In-hospital Clinical Outcomes In Patients Research Articles

Correlation of neutrophil to lymphocyte ratio to severity of coronary artery disease and in-hospital clinical outcomes in patients with acute coronary syndrome: A prospective observational study

Objective: To explore correlation of neutrophil-to-lymphocyte ratio (NLR) to severity of coronary artery disease (CAD) and in-hospital clinical outcomes in patients with acute coronary syndrome (ACS). Methods: In this prospective and observational study, we recruited 500 patients with ACS. For all the eligible patients, demographic details were collected, and laboratory parameters were evaluated. The CAD severity was evaluated in terms of the number of involved vessels. The NLR was calculated based on neutrophils and lymphocytes and the correlation of various risk factors and severity and outcome of CAD was performed. Results: 77.2% of Patients was male, and 52% of the patients aged between 55-70 years. Based on the type of ACS, 396 out of 500 patients had ST-elevation myocardial infarction. An ascending trend in the white blood cell levels and NLR value was noted as the severity of the ACS increased and the highest white blood cell levels and NLR was noted among class IV patients. The mean NLR value among the non-survivors were higher compared to the survivors (9.52±5.72 vs. 4.76±2.36; P<0.01). Receiver operating curve showed that the cut-off NLR value was 5.76 with a sensitivity of 75.0% and a specificity of 77.3%. Conclusions: The NLR can be used as an independent prognostic marker in ACS. An elevated NLR value serves as a reliable predictor for short-term complications, notably in-hospital mortality.

The relation of right ventricular outflow tract measurements with in-hospital clinical outcomes after tricuspid valve surgery.

Right ventricular (RV) function is a determining factor for clinical outcomes in patients undergoing tricuspid valve surgery (TVS). Our aim was to investigate the importance of the function of the right ventricular outflow tract (RVOT), which is an important anatomical region of the RV, in patients underwent TVS. 104 patients who underwent TVS were analyzed retrospectively. Patients with previous cardiac surgery, congenital heart disease, or heart failure were excluded. The parasternal short-axis view at the level of the aortic root was used to measure RVOT dimensions and RVOT fractional shortening (RVOT-FS). The effect of RVOT diameter and function on major adverse cardiac events (MACE) after TVS was investigated. In our study, MACE, consisting of pacemaker implantation, acute kidney injury, postoperative atrial fibrillation and mortality, was developed at 44 (42.3%) patients.We compared the predictive performances of RVOT end-systolic (RVOTs) diameter, RVOT end-diastolic (RVOTd) diameter, RVOT-FS and RV diameters in prediction of MACE. The model including the RVOTs had higher AUC, R2 and likelihood ratio X2 values (0.775, 0.287 and 25.0, respectively) than RVOTd (0.770, 0.279 and 24.2, respectively) and RVOT-FS (0.750, 0.215 and 18.1, respectively). RVOT diameters showed better performance in predicting MACE than RV diameters. Moreover, there was statistically significant association between RVOTs, RVOTd and MACE (p value were 0.014 and 0.027, respectively), while no association between RVOT-FS and MACE (p value was 0.177). In summary, we determined that the RVOT diameters are important predictors for the in-hospital clinical outcomes of patients who underwent TVS.

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study

ObjectivesTo examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the...

Higher fasting blood glucose was associated with worse in-hospital clinical outcomes in patients with primary intracerebral hemorrhage: From a large-scale nationwide longitudinal registry.

Studies that investigated the relationship between fasting blood glucose (FBG) and intracerebral hemorrhage (ICH) outcomes were insufficient. We aimed to investigate the association between FBG level and in-hospital clinical outcomes in patients with primary ICH. A total of 34,507 patients were enrolled in the final study. Compared with the reference group, the ≥6.1 and <7 mmol/L group showed nonsignificant higher in-hospital mortality (adjusted odds ratio [OR] 1.20, 95% confidence interval [CI] 0.69-2.11, p=0.52), and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 1.56, 95% CI 1.26-1.92, p < 0.001). The ≥7 mmol/L group showed both significant higher in-hospital mortality (adjusted OR 2.08, 95% CI 1.42-3.04, p=0.52) and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 2.09, 95% CI 1.78-2.47, p < 0.001). Higher FBG level was correlated with both higher mortality and proportion of evacuation of intracranial hematoma.

Impact of Prior Statin Therapy on In-Hospital Outcome of STEMI Patients Treated with Primary Percutaneous Coronary Intervention.

Background: Prior statin therapy has a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI are still controversial. We retrospectively evaluated the effect of prior statin therapy on in-hospital clinical outcomes in consecutive STEMI patients undergoing primary PCI. Methods: A total of 1790 patients (mean age 67 ± 11 years, 1354 men) were included. At admission, all patients were interrogated about prior (>6 months) statin therapy. The primary endpoint of the study was the composite of in-hospital mortality, acute pulmonary edema, and cardiogenic shock in patients with or without prior statin therapy. Results: A total of 427 patients (24%) were on prior statin therapy. The incidence of the primary endpoint was similar in patients with or without prior statin therapy (15% vs. 16%; p = 0.38). However, at multivariate analysis, prior statin therapy was associated with a lower risk of the primary endpoint, after adjustment for major prognostic predictors (odds ratio 0.61 [95% CI 0.39–0.96]; p = 0.03). Conclusions: This study demonstrated that prior statin therapy is associated with a better in-hospital clinical outcome in patients with STEMI undergoing primary PCI compared to those without prior statin therapy.

