictors of severe stroke were high-sensitivity C-reactive protein levels (relative risk [RR] 1.43, 95% confidence interval [CI] 1.08-1.91, P < .05). Patients with dependency at discharge had lower serum leptin levels (P < .05). Independent predictors of functional dependence were prior ischemic stroke (RR 7.55, 95% CI 1.69-33.58, P < .01), serum triglyceride levels (RR .98, 95% CI .96-0.99, P < .05), and NIHSS at admission (RR 1.47, 95% CI 1.17-1.84, P < .001). The G allele was more prevalent in patients who died (P < .05). Independent predictors of in-hospital mortality were systolic blood pressure (RR 1.09, 95% CI 1.01-1.19, P < .05) and NIHSS at admission (RR 1.26, 95% CI 1.08-1.48, P < .005). The G allele of the -420C>G polymorphism of the resistin gene promoter appears to be associated with more severe stroke and higher in-hospital mortality in patients with acute ischemic stroke. Higher leptin levels appear to be related to favorable functional outcome.

Association of Chronic Kidney Disease With In-Hospital Outcomes of Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR). BackgroundCKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis. MethodsThe authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes. ResultsOf 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period. ConclusionsPatients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Patients with CKD.

Advance care planning, including code/resuscitation status discussion, is an essential part of the medical care of patients with CKD. There is little information on the outcomes of cardiopulmonary resuscitation in these patients. We aimed to measure cardiopulmonary resuscitation outcomes in these patients. Our study is observational in nature. We compared the following cardiopulmonary resuscitation-related outcomes in patients with CKD with those in the general population by using the Nationwide Inpatient Sample (2005-2011): (1) survival to hospital discharge, (2) discharge destination, and (3) length of hospital stay. All of the patients were 18 years old or older. During the study period, 71,961 patients with CKD underwent in-hospital cardiopulmonary resuscitation compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with CKD (75% versus 72%; P<0.001) on univariate analysis. After adjusting for age, sex, and potential confounders, patients with CKD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.34; P≤0.001) and length of stay (odds ratio, 1.11; 95% confidence interval, 1.07 to 1.15; P=0.001). Hospitalization charges were also greater in patients with CKD. There was no overall difference in postcardiopulmonary resuscitation nursing home placement between the two groups. In a separate subanalysis of patients ≥75 years old with CKD, higher odds of in-hospital mortality were also seen in the patients with CKD (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.17; P=0.01). In conclusion, we observed slightly higher in-hospital mortality in patients with CKD undergoing in-hospital cardiopulmonary resuscitation.

Predictors of inpatient mortality in patients with systemic sclerosis: a case control study.

There are few studies on predictors of inpatient mortality in patients with systemic sclerosis (SSc). Knowledge of these predictors is important for the early identification of patients at high risk of inpatient death and for the recognition of modifiable factors. The aim of this study was to define factors associated with greater inpatient mortality in SSc. All admissions coded for SSc (ICD-9-710.1) at the Hospital of University of Pennsylvania, between 2001 and 2011, were reviewed. The diagnosis of SSc was confirmed, and deaths were identified by chart review. For each death, an age, sex, and race matched control with SSc (who did not die during their hospitalization) was identified. We hypothesized group differences in SSc characteristics, non-SSc co-morbidities, and admission labs. Group differences were analyzed using Student's t test as well as Chi(2) tests for dichotomous variables. Exposures associated with death in univariate analyses were used to form a final parsimonious multivariable logistic regression model. After analysis of 658 SSc admissions, 29 cases and 29 matched controls were studied. A significant difference in non-SSc lung disease (p = 0.03), aspiration events (p < 0.01), blood urea nitrogen (BUN) (p < 0.01), and hemoglobin (p = 0.03) was noted between subjects that died compared to matched controls. Odds of death were higher in patients with a higher BUN (OR = 1.06, CI = 1.02-1.11), non-SSc lung disease (OR = 3.87, CI = 1.26-11.88), and aspiration events (OR = 30, CI = 3.58-250.80) and lower in patients with a higher hemoglobin (OR = 0.73, CI = 0.54-0.97). A high BUN, a history of aspiration events, and low Hgb were found to be independently associated with risk of death. A history of lung disease, anemia, renal dysfunction, and aspiration events is associated with higher in-hospital mortality in patients with SSc. The odds of dying in the hospital were 30 times higher among patients with an aspiration event. Stringent measures should be considered to prevent aspiration in at-risk patients.

