Improvement In In-hospital Mortality Research Articles

Temporal trends in acute decompensated heart failure outcomes: A single-center 11-year retrospective analysis

BackgroundAcute Decompensated Heart Failure (ADHF) is associated with frequent hospitalizations, posing a significant health and economic burden globally. Despite advancements in heart failure management, studies delineating temporal trends in ADHF outcomes are sparse.Methods: in this retrospective analysis, ADHF patients admitted to Shamir Medical Center from 2007 to 2017 were categorized into two cohorts: early (2007–2011) and recent (2012–2017). Clinical characteristics, in-hospital interventions, and outcomes were compared. Survival analysis was performed using Kaplan-Meier methods with log-rank tests. Results8332 admitted patients were analyzed, 4366 (52.4 %) in the early period, and 3966 (47.6 %) in the recent period. In the recent cohort, ischemic heart disease decreased significantly (from 45.2 % to 34.7 %), while hypertension and smoking rates increased. Additionally, a significant increase in coronary artery bypass grafting (from 0.8 % to 3.5 %) and beta-blockers prescription (from 45.5 % to 63.4 %) post-discharge was observed. However, no substantial improvement in in-hospital mortality (8.9 % in early vs. 8.0 % in recent), 30-day (3.2 % in early vs. 3.1 % in recent), 1-year (23.3 % in early vs. 23.8 % in recent), or 5-year survival rates was noted between cohorts. A subset analysis of patients admitted to cardiology departments showed a significant reduction in in-hospital mortality in the recent cohort (12.3 % in early vs. 6.3 % in recent), yet without a corresponding long-term survival benefit. ConclusionsAdvancements in heart failure management over the 11-year study period did not demonstrate an improvement in clinical outcomes for ADHF patients, highlighting the challenge of translating advancements in the medical care of ADHF patients into long-term survival benefits.

Effect of rigorous fluid management using monitoring of ECW ratio by bioelectrical impedance analysis in critically ill postoperative patients: A prospective, single-blind, randomized controlled study

Background & AimsPrecise assessment of postoperative volume status is important to administrate optimal fluid management. Bioelectrical impedance analysis (BIA) which measures the body composition using electric character. Extracellular water (ECW) ratio by BIA represented as the ratio of ECW to total body water (TBW) and is known to reflect the hydration status. Based on this, we aimed to determine whether aggressive fluid control using ECW ratio could improve clinical outcomes through a single blind, randomized controlled trial. MethodsFrom November 2021 to December 2022, intensive care unit (ICU) patients admitted after surgery were randomly assigned to an intervention group or a control group whether postoperative fluid management was controlled via BIA. Among patients in the intervention group, dehydrated patients received a bolus infusion with crystalloid fluid whereas diuretics were administrated to overhydrated patients until the value of ECW ratio fell within its normal setting range (0.390–0.406). Contrarily, BIA was performed once a day for the control group. Patients in the control group received traditional fluid treatment regardless of BIA results. Primary outcome was in-hospital mortality in two groups. The secondary outcomes were postoperative morbidities, 28-day mortality. Results77 patients of the intervention group and 90 patients of the control group were finally analyzed. The in-hospital mortality (0 in intervention, 4.4% in control, p = 0.125) and 28-day mortality (1.3% in intervention, 14.4% in control, p = 0.002) showed lower incidence in the intervention group than in the control group. In multivariate analysis, the overhydrated status whose ECW ratio exceeding 0.406 [odds ratio (OR): 2.731, 95% confidence interval (CI): 1.001-7.663, p = 0.049] and high capillary leak index (CLI) value at ICU admission (OR: 1.024, 95% CI: 1.008-1.039, p = 0.002) were risk factors of postoperative morbidities. Regarding the 28-day mortality, high CLI value (OR: 1.025, 95% CI: 1.002-1.050, p = 0.037) and traditional strategy without BIA monitoring (OR: 9.903, 95% CI: 1.095-89.566, p = 0.041) were the significant predisposing factors. ConclusionOur results revealed the rigorous fluid treatment with volume control based on ECW ratio by BIA failed to achieve significant improvement in in-hospital mortality, but it could reduce 28-day mortality of ICU patients. Monitoring of ECW ratio may help establish optimal fluid treatment strategies for postoperative ICU patients who are susceptible to fluid imbalances with fluid overload. Trial registrationClinicalTrials.gov, NCT06097923, retrospectively registered on October 16, 2023, https://clinicaltrials.gov/study/NCT06097923?term=NCT06097923&rank=1

Temporal trends and rural–urban disparities in cerebrovascular risk factors, in-hospital management and outcomes in ischaemic strokes in China from 2005 to 2015: a nationwide serial cross-sectional survey

BackgroundStroke is the leading cause of mortality in China, with limited evidence of in-hospital burden obtained from nationwide surveys. We aimed to monitor and track the temporal trends and rural–urban...