Comparison of Low-Versus High-Dose Steroids in the Clinical Outcome of Hospitalized COVID-19 Patients.

(1) Objectives: Patients with COVID-19 infection have been given various formulations and dosages of steroids over the last year and a half. This study aims to compare the effects of different formulations and doses of steroids on the 30 day in-hospital clinical outcome of patients with severe COVID-19 infection. (2) Material and Methods: An analysis of a retrospective cohort was carried out on patients with severe COVID-19 infection in a high-dependency unit (HDU) between February and July 2021. In total, 557 patients were included in this study. Patients who did not receive steroids (124) were excluded. Patients were divided into three groups based on dosages of steroids (Dexamethasone = 6 mg/day, Dexamethasone > 6 mg/day, and Methylprednisolone = 500 mg/day), given for 10 days. First, clinical outcome was evaluated on the 10th day of steroid administration in relation to mode of oxygen delivery. Then, Kaplan–Meier analysis was employed to determine 30 day in-hospital survival in relation to the use of steroid. (3) Results: Three groups were statistically equal according to biochemical characteristics. After 10 days of Methylprednisolone = 500 mg/day vs. Dexamethasone = 6 mg/day, 10.9% vs. 6.2% of patients required invasive ventilation (p = 0.01). The 30 day in-hospital mortality was lowest, 3%, in individuals receiving Dexamethasone = 6 mg/day, compared to 3.9% in individuals receiving Dexamethasone > 6 mg/day and 9.9% in individuals receiving Methylprednisolone = 500 mg/day, respectively. The median elapsed time was longer than 28 days between admission and outcome for Dexamethasone = 6 mg/day, compared to 18 days for Dexamethasone > 6 mg/day and 17 days for Methylprednisolone = 500 mg/day (p = < 0.0001). Dexamethasone = 6 mg/day was found to be a positive predictor of clinical outcome in COVID-19 patients on regression analysis. (4) Conclusions: Low-dose Dexamethasone (6 mg/day) is more effective than high-dose Dexamethasone and Methylprednisolone in improving the survival outcome of severe COVID-19 cases.

Effect of Procedural Volume on In-Hospital Outcomes After Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease (from the Japanese National Clinical Data [J-PCI Registry])

Chronic kidney disease (CKD) increases the risk of death and other poor outcomes in patients with cardiovascular diseases. This study investigated the relation between the institutional CKD percutaneous coronary intervention (PCI) volume and in-hospital clinical outcomes in patients with CKD. Among 1,199,901 patients who underwent PCI in 2014 to 2018 from the Japanese nationwide registry, we analyzed 220,509 patients with CKD. Patients were classified into quartiles (Q) according to the mean annual institutional CKD-PCI volume (Q1 <42 PCIs/year, Q2 <74 PCIs/year, Q3 <124 PCIs/year, Q4 ≥125 PCIs/year). The primary outcome was a composite of in-hospital death and periprocedural complications. The mean age of patients was 73 ± 10 years, and 36% (n=78,332) were on dialysis. PCI was more likely to be performed with rotational atherectomy devices in high-volume institutions. Contrast volume was lower, the rate of radial access PCI was higher, and door-to-balloon time (for ST-elevation myocardial infarction) was shorter in the highest quartile institutions. Primary outcomes were observed in 6,539 patients (3.0%). The crude rate of the primary outcome was lowest in institutions with the highest PCI volume (Q1 3.4%, Q2 3.0%, Q3 3.0%, Q4 2.4%, p <0.001); higher PCI volume was associated with reduced frequency of the primary outcome (odds ratio [95% confidence interval] relative to Q1:Q2, 0.89 [0.83 to 0.96]; Q3 0.90 [0.84 to 0.97]; and Q4 0.76 [0.84 to 0.97]). In conclusion, the procedural characteristics and outcomes of PCI differed significantly by institutional volume in patients with CKD. When considering revascularization among these patients, institutional CKD-PCI volume needs to be incorporated in decision-making.

Effect of Admission Hyperglycemia on Short-Term Prognosis of Patients with Non-ST Elevation Acute Coronary Syndrome without Diabetes Mellitus.