Preoperative abnormalities in serum sodium concentrations are associated with higher in-hospital mortality in patients undergoing major surgery

BackgroundAbnormal serum sodium concentrations are common in patients presenting for surgery. It remains unclear whether these abnormalities are independent risk factors for postoperative mortality. MethodsThis is a secondary analysis of the European Surgical Outcome Study (EuSOS) that provided data describing 46 539 patients undergoing inpatient non-cardiac surgery. Patients were included in this study if they had a recorded value of preoperative serum sodium within the 28 days immediately before surgery. Data describing preoperative risk factors and serum sodium concentrations were analysed to investigate the relationship with in-hospital mortality using univariate and multivariate logistic regression techniques. ResultsOf 35 816 (77.0%) patients from the EuSOS database, 21 943 (61.3%) had normal values of serum sodium (138–142 mmol litre−1) before surgery, 8538 (23.8%) had hyponatraemia (serum sodium ≤137 mmol litre−1) and 5335 (14.9%) had hypernatraemia (serum sodium ≥143 mmol litre−1). After adjustment for potential confounding factors, moderate to severe hypernatraemia (serum sodium concentration ≥150 mmol litre−1) was independently associated with mortality [odds ratio 3.4 (95% confidence interval 2.0–6.0), P<0.0001]. Hyponatraemia was not associated with mortality. ConclusionsPreoperative abnormalities in serum sodium concentrations are common, and hypernatraemia is associated with increased mortality after surgery. Abnormalities of serum sodium concentration may be an important biomarker of perioperative risk resulting from co-morbid disease.

Impact of admission serum total cholesterol level on in-hospital mortality in patients with acute aortic dissection.

Objective:To find out the association between serum total cholesterol (TC) on admission and in-hospital mortality in patients with acute aortic dissection (AAD).Methods:From January 2007 to January 2014, we enrolled 1492 consecutive AAD patients with serum TC measured immediately on admission. Baseline characteristics and in-hospital mortality were compared between the patients with serum TC above and below the median (4.00 mmol/L). Propensity score matching (PSM) was used to account for known confounders in the study. Cox proportional hazard model was performed to calculate the hazard ratio (HR) and 95% confidence interval (CI) for admission serum TC levels.Results:With the use of PSM, 521 matched pairs of patients with AAD were yielded in this analysis due to their similar propensity scores. Patients with admission serum TC < 4.00 mmol/L, as compared with those with admission serum TC ≥ 4.00 mmol/L, had higher in-hospital mortality (11.7% vs. 5.8%; HR, 2.06; 95% CI, 1.33-3.19, P = 0.001). Stratified analysis according to Stanford classification showed that the inverse association between admission serum TC and in-hospital mortality was observed in patients with Type-A AAD (24.0% vs. 11.3%; HR, 2.18; 95% CI, 1.33 - 3.57, P = 0.002) but not in those with Type-B AAD (3.8% vs. 2.2%; HR, 1.71; 95% CI, 0.67 - 4.34, P = 0.261).Conclusions:Lower serum TC level on admission was strongly associated with higher in-hospital mortality in patients with Type-A AAD.

Extracorporeal Membrane Oxygenation as a Bridge for Heart Failure and Cardiogenic Shock.

Heart failure (HF) can be defined as cardiac structural or functional abnormality leading to a series of symptoms due to deficiency of oxygen delivery. In the clinical practice, acute heart failure (AHF) is usually performed as cardiogenic shock (CS), pulmonary edema, and single or double ventricle congestive heart failure. CS refers to depressed or insufficient cardiac output (CO) attributable to myocardial infarction, fulminant myocarditis, acute circulatory failure attributable to intractable arrhythmias or the exacerbation of chronic heart failure, postcardiotomy low CO syndrome, and so forth. Epidemiological studies have shown that CS has higher in-hospital mortality in patients with AHF. Besides, we call the induced, sustained circulatory failure even after administration of high doses of inotropes and vasopressors refractory cardiogenic shock. In handling these cases, mechanical circulatory support devices are usually needed. In this review, we discuss the current application status and clinical points in utilizing extracorporeal membrane oxygenation (ECMO).