Mortality in hospitalized older adults with COVID-19 during three waves: A multicenterretrospective cohort study.

BackgroundThe waves of COVID‐19 infections in Ontario, Canada, were marked by differences in patient characteristics and treatment. Our objectives were to (i) describe patient characteristics, treatment, and outcomes of hospitalized older adults with COVID‐19 between waves 1, 2, and 3, (ii) determine if there was an improvement in in‐hospital mortality in waves 2 and 3 after adjusting for covariates.MethodsThis retrospective cohort study was done in five acute care hospitals in Toronto, Ontario. Consecutive hospitalized older adults aged ≥65 years with confirmed COVID‐19 infection were included. Wave 1 extended from March 11 to July 31, 2020, wave 2 from August 1, 2020 to February 20, 2021, and wave 3 from February 21 to June 30, 2021. Patient characteristics and outcomes were abstracted from charts. A logistic regression model was used to determine the association between COVID‐19 and in‐hospital mortality in waves 2 and 3 compared with wave 1.ResultsOf the 1671 patients admitted to acute care, 297 (17.8%) were admitted in wave 1, 751 (44.9%) in wave 2, and 623 (37.3%) in wave 3. The median age of our cohort was 77.0 years (interquartile range: 71.0–85.0) and 775 (46.4%) were female. The prevalence of frailty declined in progressive waves. The use of dexamethasone, remdesivir, and tocilizumab was significantly higher in waves 2 and 3 compared with wave 1. In the unadjusted analysis, in‐hospital mortality was unchanged between waves 1 and 2, but it was lower in wave 3 (18.3% vs. 27.4% in wave 1). After adjustment, in‐hospital mortality was unchanged in waves 2 and 3 compared with wave 1.ConclusionIn‐hospital mortality in hospitalized older adults with COVID‐19 was similar between waves 1 and 3. Further research should be done to determine if COVID‐19 therapies have similar benefits for older adults compared with younger adults.

Anaerobe coverage is important for the prognosis of pyogenic liver abscess: A population-based study in Korea

BackgroundGram-negative bacteria such as Klebsiella pneumoniae and Escherichia coli are the most common cause of pyogenic liver abscess (PLA).We investigated whether the use of anaerobic-covering antibiotics is essential for the treatment of pyogenic liver abscess. MethodsWe analyzed the Health Insurance Review and Assessment Service data in Korea between 2007 and 2017. We classified PLA into two groups: a group using antibiotics that inhibited only aerobic strains (anaerobe (-) group) and a group using antibiotics that inhibited both aerobic and anaerobic strains (anaerobe (+) group). The primary outcome was the difference in in-hospital mortality between the two groups. ResultsDuring this period, a total of 30,690 PLA patients were obtained. There were 6733 patients in the anaerobe (-) group and 23,957 patients in the anaerobe (+) group. In-hospital mortality was significantly lower in the anaerobe (+) group than the anaerobe (-) group (7.9% vs. 15.6%, p < 0.001). In multivariate analysis, the use of anaerobic antibiotics reduced the in-hospital mortality by 42% (odds ratio 0.42, 95% confidence interval 0.38–0.46, p < 0.001) after adjusting for age and comorbidities. Furthermore, the improvement of in-hospital mortality was present regardless of the presence of cancer or diabetes. ConclusionThe use of broad-spectrum empirical antibiotics covering anaerobic strains is important for the treatment of pyogenic liver abscess.