Objective To evaluate the effect of admission hyperglycemia on the short-term prognosis of patients with non-ST elevation acute coronary syndrome (NSTE-ACS) without diabetes mellitus. Methods The clinical data of 498 patients with NSTE-ACS admitted to the Department of Cardiology of the First Affiliated Hospital of Henan University of Science and Technology between March 2018 and November 2020 were analyzed. Based on the blood glucose (BG) level at admission, patients were divided into three groups: A (BG < 7.8 mmol/L), B (7.8 mmol/L ≤ BG < 11.1 mmol/L), and C (BG ≥ 11.1 mmol/L). The clinical data of the three groups were compared. Results There was no significant difference between the three groups in terms of age, sex, hypertension, hyperlipidemia, smoking, and history of myocardial infarction (p > 0.05). However, there were significant differences in the incidences of multivessel disease, renal insufficiency, pump failure, and emergency percutaneous coronary intervention, and levels of high-sensitivity C-reactive protein, cardiac troponin T, and creatine kinase isoenzyme MB among the three groups (p < 0.05 for all). The incidences of severe pump failure, malignant arrhythmias, and death were significantly higher in groups B and C compared to group A (p < 0.05). Additionally, the incidences of severe pump failure, malignant arrhythmias, and death were significantly higher in group C compared to group B (p < 0.05). Multivariate logistic regression analysis showed that hyperglycemia, renal insufficiency, Killip grade III/IV, and age were risk factors of in-hospital death. Conclusion Hyperglycemia at admission is a risk factor for adverse in-hospital clinical outcomes in patients with NSTE-ACS.

In-Hospital Clinical Outcomes in Patients with Fragility Fractures of the Lumbar Spine, Thoracic Spine, and Pelvic Ring: A Comparison of Data before and after Certification as a DGU® Geriatric Trauma Centre.

Background and Objectives: The implementation of orthogeriatric co-management (OGCM) reflects the demand for interdisciplinary collaborations due to the increasing comorbidities of geriatric trauma patients. This study aimed to assess clinical in-hospital outcomes in lumbar spine, thoracic spine, and pelvic ring fragility fracture patients before and after the implementation of a Geriatric Trauma Centre (GTC) certified by the German Trauma Society (DGU®). Materials and Methods: In this observational, retrospective cohort study, geriatric trauma patients (>70 years of age) were stratified into either a pre-GTC group (hospital admission between 1 January 2012 and 31 December 2013) or a post-GTC group (hospital admission between 1 January 2017 and 31 December 2018). Patients’ pre-injury medical complexity was measured by ASA class (American Society of Anaesthesiologists classification), the use of anticoagulant medication, and the ACCI (Age-adjusted Charlson Comorbidity Index). Outcome parameters were patients’ in-hospital length of stay (LOS) and mortality rates, as well as new in-hospital findings and diagnoses. Further, the necessity of deviation from initial management plans due to complications was assessed using the Adapted Clavien–Dindo Scoring System in Trauma (ACDiT score of ≥1). Results: Patients in the post-GTC group (n = 111) were older (median age 82.0 years) compared to the pre-GTC group (n = 108, median age 80.0 years, p = 0.016). No differences were found in sex, body mass index, ASA class, or ACCI (all p > 0.05). Patients in the post-GTC group used vitamin K antagonists or direct oral anticoagulants more frequently (21.3% versus 10.8%). The incidence of non-surgical treatment and mortality was comparable between groups, while LOS tended to be shorter in the post-GTC group (7.0 days versus 9.0 days, p = 0.076). In the post-GTC group, the detection of urinary tract infections (UTI) increased (35.2% versus 16.2%, p = 0.001), and the delirium diagnoses tended to increase (13.0% versus 6.3%, p = 0.094), while an ACDiT score of ≥1 was comparable between groups (p = 0.169). Conclusions: In this study including lumbar spine, thoracic spine, and pelvic ring geriatric fragility fractures, patients in the post-GTC group were more medically complex. More UTIs and the tendency for increased delirium detection was observed in the post-GTC group, likely due to improved diagnostic testing. Nonetheless, the necessity of deviation from initial management plans (ACDiT score of ≥1) was comparable between groups, potentially a positive result of OGCM.

OFF-HOURS PRESENTATION AND CLINICAL OUTCOMES IN PATIENTS TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: ANALYSIS OF THE UNIVERSITY OF OTTAWA HEART INSTITUTE REGISTRY

BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), presentation during off-hours may have an impact on clinical outcomes. Research in this area is not only scarce, but also conflicting. This study investigated the relationship between off-hours presentation and in-hospital clinical outcomes in patients presenting with STEMI. METHODS AND RESULTS We included all consecutive STEMI patients referred to the University of Ottawa Heart Institute as part of a primary percutaneous coronary intervention (PCI) strategy between July 2004 and December 2017 inclusive. Patients were included if they had < 24 hrs of ischemic symptoms and >=1mm ST-segment elevation in two contiguous leads on a 12-lead ECG. Patients who received fibrinolysis or required therapeutic hypothermia were excluded. Patients were stratified into two groups based on the time of presentation at the PCI center: Group 1 consisted of patients presenting during on-hours defined as between 08:00 and 17:59 hrs; Group 2 consisted of patients presenting during the off-hours defined as 18:00 and 07:59 hrs, on weekends, or statutory holidays. The primary outcome was defined as in-hospital mortality. We identified 5626 patients meeting the inclusion criteria: 2150 (38%) in the on-hours group, and 3476 (62%) in the off-hours group. At baseline, the two groups were similar except for lower rates of diabetes (17.6% vs. 20.4%, p=0.01) and smokers (38.2% vs. 41.5%, p=0.02) in the on-hours group. The median door-to-balloon time was 77 min (interquartile range [IQR]: 43-116) in the on-hours group and 102 min (IQR: 76-134) in the off-hours group (p < 0.001), while the median onset-to-door times were no different between the two groups; 95 min (IQR: 58-202) vs 99 min (IQR: 59-208; p=0.5). There were no differences in the rates of stent insertion (91% vs. 90%), balloon-alone PCI (2.9% vs. 2.7%), and coronary bypass surgery (2.9% vs. 2.9%). While the rate of initial TIMI-3 flow in the infarct-related artery was lower in the on-hours group (20% vs. 22.8%, p=0.001), there was no difference between groups in post-catheterization TIMI-3 flow rates (91.8% vs. 91%, p=0.1). In-hospital mortality was lower in the on-hours group (3.4% vs. 4.8%, p=0.03). Cardiogenic shock also occurred less often in the on-hours group (4.8% vs. 6.4%, p=0.02); whereas, there was no difference in stroke (1.1% vs 0.9%, p=0.4) or reinfarction (1.6% vs. 2.5%, p=0.7). CONCLUSION Patients who presented for primary PCI during regular hours had significantly lower in-hospital mortality as compared to patients presenting during off-hours. In patients with ST-segment elevation myocardial infarction (STEMI), presentation during off-hours may have an impact on clinical outcomes. Research in this area is not only scarce, but also conflicting. This study investigated the relationship between off-hours presentation and in-hospital clinical outcomes in patients presenting with STEMI. We included all consecutive STEMI patients referred to the University of Ottawa Heart Institute as part of a primary percutaneous coronary intervention (PCI) strategy between July 2004 and December 2017 inclusive. Patients were included if they had < 24 hrs of ischemic symptoms and >=1mm ST-segment elevation in two contiguous leads on a 12-lead ECG. Patients who received fibrinolysis or required therapeutic hypothermia were excluded. Patients were stratified into two groups based on the time of presentation at the PCI center: Group 1 consisted of patients presenting during on-hours defined as between 08:00 and 17:59 hrs; Group 2 consisted of patients presenting during the off-hours defined as 18:00 and 07:59 hrs, on weekends, or statutory holidays. The primary outcome was defined as in-hospital mortality. We identified 5626 patients meeting the inclusion criteria: 2150 (38%) in the on-hours group, and 3476 (62%) in the off-hours group. At baseline, the two groups were similar except for lower rates of diabetes (17.6% vs. 20.4%, p=0.01) and smokers (38.2% vs. 41.5%, p=0.02) in the on-hours group. The median door-to-balloon time was 77 min (interquartile range [IQR]: 43-116) in the on-hours group and 102 min (IQR: 76-134) in the off-hours group (p < 0.001), while the median onset-to-door times were no different between the two groups; 95 min (IQR: 58-202) vs 99 min (IQR: 59-208; p=0.5). There were no differences in the rates of stent insertion (91% vs. 90%), balloon-alone PCI (2.9% vs. 2.7%), and coronary bypass surgery (2.9% vs. 2.9%). While the rate of initial TIMI-3 flow in the infarct-related artery was lower in the on-hours group (20% vs. 22.8%, p=0.001), there was no difference between groups in post-catheterization TIMI-3 flow rates (91.8% vs. 91%, p=0.1). In-hospital mortality was lower in the on-hours group (3.4% vs. 4.8%, p=0.03). Cardiogenic shock also occurred less often in the on-hours group (4.8% vs. 6.4%, p=0.02); whereas, there was no difference in stroke (1.1% vs 0.9%, p=0.4) or reinfarction (1.6% vs. 2.5%, p=0.7). Patients who presented for primary PCI during regular hours had significantly lower in-hospital mortality as compared to patients presenting during off-hours.

Impact of COVID-19 outbreak on patients with ST-segment elevation myocardial ınfarction (STEMI) in Turkey: results from TURSER study (TURKISH St-segment elevation myocardial ınfarction registry).