Effect of Weekend Admission on In-Hospital Mortality in Patients with Ischemic Stroke: An Analysis of Korean Nationwide Claims Data from 2002 to 2013

Studies conducted on patients with stroke in countries other than Korea demonstrated a phenomenon known as the weekend effect on 7-day, 30-day, and in-hospital mortalities. We studied patients with stroke using nationwide cohort data to determine if there was a weekend effect on mortality in a Korean population. Nationwide cohort data, collected from 2002 to 2013, were searched for all hospitalizations via the emergency department due to ischemic stroke. Cox's proportional hazards frailty model was employed, and we adjusted for all patient and hospital characteristics. There were 8957 patients with ischemic stroke admitted via the emergency department: 2632 weekend admissions and 6325 weekday admissions. Of these, 478 (5.3%) patients were dead. After adjusting for patient and hospital characteristics, the frailty model analysis revealed significantly higher in-hospital mortality in patients admitted on weekends than in those admitted on weekdays (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.01-1.47). We obtained consistent results for the 30-day mortality findings (HR, 1.27; 95% CI, 1.04-1.55). However, no significant differences were observed in the 7-day mortality (HR, 1.13; 95% CI, .88-1.45). Weekend admission for ischemic stroke was significantly associated with higher in-hospital and 30-day mortality after adjusting for individual characteristics and hospital factors.

Prognostic Value of Left Ventricular End-Diastolic Pressure in Patients With Non-ST-Segment Elevation Myocardial Infarction.

BackgroundElevated left ventricular end-diastolic pressure (LVEDP) has been reported to predict an increased mortality in patients with ST-segment elevation myocardial infarction. However, its prognostic value in patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear.MethodsWe performed a retrospective analysis of NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. We excluded patients who did not undergo LVEDP measurements. Baseline and angiographic characteristics, in-hospital heart failure as well as in-hospital mortality were recorded.ResultsAfter exclusion, 367 patients were included in the final analysis. The median (interquartile range) LVEDP was 19 mm Hg (14 - 24 mm Hg). By receiver operating characteristic curve analysis, the optimal cutoff value for predicting in-hospital mortality was 22 mm Hg (area under the curve 0.80, sensitivity 80%, and specificity 71%). Of 367 patients, 109 patients (29.7%) had LVEDP > 22 mm Hg. Patients with LVEDP > 22 mm Hg had a greater number of comorbidities. There was no statistically significant difference in the rate of multi-vessel disease. Patients with LVEDP > 22 mm Hg had a significantly higher rate of in-hospital heart failure (22.0% vs. 13.2%, P = 0.03) and in-hospital mortality (3.7% vs. 0.4%, P = 0.03) than those with LVEDP ≤ 22 mm Hg.ConclusionElevated LVEDP was significantly associated with a higher in-hospital mortality in patients with NSTEMI.

Predictors of Ventricular Fibrillation at Reperfusion in Patients With Acute ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Ventricular fibrillation (VF) during reperfusion (rVF) in ST-segment elevation myocardial infarction (STEMI) is an infrequent but serious event that complicates coronary interventions. The aim of this study was to analyze clinical predictors of rVF in an unselected population of patients with STEMI treated with percutaneous coronary intervention (PCI). Consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2012 were retrospectively assessed for the presence of rVF. Admission electrocardiograms, stored in a digital format, were analyzed for a maximal ST-segment elevation in a single lead and the sum of ST-segment deviations in all leads. Clinical, electrocardiographic, and angiographic characteristics were tested for associations with rVF using logistic regression analysis. Among 3,724 patients with STEMI admitted from 2007 to 2012, 71 (1.9%) had rVF. In univariate analysis, history of myocardial infarction, aspirin and β-blocker use, VF before PCI, left main coronary artery disease, inferior myocardial infarction localization, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV were associated with increased risk for rVF. In a multivariate analysis, sum of ST-segment deviations in all leads >1500 μV (odds ratio 3.7, 95% confidence interval 1.45 to 9.41, p = 0.006) before PCI remained an independent predictor of rVF. In-hospital mortality was 18.3% in the rVF group and 3.3% in the group without VF (p <0.001), but rVF was not an independent predictor of in-hospital death. In conclusion, the magnitude of ST-segment elevation before PCI for STEMI independently predicts rVF and should be considered in periprocedural arrhythmic risk assessment. Despite higher in-hospital mortality in patients with rVF, rVF itself has no independent prognostic value for prognosis.