Abstract 10894: Socioeconomic Status and Differences in Trends of Atrial Fibrillation In-Hospital Mortality Among Black and Non-Black Adults in the United States

Introduction: Race and socioeconomic status (SES) is interconnected. There is scarce data analyzing trends of atrial fibrillation (AF) in-hospital mortality in black and non-black adults based on SES. Methods: We queried the National Inpatient Sample database from January 2004 to December 2018 to identify patients admitted with AF. We used ICD-9-CM and ICD-10-CM diagnosis codes to identify all patients who were 18 years of age or older and hospitalized with a primary discharge diagnosis of Atrial Fibrillation. Our cohort was further categorized by race, into black and non-black groups, and socioeconomic status (SES) using median household income (MHI) as a surrogate, into low SES (MHI 0-50) and high SES (MHI 51-100). We excluded all patients with incomplete data on age, gender, race, MHI and in-hospital mortality status. Also, in order to reduce the possibility of data duplication, the patients with an indicator for transfer to another acute-care facility were excluded. Cochran-Armitage Test was utilized to estimate temporal trends. Results: Black and non-black adults have had improvement of in-hospital mortality, although black adults still have higher trends as compared to non-black counterparts (p&lt;0.001). Conclusions: Trends of AF in-hospital mortality between black and non-black individuals are comparable despite a significantly smaller proportion of blacks in our study. There is a dynamic interplay among social and health risk factors associated with AF in black individuals and further studies are required to better understand this relation.

Surgical treatment for post-infarction papillary muscle rupture: a multicentre study.

Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07-6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02-15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00-1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16-0.92, P = 0.031). Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. clinicaltrials.gov: NCT03848429.

Trends in extracorporeal membrane oxygenation treatment from 2005 to 2018 in South Korea.

This study aimed to investigate trends in extracorporeal membrane oxygenation (ECMO) treatment during 2005-2018 and examine factors associated with in-hospital mortality. We conducted a population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea. All adult patients (⩾18 years old) who received ECMO treatment in the intensive care unit after hospitalization from 2005 to 2018 were enrolled. We analyzed data for 21,129 adult ECMO patients from 128 hospitals. The prevalence of ECMO treatment gradually and continuously increased from 4 per 100,000 individuals (95% confidence interval [CI]: 3-4) in 2005 to 67.4 per 100,000 individuals (95% CI: 65-68) in 2018. There was a significant increase in ECMO treatment for acute respiratory distress syndrome (ARDS) or respiratory failure (from 2.5% during 2005-2008 to 14.5% during 2016-2018). The overall in-hospital and 30-day mortality rates of the patients were 48.4% and 53.5%, respectively. The in-hospital mortality rate was highest among patients with shock (62.1%) and lowest among ECMO patients with liver failure (21.6%). On multivariable logistic regression, a higher hospital case volume was associated with improvement in in-hospital mortality (p < 0.001). In South Korea, the prevalence of ECMO treatment has increased gradually and continuously between 2005 and 2018. There was a significant increase in the prevalence of ECMO treatment for ARDS or respiratory failure. Our results support that ECMO treatment indications have been expanding, and ECMO will become vital for treating critically ill patients in the future.

Changes in in-hospital mortality in the first wave of COVID-19: a multicentre prospective observational cohort study using the WHO Clinical Characterisation Protocol UK

SummaryBackgroundMortality rates in hospitalised patients with COVID-19 in the UK appeared to decline during the first wave of the pandemic. We aimed to quantify potential drivers of this change and identify groups of patients who remain at high risk of dying in hospital.MethodsIn this multicentre prospective observational cohort study, the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK recruited a prospective cohort of patients with COVID-19 admitted to 247 acute hospitals in England, Scotland, and Wales during the first wave of the pandemic (between March 9 and Aug 2, 2020). We included all patients aged 18 years and older with clinical signs and symptoms of COVID-19 or confirmed COVID-19 (by RT-PCR test) from assumed community-acquired infection. We did a three-way decomposition mediation analysis using natural effects models to explore associations between week of admission and in-hospital mortality, adjusting for confounders (demographics, comorbidities, and severity of illness) and quantifying potential mediators (level of respiratory support and steroid treatment). The primary outcome was weekly in-hospital mortality at 28 days, defined as the proportion of patients who had died within 28 days of admission of all patients admitted in the observed week, and it was assessed in all patients with an outcome. This study is registered with the ISRCTN Registry, ISRCTN66726260.FindingsBetween March 9, and Aug 2, 2020, we recruited 80 713 patients, of whom 63 972 were eligible and included in the study. Unadjusted weekly in-hospital mortality declined from 32·3% (95% CI 31·8–32·7) in March 9 to April 26, 2020, to 16·4% (15·0–17·8) in June 15 to Aug 2, 2020. Reductions in mortality were observed in all age groups, in all ethnic groups, for both sexes, and in patients with and without comorbidities. After adjustment, there was a 32% reduction in the risk of mortality per 7-week period (odds ratio [OR] 0·68 [95% CI 0·65–0·71]). The higher proportions of patients with severe disease and comorbidities earlier in the first wave (March and April) than in June and July accounted for 10·2% of this reduction. The use of respiratory support changed during the first wave, with gradually increased use of non-invasive ventilation over the first wave. Changes in respiratory support and use of steroids accounted for 22·2%, OR 0·95 (0·94–0·95) of the reduction in in-hospital mortality.InterpretationThe reduction in in-hospital mortality in patients with COVID-19 during the first wave in the UK was partly accounted for by changes in the case-mix and illness severity. A significant reduction in in-hospital mortality was associated with differences in respiratory support and critical care use, which could partly reflect accrual of clinical knowledge. The remaining improvement in in-hospital mortality is not explained by these factors, and could be associated with changes in community behaviour, inoculum dose, and hospital capacity strain.FundingNational Institute for Health Research and the Medical Research Council.