ObjectiveWe aimed to investigate both the impact of COVID-19 pandemic on ST-segment elevation myocardial infarction (STEMI) admission, and demographic, angiographic, procedural characteristics, and in-hospital clinical outcomes of patients with COVID-19 positive STEMI in Turkey. MethodsThis was a multi-center and cross-sectional observational study. The study population included 1788 STEMI patients from 15 centers in Turkey. The patients were divided into two groups: COVID-19 era (March 11st–May 15st, 2020; n = 733) or pre- COVID-19 era group (March 11st–May 15st, 2019; n = 1055). Also, the patients in COVID-19 era were grouped as COVID-19 positive (n = 65) or negative (n = 668).ResultsThere was a 30.5% drop in STEMI admission during COVID-19 era in comparison to pre-COVID-19 era. The patients admitted to the medical centers during COVID-19 era had a longer symptom-to-first medical contact time [120 (75–240) vs. 100 (60–180) minutes, p < 0.001]. COVID-19 positive STEMI patients had higher thrombus grade and lower left ventricular ejection fraction compared to COVID-19 negative patients. COVID-19 positive patients had higher mortality (28% vs. 6%, p < 0.001) and cardiogenic shock (20% vs. 7%, p < 0.001) rates compared with those without COVID-19. Matching based on propensity scores showed higher mortality and high thrombus grade in STEMI patients who were infected by SARS-COV-2 (each p < 0.05).ConclusionsWe detected significantly lower STEMI hospitalization rates and significant delay in duration of symptom onset to first medical contact in the context of Turkey during the COVID-19 outbreak. Moreover, high thrombus grade and mortality were more common in COVID-19 positive STEMI patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11239-021-02487-3.