Body Mass Index is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m(2) or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m(2) or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m(2) or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Lower Hospital Volume Is Associated With Higher In-Hospital Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction

Current guidelines recommend >36 primary percutaneous coronary interventions (PCIs) per hospital per year. Whether these standards remain valid when routine coronary stenting and newer pharmacological agents are used is unclear. We analyzed patients who underwent primary PCI from July 2006 through June 2009 included in the CathPCI Registry. Hospitals were separated into 3 groups: low (≤36 primary PCIs/y, current guideline recommendation), intermediate (>36-60 primary PCIs/y), and high volume (>60 primary PCIs/y). In-hospital mortality and door-to-balloon time were examined for each group. A total of 87 324 patient visits for 86 044 patients from 738 hospitals were included. There were 278 low- (38%), 236 (32%) intermediate-, and 224 (30%) high-volume hospitals. The majority of patients with primary PCI (54%) were treated at high-volume hospitals, with 15% at low-volume hospitals. Unadjusted mortality was significantly higher in low-volume hospitals compared with high-volume hospitals (5.6% versus 4.8%; P<0.001), which was maintained after multivariate adjustment (1.20; 95% confidence interval, 1.08-1.33; P=0.001). In contrast, mortality was not significantly different between intermediate-volume and high-volume hospitals (4.8% versus 4.8%; adjusted odds ratio, 1.02; 95% confidence interval, 0.94-1.11; P=0.61). Door-to-balloon times were significantly shorter in high-volume hospitals compared with low-volume hospitals (median, 72 minutes; interquartile range, [53-91] versus 77 [57-100] minutes; P<0.0001). Higher annual hospital volume of primary PCI continues to be associated with lower mortality, with higher mortality in hospitals performing ≤36 primary PCIs/y.

In-Hospital Prognosis of Prosthetic Valve Endocarditis After Urgent Surgery

Prosthetic valve endocarditis is associated with high morbidity and mortality, particularly when urgent surgery is needed. The identification of factors that predict a poor prognosis is the first step in improving outcomes. The study objectives were to characterize patients with prosthetic valve endocarditis who need urgent surgery and to identify factors that predict in-hospital mortality in this high-risk group. From a database of 648 consecutive patients with infective endocarditis diagnosed between 1996 and 2006 at four tertiary-care centers with cardiac surgery facilities, 46 patients with left-sided prosthetic valve endocarditis who needed urgent surgery were identified. A retrospective study was carried out to determine these patients' main characteristics and to identify predictors of in-hospital mortality. The main indications for urgent surgery were heart failure (57%) and persistent infection (33%). In-hospital mortality was 41%. Factors significantly associated with a poor prognosis were fever at admission, persistent infection, positive blood cultures, persistently positive cultures, and echocardiographic evidence of vegetations (P< .05). No specific microorganism was associated with a poor prognosis. Prosthetic valve endocarditis was associated with high mortality when urgent surgery was needed. Although heart failure was the principle reason for urgent surgery, it did not lead to a worse in-hospital prognosis. The presence of vegetations and uncontrolled infection were the main factors associated with higher in-hospital mortality in patients with left-sided infective endocarditis who needed urgent surgery.

Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000: Does the evidence support current procedure volume minimums?

ObjectivesThe aim of this study was to evaluate current American College of Cardiology/American Heart Association (ACC/AHA) hospital percutaneous coronary intervention (PCI) volume minimum recommendations. BackgroundIn order to reduce procedure-associated mortality, ACC/AHA guidelines recommend that hospitals offering PCIs perform at least 400 PCIs annually. It is unclear whether this volume standard applies to current practice. MethodsWe conducted a retrospective analysis of the Agency for Healthcare Research and Quality's Nationwide In-patient Sample hospital discharge database to evaluate in-hospital mortality among patients (n = 362,748) who underwent PCI between 1998 and 2000 at low (5 to 199 cases/year), medium (200 to 399 cases/year), high (400 to 999 cases/year), and very high (1,000 cases or more/year) PCI volume hospitals. ResultsCrude in-hospital mortality rates were 2.56% in low-volume hospitals, 1.83% in medium-volume hospitals, 1.64% in high-volume hospitals, and 1.36% in very high-volume hospitals (p < 0.001 for trend). Compared with patients treated in high-volume hospitals (odds ratio [OR] 1.00, referent), patients treated in low-volume hospitals remained at increased risk for mortality after adjustment for patient characteristics (OR 1.21, 95% confidence interval [CI] 1.06 to 1.28). However, patients treated in medium-volume hospitals (OR 1.02, 95% CI 0.92 to 1.14) and patients treated in very high-volume hospitals (OR 0.94, 95% CI 0.85 to 1.03) had a comparable risk of mortality. Findings were similar when high- and very high-volume hospitals were pooled together. ConclusionsWe found no evidence of higher in-hospital mortality in patients undergoing PCI at medium-volume hospitals compared with patients treated at hospitals with annual PCI volumes of 400 cases of more, suggesting current ACC/AHA PCI hospital volume minimums may merit reevaluation.

Left ventricular mass index in aortic valve surgery: a new index for early valve replacement?