Trends in COVID-19-related in-hospital mortality: lessons learned from nationwide samples

Trends in COVID-19-related in-hospital mortality: lessons learned from nationwide samples

Abstract 14739: Temporal Trends, Predictors and Outcomes of Acute Ischemic Stroke in Acute Myocardial Infarction in the United States

Introduction: There are limited contemporary data on prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods: Adult (&gt;18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, and use of tracheostomy and percutaneous endoscopic gastrostomy (PEG). The discharge destination was used to classify AIS survivors into good and poor functional outcomes with poor (moderate to severe disability) defined as discharge to extended care facility including short-term hospital/rehabilitation facility, intermediate care or long-term care facilities. Results: Of a total 11,622,528 AMI admissions, 183,896 (1.6%) had concomitant AIS. Over the 18-year period, AIS rates were stable in STEMI admissions and decreased in NSTEMI (p&lt;0.001). Compared to those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% vs. 63.8%) and percutaneous coronary angiography (22.7% vs 41.8%) (p&lt;0.001). Female sex, non-White race, higher comorbidity, ST-segment-elevation AMI presentation, atrial fibrillation/flutter, use of mechanical circulatory support and invasive mechanical ventilation were identified as individual predictors of AIS after AMI. The AIS cohort had higher in-hospital mortality (16.4% vs. 6.0%; adjusted OR 1.75 [95% CI 1.72-1.78]; p&lt;0.001) with a steady decrease in the adjusted in-hospital mortality in over the 18-year period (21% in 2000 vs 17% in 2017). The AIS cohort had longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and PEG, and less frequent discharges to home (all p&lt;0.001). In AMI-AIS survivors (N=153,318), 57.3% had a poor functional outcome with temporal trends showing a slight increase in recent years (57% in 2000 vs 62% in 2017). Conclusions: AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions. Despite improvement in in-hospital mortality, poor functional outcomes remain high.

Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality.

Tranexamic acid (TXA) has been demonstrated to decrease mortality in adult trauma, particularly in those with massive transfusions needs sustained in combat injury. Limited data are available for the efficacy of TXA in pediatric trauma patients outside of a single combat support hospital in Afghanistan. The Department of Defense Trauma Registry was queried for trauma patients younger than 18 years from Iraq and Afghanistan requiring 40 mL/kg or greater of blood product within 24 hours of injury. Burns and fatal head traumas were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were hospital, ventilator, and intensive care unit-free days, as well as total blood product volume. Among those pediatric patients receiving massive transfusions, those who received TXA were less likely to die in hospital (8.5% vs. 18.3%). Patients who received TXA and those who did not have similar hospital-free days (19 vs. 20), ventilator-free days (27 vs. 27), and intensive care unit-free days (25 vs. 24). Those who received TXA had higher 24-hour blood product administration (100 mL/kg vs. 75 mL/kg). None of our results rose to the level of statistical significance. The TXA administration significantly reduced odds of death on logistic regression (odds ratio, 0.35; 95% confidence interval, 0.123-0.995; p = 0.0488). Use of TXA in pediatric patients with combat trauma requiring massive transfusions trended toward a significant improvement in in-hospital mortality (p = 0.055). This mortality benefit is similar to that seen in adult studies and a less well characterized cohort in another pediatric study suggesting TXA administration confers mortality benefit in massively transfused pediatric combat trauma victims. Evidence (retrospective cohort), Level IV.