Multiple Biomarker Approach to Risk Stratification in COVID-19

HomeCirculationVol. 143, No. 13Multiple Biomarker Approach to Risk Stratification in COVID-19 Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBMultiple Biomarker Approach to Risk Stratification in COVID-19 Nathaniel R. Smilowitz, Vuthy Nguy, Yindalon Aphinyanaphongs, Jonathan D. Newman, Yuhe Xia, Harmony R. Reynolds, Judith S. Hochman, Glenn I. Fishman and Jeffrey S. Berger Nathaniel R. SmilowitzNathaniel R. Smilowitz Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Department of Medicine, VA New York Harbor Healthcare System (N.R.S.). Search for more papers by this author , Vuthy NguyVuthy Nguy Department of Population Health, New York University Langone Health, New York (V.N., Y.A.). Search for more papers by this author , Yindalon AphinyanaphongsYindalon Aphinyanaphongs Department of Population Health, New York University Langone Health, New York (V.N., Y.A.). Search for more papers by this author , Jonathan D. NewmanJonathan D. Newman https://orcid.org/0000-0001-6855-7305 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Search for more papers by this author , Yuhe XiaYuhe Xia https://orcid.org/0000-0001-5723-7648 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Search for more papers by this author , Harmony R. ReynoldsHarmony R. Reynolds https://orcid.org/0000-0003-0284-0655 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Search for more papers by this author , Judith S. HochmanJudith S. Hochman https://orcid.org/0000-0002-5889-5981 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Search for more papers by this author , Glenn I. FishmanGlenn I. Fishman https://orcid.org/0000-0002-2366-8527 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Search for more papers by this author and Jeffrey S. BergerJeffrey S. Berger Jeffrey S. Berger, MD, MS, Associate Professor of Medicine and Surgery, Director, Center for the Prevention of Cardiovascular Disease, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY 10016. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8216-4647 Leon H. Charney Division of Cardiology, Department of Medicine (N.R.S., J.S.N., Y.X., H.R.R., J.S.H., G.I.F., J.S.B.), School of Medicine, New York University. Department of Surgery (J.S.B.), School of Medicine, New York University. Search for more papers by this author Originally published15 Feb 2021https://doi.org/10.1161/CIRCULATIONAHA.120.053311Circulation. 2021;143:1338–1340Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 15, 2021: Ahead of Print Infection with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is responsible for the coronavirus disease 2019 (COVID-19) pandemic. Myocardial injury, thrombosis, and a systemic inflammatory response to SARS CoV-2 are common features of COVID-19, and biomarkers of each of these processes (cardiac troponin [cTn], d-dimer, and C-reactive protein [CRP], respectively) are associated with disease severity and mortality.1–3 This study aimed to determine whether a constellation of biomarkers at admission would predict in-hospital clinical outcomes in patients with COVID-19.Consecutive adults ≥18 years of age with COVID-19 admitted to the New York University Langone Health system between March 1, 2020, and April 16, 2020, were identified and included if cTn, d-dimer, and CRP were measured. Routine multimarker surveillance was standard of care for patients with COVID-19; electronic admission order sets included cTn, d-dimer, and CRP laboratory tests. Myocardial injury was defined as an initial cTn above the site-specific upper limit of normal (ULN) for the assay (Siemens Dimension Vista [>0.045 ng/mL]/Centaur XPT [>0.5 ng/mL], Abbot Architect Troponin I [>0.04 ng/mL]). An elevated d-dimer was defined based on the assay ULN (>230 ng/mL). Given that 98.5% of our hospitalized patients with COVID-19 had an initial CRP concentration above the ULN, we defined increased inflammation as a CRP (Siemens Dimension, Abbot Architect) >50 mg/L. This threshold was prognostically important in prior studies.4,5 Demographics, comorbidities, medications, clinical presentation, and laboratory data were abstracted from the electronic health record. Comorbidities were defined by International Classifications of Diseases, 10th Revision codes. All-cause, in-hospital mortality was recorded. Critical illness was defined by receipt of intensive care, mechanical ventilation, transfer to hospice, or death. Categorical variables are reported as frequencies and proportions and compared by χ2 tests. We used logistic regression models to estimate the odds of study end points on the basis of the number of elevated biomarkers. We used the Harrell C-statistic to evaluate the survival model; areas under the curve were compared using the Delong test. The discriminative ability of the number of elevated biomarkers was characterized by the continuous net reclassification improvement. Adjusted risk models included demographics, clinical comorbidities, and characteristics at hospital presentation as covariates. Statistical analyses were performed using R. Statistical tests were 2-sided, and P values <0.05 were statistically significant. The study was approved by the New York University Langone Health Institutional Review Board with a waiver of informed consent; identifiable data will not be made publicly available.A total of 3281 consecutive adults with COVID-19 were identified, and 2895 (88.2%) had measurement of all 3 biomarkers (cTn: median 0.015 ng/mL [interquartile range, <0.015–0.03]; D-dimer: median 403 ng/mL [interquartile range, 244–769]; and CRP: median 113 mg/L [interquartile range, 57–178]) at admission. Myocardial injury was present in 486 (16.8%) patients, the D-dimer level was elevated in 2243 (77.5%), and CRP was >50 mg/L in 2261 (78.1%). Only 196 (6.8%) patients had normal cTn, normal D-dimer, and a CRP of <50 mg/L (no elevated biomarkers). Elevations of all 3 biomarkers, reflecting the pathobiological axes of myocardial injury, coagulation, and inflammation, were present in 334 (11.5%; Figure). Patients with no elevated biomarkers were at low risk of critical illness and in-hospital mortality. Continuous CRP (C-statistic, 0.611 [95% CI, 0.587–0.634]), D-dimer (C-statistic, 0.639 [95% CI, 0.615–0.664]), and troponin (C-statistic, 0.680 [95% CI, 0.655–0.705]) concentrations were each separately associated with mortality. Patients with 1, 2, or 3 elevated biomarkers had stepwise increases in the risk of adverse events (Figure). The number of elevated biomarkers alone yielded a C-statistic of 0.672 (95% CI, 0.649–0.696) for mortality, with no difference in model performance compared with continuous data for all 3 biomarkers (0.657 [95% CI, 0.633–0.681], P=0.17). Addition of the number of elevated biomarkers to an adjusted risk model yielded improvements in the C-statistic (from 0.765 [95% CI, 0.745–0.785] to 0.789 [95% CI, 0.770–0.807], P<0.001) and the appropriate reclassification of risk (net reclassification improvement, 0.227 [95% CI, 0.141–0.313]) for mortality.Download figureDownload PowerPointFigure. The frequency of elevated biomarkers reflecting myocardial injury, coagulation, and inflammation in COVID-19 and associations with in-hospital outcomes. A, Venn diagram illustrating overlap of elevated biomarkers at the time of initial hospital presentation in patients with COVID-19 and ≥1 elevated biomarker (n=2699). One hundred ninety-six patients had no elevated biomarkers. The proportion of patients with in-hospital mortality (B) and critical illness (C) are shown stratified by the number of elevated biomarkers measured at hospital presentation with COVID-19. Odds ratios (versus 0 biomarkers elevated) shown in B and C are adjusted for age, sex, race, body mass index, tobacco use, hypertension, hyperlipidemia, diabetes, chronic kidney disease, prior myocardial infarction, prior heart failure, atrial fibrillation, temperature at presentation, pulse oximetry at presentation, and outpatient prescriptions for antiplatelets, statin, and β-blockers. aOR indicates adjusted odds ratio; and CRP, C-reactive protein.In this analysis of patients with COVID-19, 93% had myocardial injury, abnormalities in coagulation, or marked inflammation at hospital presentation. The combination of abnormalities across these pathobiological axes of disease provided incremental prognostic information for risk stratification. Patients with 1, 2, and 3 elevated biomarkers had 3-, 6-, and 11-fold higher adjusted odds of death, respectively, compared with patients who had COVID-19 with no elevated biomarkers at presentation. These findings extend prior observations on the prognostic nature of these biomarkers in COVID-19 and provide a framework for rapid estimation of risk.This study was retrospective, and selection bias cannot be excluded. Only in-hospital events were recorded. We used dichotomous biomarker data to generate a simple scoring system for clinical use. A threshold higher than the ULN was selected for CRP, myocardial injury was defined by site-specific values for the cTn ULN, and high-sensitivity cTn assays were not used. Last, a separate validation cohort was not available. Still, a simple multimarker strategy, in which patients are categorized based on the number of elevated biomarkers, was effective to identify patients at risk for in-hospital adverse events.Sources of FundingDr Smilowitz is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health (grant no. K23HL150315). Dr Newman is funded, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health (grant no. K23HL125991). Dr Berger is funded, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health (grant no. R01HL139909 and R35HL144993).Disclosures Dr Smilowitz reports consulting for Abbott Vascular. The remaining authors report no conflicts.Footnoteshttps://www.ahajournals.org/journal/circJeffrey S. Berger, MD, MS, Associate Professor of Medicine and Surgery, Director, Center for the Prevention of Cardiovascular Disease, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY 10016. Email jeffrey.[email protected]org

Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: a retrospective study using a national database

BackgroundLarge-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare.MethodsThis study is...