Increased left ventricular mass index has been associated with higher mortality. We analyze the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index in 614 patients who underwent aortic valve replacement between June 1993 and November 2001. Left ventricular mass index was considered increased if higher than the value of the superior decile (277 g/m(2) in males and 251 in females). Mean left ventricular mass index was: 178+/-111 g/m(2), and increased index was considered in 9.9% of patients. Postoperative complications (low cardiac output syndrome, respiratory failure, arrhythmias, pneumonia and mediastinitis), median length of hospital stay: 12 days (6-57) versus 11 days (5-51), and in-hospital mortality (11.4, 3.2%, P<0.01) were higher in patients with increased left ventricular mass index. Multivariable analysis identified increased left ventricular mass index (odds ratio: 5.6; 95% confidence interval: 1.2-25.0; P=0.02) and other three variables: age (P=0.04), history of chronic renal failure (P=0.03) and cardiopulmonary bypass time (P=0.004), as independent predictors of early mortality. Increased left ventricular mass index is associated with an in-hospital adverse outcome and a significantly higher in-hospital mortality in patients undergoing aortic valve replacement. Outcomes in asymptomatic patients could be improved before a clinically significant increase in left ventricular mass index. Further studies should be performed to determine the usefulness of this index in selecting patients for earlier aortic valve replacement.

Influence of hyperglycemia on stroke mortality

Background: The influence of hyperglycemia on stroke mortality is controversial. The aim of this study was to investigate the prognostic role of hyperglycemia and diabetes on short-term and long-term mortality in patients with acute ischemic stroke. Methods: This retrospective cohort study included 416 acute ischemic stroke patients admitted to a tertiary hospital between July 1, 1995 and June 30, 1997. In-hospital mortality and 1-year mortality after discharge were the outcomes of the study. All patients were classified into four groups according to the glucose status and history of diabetes: group 1, normoglycemic without diabetes; group 2, normoglycemic with diabetes; group 3, hyperglycemic with diabetes and group 4, hyperglycemic without diabetes. Cochrane-Armitage trend test was used to assess the trend of mortality across the 4 groups. The influence of hyperglycemia on in-hospital and 1-year mortality were studied by logistic regression and Cox proportional hazards regression adjusting for confounders. Results: The Cochrane-Armitage trend test showed there was a strong trend towards increasing in-hospital mortality across groups 1 to 4 (P < .001). Hyperglycemia without a history of diabetes was an independent predictor of in-hospital mortality, odds ratio 3.0 (95% confidence interval: 1.1-8.3; P = .035). Hyperglycemia (with or without diabetes) did not predict in-hospital mortality significantly. Neither hyperglycemia per se nor hyperglycemia without a history of diabetes were significant in predicting 1-year mortality. Conclusion: Hyperglycemia without diabetes is independently associated with higher in-hospital mortality in patients with acute ischemic stroke. There was a trend to increasing in-hospital mortality across groups 1 to 4. Copyright © 2001 by National Stroke Association

Early appearance of left ventricular thrombi after anterior myocardial infarction: A marker of higher in-hospital mortality in patients not treated with antithrombotic drugs

Left ventricular thrombus may develop both early and late after acute anterior myocardial infarction. To assess the possible prognostic implication of the time of thrombus appearance, 125 patients (87 males; age ranging from 35 to 92 years, mean: 65 +/- 10 years) consecutively admitted to our coronary care unit within 24 h of a first acute anterior myocardial infarction, untreated with antithrombotic drugs, underwent serial two-dimensional echocardiographic studies during hospitalization, then monthly for a follow-up of 1-48 (mean: 23 +/- 16) months among survivors. Left ventricular thrombi, detected in 71 patients (57%), appeared from 1 to 362 (mean: 13 +/- 44) days after acute infarction. In 40 patients (56%), early thrombus development, within 48 h of symptom onset, was noted. During the study period, 52 patients (42%) died. Global mortality rate was similar in patients with thrombi compared with those without thrombi (32/71: 45%, vs 20/54: 37%; P = ns). However, in-hospital mortality of patients who developed left ventricular thrombi within 48 h (17/40: 42.5%) was significantly higher compared with both patients with later thrombus appearance (4/31: 13%; P less than 0.008) and those without thrombi (10/54: 20%; P less than 0.01). Embolic events were more frequent in patients with thrombi (9/71, 13% vs 1/54, 2%; P less than 0.02), but there was no relationship with the time of thrombus appearance. The values of peak CPK levels and the degree of left ventricular wall motion abnormalities observed in patients with early left ventricular thrombus were significantly higher than the values detected in patients without thrombi, but similar to those obtained in patients with later thrombus occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)