Hospitalization Trends for Acute Kidney Injury in Kidney Transplant Recipients in the United States, 2004-2014.

The incidence of acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) in the general population is increasing. However, there is limited information on the epidemiology of AKI-related hospitalizations in the prevalent US kidney transplant population. We analyzed trends in the incidence of hospitalizations with primary diagnosis of AKI and secondary diagnosis of AKI and AKI-D using data from the National Inpatient Sample 2004-2014. Co-primary endpoints were in-hospital mortality, length of stay (LOS), and cost. Survey analysis techniques were used to compute national estimates. Linear trends in outcomes were evaluated using linear regression. There were a total of 37 562 hospitalizations for primary AKI, 136 628 for secondary AKI, and 10 731 for AKI-D during the study period. We found an increase in hospitalizations for all 3 diagnoses over time (13.7-24.7 per thousand kidney transplant recipients [KTRs] for primary AKI, 37.4-108.0 per thousand KTRs for secondary AKI, and 4.2-6.0 per thousand KTRs for AKI-D; all P trend < 0.01). This was accompanied by significant improvements in in-hospital mortality (3.2%-0.5% for primary and 6.1%-4.4% for secondary AKI; both P trend < 0.01), average LOS (5.3-4.6 days for primary and 8.4-7.2 days for secondary AKI; both P trend < 0.001), and cost ($11 635-$8234 for primary and $21 373-$17 470 for secondary AKI; P trend < 0.001 for both). The incidence of hospitalizations for AKI and AKI-D among KTRs is rapidly rising. This has been accompanied by significant improvements in in-hospital mortality, LOS, and cost.

Pathophysiology, Diagnosis, and Management of the No-Reflow Phenomenon.

Successful reperfusion of an infarct-related coronary artery by primary percutaneous intervention or fibrinolysis during acute ST-elevation myocardial infarction (STEMI) does not always restore myocardial tissue perfusion, a phenomenon termed "no-reflow." Herein we discuss the pathophysiology of this highly prevalent phenomenon and highlight the most salient aspects of its clinical diagnosis and management as well as the limitations of presently used methods. There is a great need for understanding the dynamic nature of no-reflow, as its occurrence is associated with poor cardiovascular outcomes. The no-reflow phenomenon may lend an explanation to the lack of further improvements in in-hospital mortality in STEMI patients despite decreases in door-to-balloon time. Hence, no-reflow potentially presents an important target for investigators interested in improving outcomes in STEMI.

Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction

Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states' decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI. To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states. Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016. State Medicaid expansion in 2014. Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes. The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P < .001 difference in trend expansion vs nonexpansion). Medicaid coverage increased from 7.5% (1818 of 24 358 hospitalizations) to 14.4% (4502 of 31 382 hospitalizations) in expansion states and 6.2% (1924 of 31 137 hospitalizations) to 6.6% (2717 of 41 120 hospitalizations) in nonexpansion states (P < .001). The low-income cohort included 55 737 patients across 765 sites. In expansion states, low-income adults' odds of receipt of defect-free care increased (76.3% to 75.9%, adjusted odds ratio 1.11; 95% CI, 1.02-1.21) but to a lesser degree than in nonexpansion states (72.8% to 74.5%, adjusted odds ratio, 1.38; 95% CI, 1.30-1.47; P for interaction < .001). There was no change in use of most procedures (ie, percutaneous coronary intervention for non-ST-segment elevation myocardial infarction) in expansion compared with nonexpansion states. Improvement in in-hospital mortality was similar between expansion and nonexpansion states (3.2% to 2.8%, adjusted odds ratio, 0.93; 95% CI, 0.77-1.12 vs 3.3% to 3.0%, adjusted odds ratio, 0.85; 95% CI, 0.73-0.99; P for interaction = .48). Medicaid expansion was associated with a significant reduction in rates of uninsurance among patients hospitalized with AMI. Quality of care and outcomes did not improve among low-income adults in expansion compared with nonexpansion states. Hospital care for AMI may be less sensitive to insurance than has been recognized in the past.