Socioeconomic Status and Differences in the Management and Outcomes of 6.6 Million US Patients With Acute Myocardial Infarction

Little is known about the impact of socioeconomic status (SES) on management strategies and in-hospital clinical outcomes in patients with acute myocardial infarction (AMI) and its subtypes, and whether these trends have changed over time. All AMI hospitalizations from the National Inpatient Sample (2004 to 2014) were analyzed and stratified by zip code-based median household income (MHI) into 4 quartiles (poorest to wealthiest): 0th to 25th, 26th to 50th, 51st to 75th, and 76th to 100th. Logistic regression was performed to examine the association between MHI and AMI management strategy and in-hospital clinical outcomes. A total of 6,603,709 AMI hospitalizations were analyzed. Patients in the lowest MHI group had more co-morbidities, a worse cardiovascular risk factor profile and were more likely to be female. Differences in receipt of invasive management were observed between the lowest and highest MHI quartiles, with the lowest MHI group less likely to undergo coronary angiography (63.4% vs 64.3%, p <0.001) and percutaneous coronary intervention (40.4% vs 44.3%, p <0.001) compared with the highest MHI group, especially in the STEMI subgroup. In multivariable analysis, the highest MHI group experienced better outcomes including lower risk (adjusted odds ratio; 95% confidence intervals) of mortality (0.88; 0.88 to 0.89), MACCE (0.91; 0.91 to 0.92) and acute ischemic stroke (0.90; 0.88 to 0.91), but higher all-cause bleeding (1.08; 1.06 to 1.09) in comparison to the lowest MHI group. In conclusion, the provision of invasive management for AMI in patients with lower SES is less than patients with higher SES and is associated with worse in-hospital clinical outcomes. This work highlights the importance of ensuring equity of access and care across all strata SES.

Clinical features, sex differences and outcomes of myocardial infarction with nonobstructive coronary arteries: a registry analysis.

Clinical characteristics and outcomes of patients diagnosed with myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) remain largely unknown. Furthermore, we do not yet understand if women with MINOCA have worse outcomes similar to what has historically been observed with MI. The aims of the current study were to evaluate the (1) incidence of MINOCA in patients presenting with MI, (2) compare in-hospital outcomes of MINOCA and obstructive atherosclerotic coronary artery disease MI (OACD-MI), and (3) comparison of in-hospital clinical outcomes of patients with MINOCA stratified by sex. In this observational study, we combined data from two large university hospitals from Canada and Australia. Clinical characteristics and in-hospital outcomes of MINOCA and OACD-MI were analyzed by matching these patients in a 1:1 ratio after selecting patients with OACD-MI by systematic random sampling. Clinical characteristics associated with MINOCA were identified through multivariate logistic regression. Primary outcome of interest was net adverse cardiovascular events (NACE) defined as death, heart failure, stroke, and major bleeding. The incidence rate of MINOCA was 9.5%. Women, absence of traditional cardiac risk factors, and absence of ST-deviations on ECG were associated with diagnosis of MINOCA on angiography. NACE (P = 0.0001), death (P = 0.019), stroke (P = 0.002), and heart failure (P = 0.001) were significantly lower in patients with MINOCA. Subgroup analysis of women and men diagnosed with MINOCA revealed similar in-hospital outcomes. The incidence of MINOCA was 9.5%. Compared to OACD-MI, patients with MINOCA have less cardiac risk factors. In-hospital outcomes of patients diagnosed with MINOCA were better than OACD-MI.

CRT-100.36 Predictors of Suboptimal Coronary Blood Flow After Primary Angioplasty and Its Implications on In-Hospital Clinical Outcomes in Patients With Acute Anterior Wall Myocardial Infarction

Suboptimal coronary blood flow after primary percutaneous coronary intervention (PCI) is a multifactorial complex phenomenon. Although extensively studied, defined modifiable risk factors and efficient management strategy are lacking. The aim of this study is to determine the potential causes of

Impact of Hospital Volume of Percutaneous Coronary Intervention (PCI) on In-Hospital Outcomes in Patients with Acute Myocardial Infarction: Based on the 2014 Cohort of the Korean Percutaneous Coronary Intervention (K-PCI) Registry.