Abstract 21407: Effect of Aspiration Thrombectomy on in Hospital Mortality in Patients With ST Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Insights From the U.S National Inpatient Sample Database

Introduction: Aspiration thrombectomy (AT) during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) has been widely used. Recent large multicenter trials have created uncertainty about the benefit of thrombus aspiration and suggested possible harm from increased stroke risk. There is lack of real world data regarding outcomes with AT when performed in addition to PCI of the culprit artery for STEMI. Hypothesis: We sought to investigate the effect of AT on in-hospital mortality when performed in addition to culprit artery PCI for STEMI. Methods: Using the U.S. National Inpatient Sample (NIS) database from 2007-14, we identified all discharge records with a primary diagnosis of STEMI (ICD-9-CM diagnosis codes 410.XX) undergoing PCI (ICD-9-CM procedure codes 00.66, and 36.0X). Patients receiving AT in addition to PCI during the hospitalization were identified using ICD-9-CM procedure code 36.09, and in-hospital mortality was compared in patients with and without AT. Statistical analyses were performed using R (Vienna, Austria). To account for the single cluster stratified random sampling design of NIS, R survey package was used to obtain national estimates. Proportions were compared with Chi-Square test, and p trend computed using Mann-Kendall test. Results: Of 951,322 PCIs for STEMI, 4299 (0.4%) had AT in addition to PCI. Use of AT remained consistent over the study period (0.53% vs. 0.70%; p trend = 0.896). We observed no statistically significant difference in the age adjusted in-hospital mortality in patients with and without AT (3.8% vs. 4.4 %; p = 0.06). Conclusion: In this nationally representative study population, aspiration thrombectomy is not associated with improvement in in-hospital mortality when performed in addition to PCI of the culprit artery for STEMI.

Impact of Inferior Vena Cava Filter Placement on Short-Term Outcomes in Patients with Acute Pulmonary Embolism

Inferior vena cava filters (IVCFs) have been associated with improved survival in patients with acute pulmonary embolism (PE) in some studies. However, without randomization, those with early mortality who did not receive an IVCF might have died prior to treatment decision about filter placement, falsely contributing a survival advantage to those receiving IVCF and biasing the results of previous observational studies. The objective of this study is to evaluate the impact of IVCF on in-hospital mortality after adjusting for this survivor treatment selection. National Inpatient Sample data sets from 2009 to 2012 were analyzed to assess the impact of IVCF placement on in-hospital mortality in all patients with acute PE. Subgroup analyses were performed in those with high-risk PE (hemodynamic shock) and also for those with both shock and concomitant thrombolysis. Inverse propensity-score weighting was used to balance clinical and comorbid differences between filter and nonfilter groups. To account for survivor treatment selection bias, an extended Cox model was fitted with IVCF placement as a time-dependent covariate. We identified 263,955 patients with acute PE over this period; 36,702 (13.9%) received IVCF. Those receiving IVCF in the unadjusted cohort were older (IVCF: 66.3±15.9 vs. non-IVCF: 62.4±17.4; P<0.001) with higher rates of shock (6.8% vs. 3.8%; P<0.001), deep venous thrombosis (32.8% vs. 13.9%; P<0.001), thrombolytic therapy (5.9% vs. 1.6%; P<0.001), and lower crude mortality (6.0% vs. 6.7%; P<0.001). Propensity weighted extended Cox analysis showed that IVCF placement did not significantly decrease mortality hazard compared to an untreated patient (hazard ratio [HR]: 0.93, 95% confidence interval [CI]: 0.89-1.01). Similar results were seen in the combined high-risk and thrombolysis (HR: 0.85, 95% CI: 0.60-1.21) subgroup and associated with worse outcomes in the high-risk (HR: 1.2, 95% CI 1.11-1.38) subgroup. Placement of IVCF in all patients with acute PE, in high-risk patients, or in high-risk patients concurrently treated with thrombolysis is not significantly associated with improvement of in-hospital mortality when accounting for survivor treatment selection bias.