Background and ObjectivesThe relationship between the hospital percutaneous coronary intervention (PCI) volumes and the in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) remains the subject of debate. This study aimed to determine whether the in-hospital clinical outcomes of patients with AMI in Korea are significantly associated with hospital PCI volumes.MethodsWe selected and analyzed 17,121 cases of AMI, that is, 8,839 cases of non-ST-segment elevation myocardial infarction and 8,282 cases of ST-segment elevation myocardial infarction, enrolled in the 2014 Korean percutaneous coronary intervention (K-PCI) registry. Patients were divided into 2 groups according to hospital annual PCI volume, that is, to a high-volume group (≥400/year) or a low-volume group (<400/year). Major adverse cardiovascular and cerebrovascular events (MACCEs) were defined as composites of death, cardiac death, non-fatal myocardial infarction (MI), stent thrombosis, stroke, and need for urgent PCI during index admission after PCI.ResultsRates of MACCE and non-fatal MI were higher in the low-volume group than in the high-volume group (MACCE: 10.9% vs. 8.6%, p=0.001; non-fatal MI: 4.8% vs. 2.6%, p=0.001, respectively). Multivariate regression analysis showed PCI volume did not independently predict MACCE.ConclusionsHospital PCI volume was not found to be an independent predictor of in-hospital clinical outcomes in patients with AMI included in the 2014 K-PCI registry.

Percutaneous coronary intervention and in-hospital outcomes in patients with leukemia: a nationwide analysis.

To examine the association between current leukemia diagnosis and in-hospital clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) in the United States. Leukemia is the most common hematological malignancy and is associated with an increased risk of thrombotic and bleeding complications in patients undergoing PCI. There are limited data around clinical outcomes of leukemia patients undergoing PCI. We used the National Inpatient Sample to investigate the outcomes of leukemia patients undergoing PCI between 2004 and 2014. Patients were then subdivided into diagnoses of acute myeloid leukemia (AML) or chronic myeloid leukemia and acute lymphoid leukemia or chronic lymphoid leukemia (CLL). Multiple logistic regressions were used to study the association of a leukemia diagnosis with in-hospital outcomes: mortality, bleeding, vascular and cardiac complications, and stroke. There were 6,561,445 records of patients who underwent PCI during the study time, of which 15,789 patients had a diagnosis of leukemia. The most common leukemia subtype was CLL accounting for 75% of the cohort (n = 10,800). After multivariable adjustment, a leukemia diagnosis was associated with significantly increased odds of in-hospital mortality (odds ratio [OR]: 1.41; 95% confidence interval [CI]: [1.11-1.79]) and bleeding (OR: 1.87; 95% CI: [1.56-2.09]), whereas patients with AML had a fivefold increase of in-hospital mortality (OR: 5.38; 95% CI: [2.94-9.76]). Patients with current diagnosis of leukemia are at increased risk of procedure-related complications following PCI. A multidisciplinary approach is needed among interventional cardiologists, oncologists, and hematologists to minimize procedural complications and improve outcomes in this high-risk cohort.

Abstract 21309: Transcatheter Aortic Valve Implantation Outcomes in Patients With History of Previous Cardiac Surgery: A National in Patient Sample Analysis

Introduction: The influence of previous cardiac surgery (CABG, Valve Replacement or both) on In-hospital clinical outcomes in patients(pts) undergoing Transcatheter Aortic Valve Implantation (TAVI) has not been well established. Methods: We analyzed the clinical characteristics and periprocedural in-hospital outcomes among pts undergoing TAVI using 2011-2014 HCUP-Nationwide Inpatient Sample database. ICD-9-CM codes were used to identify pts undergoing TAVI with and without history cardiac surgery. Propensity score matching has been attempted to minimize bias. SAS software was used for statistical analysis with p &lt; .05 used to indicate statistical significance. Results: Among a total of 8466 pts who underwent TAVI during the study period, 1982 had a history of previous cardiac surgery. It was noted that pts with prior cardiac surgery were dominantly male and had a higher prevalence of unfavorable clinical characteristics except pulmonary hypertension (Table). The propensity-matched analysis for 3834 patients showed that the incidence of periprocedural of stroke (2.61% vs1.62%,p=0.03) was lower in pts with previous cardiac surgery. Whereas the prevalence of In-hospital mortality(3.29% vs 2.35% p=0.07), vascular complications(9.96% vs 9.08%,p=0.34), transfusion(23% vs 20.45%,p=0.055), Acute Kidney Injury (AKI)(18.41% vs 16.95%, p=0.23), and pacemaker implantation(10.64 vs 9.29, p=0.16) were comparable for the two cohorts. Conclusions: In Pts with a history of previous cardiac surgery undergoing TAVI there is a lower incidence of periprocedural stroke compared to those without a history of cardiac surgery. The rates of in-hospital mortality, vascular complications, transfusion, Acute Kidney Injury (AKI), and pacemaker implantation were similar between both the groups.

Improved in-hospital clinical outcomes in patients with acute ST-elevation myocardial infarction undergoing remote ischemic preconditioning before primary percutaneous coronary intervention

Improved in-hospital clinical outcomes in patients with acute ST-elevation myocardial infarction undergoing remote ischemic preconditioning before primary percutaneous coronary intervention