Abstract WP29: Temporal Trends of Intravenous Recombinant Tissue Plasminogen Activator Infusion and Endovascular Treatment for Acute Ischemic Stroke in Japan: J-ASPECT Study

Objective: This study aimed to investigate recent nationwide trends in the epidemiology of acute ischemic stroke (AIS) in Japan. Methods: We analyzed 328,147 acute ischemic stroke patients in 350 certified training hospitals in Japan using data obtained from the Japanese Diagnosis Procedure Combination Database. Data between the period April 1, 2010 and May 31, 2014 were used. We divided patients into three treatment groups: medical treatment only (group M), intravenous t-PA infusion only (group IVT), and endovascular treatment (group ET). Outcome was assessed by in-hospital mortality and modified Rankin Scale (mRS) score at discharge, and poor outcome was defined as a mRS score of 3-6. Results: The patient proportion in groups M, IVT, and ET changed from 94.3%, 3.2%, and 1.6% in 2010 to 90.9%, 4.3%, and 3.7% in 2014, respectively (P&lt;0.0001). In all AIS patients, in-hospital mortality significantly decreased from 6.5% in 2010 to 5.3% in 2014 (p&lt;0.0001) and poor outcome at discharge also decreased from 42.7% in 2010 to 41.6% in 2014 (p&lt;0.0001). In groups M and IVT, in-hospital mortality significantly decreased from 6.3% and 12.0% in 2010 to 5.0% and 9.1% in 2014, respectively (p&lt;0.0001), and poor outcome at discharge also decreased from 42.1% and 60.7% in 2010 to 40.7% (P&lt;0.0001) and 55.4% (p&lt;0.005) in 2014, respectively. In contrast, in group ET, both in-hospital mortality (from 11% in 2010 to 9.5% in 2014) and poor outcome at discharge (from 53.4% in 2010 to 54.0% in 2014) were not significantly different between the two time points. Conclusion: In Japan, during the 5-year period before the guidelines concerning proper use of ET for AIS were revised in 2015, a significant improvement in in-hospital mortality and functional outcomes of AIS patients undergoing medical treatment and intravenous rt-PA infusion was observed. This was probably due to a gradual increase in the proportion of patients undergoing IVT; the outcomes of ET, however, remained the same.

Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review

Objective The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4h of presentation. Methods A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies. Results Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currently NEAT combines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital. Conclusions Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients. What is known about the topic? Time targets for emergency care originated in the UK. The introduction of NEAT in Australia has been controversial. NEAT directs that a certain proportion of patients will be admitted or discharged from an emergency department (ED) within 4h. Recent dissolution of the Australian National Partnership Agreement (which provided hospitals with financial incentives for achieving NEAT compliance) has prompted a re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients What does this paper add? This paper is executive summary of key findings from a systematic literature review on the benefits and limitations of NEAT (the 4-h rule) commissioned by the Queensland Clinical Senate to inform future policy and targets. What are the implications for practitioners? There is evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals. Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care. A time-based target should be coupled with close monitoring of patient outcomes of emergency care. Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to the ED.

Temporal trends in epidemiology, clinical presentation and management of acute heart failure: results from the Greek cohorts of the Acute Heart Failure Global Registry of Standard Treatment and the European Society of Cardiology-Heart Failure pilot survey.

Temporal trends of epidemiological data on acute heart failure (AHF) are limited. We sought to assess changes in epidemiology, clinical presentation and management of AHF in Greece using data from two international registries conducted three years apart. The Acute Heart Failure Global Registry of Standard Treatment (ALARM-HF) and the European Society of Cardiology-Heart Failure (ESC-HF) pilot survey were conducted during 2006-2007 and 2009-2010, respectively. A total of 432 AHF patients were recruited by Greek sites in the two registries (255 in ALARM-HF and 177 in ESC-HF pilot survey). About 60% of patients in both registries presented with acutely decompensated chronic HF and 40% with de novo AHF. The use of life-prolonging, guideline-recommended medications increased over time (pre-admission use of angiotensin-converting enzyme (ACE) inhibitors/ angiotensin receptor blockers (ARBs) from 47% to 60%, beta-blockers from 31% to 65%, aldosterone antagonists from 18% to 45%). Those therapies also increased during hospitalisation in both registries. Patients were treated by cardiologists in >90% of cases during hospitalisation; the main intravenous therapies in both registries were diuretics (94% and 97%), followed by vasodilators (47% and 22%) and inotropes (31% and 20%). The length of hospitalisation remained similar (6-7 days in both registries), while in-hospital mortality dropped from 8.5% in the ALARM-HF to 4.5% in the ESC-HF pilot survey. A temporal increase in the use of life-prolonging therapies along with an improvement of in-hospital mortality was observed. Clinical profiles, in-hospital management and outcome of AHF patients in Greece were similar to other European countries, despite regional differences in healthcare systems.