Pre-existing Congestive Heart Failure Research Articles

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality.

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease. In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package. A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001). This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

The association of congestive heart failure on in-hospital lengths of stay, morbidity, and financial burden following primary total knee arthroplasty.

Current literature states that 6.2 million adults in the United States are living with heart failure. Studies investigating the impact of congestive heart failure (CHF) following primary total knee arthroplasty (TKA) are scarce. Hence, this research aimed to investigate whether individuals with congestive heart failure (CHF) undergoing primary total knee arthroplasty (TKA) experience: (1) longer durations of in-hospital stay; (2) increased incidences of health complications; and (3) a higher financial load. A retrospective query using the 100% Parts A and B of the Medicare claims was performed. Cohorts of interest were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology. Inclusion criteria for the study group consisted of patients with CHF undergoing primary TKA, whereas patients without CHF undergoing primary TKA served as the comparison cohort. The query yielded 1,101,169 patients (CHF = 183,540; case-matched = 917,629). Patients with CHF had longer in-hospital LOS (5- vs. 4-days) and a higher incidence and odds of developing 90-day medical complications (49.22% vs. 7.45%) following primary TKA. CHF patients incurred higher day of surgery and total global ninety-day episode of care costs compared to their matched counterparts. This study illustrated those patients with preexisting CHF undergoing a primary TKA have longer in-hospital lengths of stay and higher rates of morbidity and financial burden. With the increasing prevalence of CHF worldwide, orthopedists and other healthcare professionals can utilize the information provided in this study to educate patients and establish comprehensive treatment plans to help mitigate postoperative effects associated with CHF.

Multiparametric ultrasound for upper extremity dialysis access evaluation.

The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.

Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study.

Sepsis management includes intravenous fluid (IVF) resuscitation, but patients with pre-existing congestive heart failure (CHF) have a higher risk of fluid overload. Further, patients with sepsis with concomitant CHF present worse clinical outcomes. Nevertheless, there is limited evidence of the association between fluid management and the outcomes of patients with concomitant sepsis and CHF. This retrospective cohort study aimed to evaluate the association between fluid management and in-hospital mortality in patients with sepsis and concomitant heart failure (HF). The patients' data were extracted from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was in-hospital mortality. A restricted cubic spline model was used to explore the relationship between variables and in-hospital mortality. Logistic models were built using the linear spline function and design variables to investigate the association of fluid balance (FB), fluid intake (FI), and fluid accumulation index (FAI, calculated as the FB/FI ratio) with mortality. Overall, 1,801 patients were included. The overall mortality rate was 27.7%. After adjusting for confounding variables, FAI was found to be associated with in-hospital mortality, whereas FB and FI were not. With FAI values of 0–0.42 set as references, FAI values <0 were not associated with in-hospital mortality [odds ratio (OR): 1.078; 95% confidence interval (CI): 0.774–1.503], whereas FAI values > 0.42 were significantly associated with higher in-hospital mortality (OR: 1.461; 95% CI: 1.099–1.954). High FAI values (>0.42) were associated with high in-hospital mortality in patients with sepsis with HF, while FB and FI were not. Proper fluid management may improve the outcomes of patients with sepsis and concomitant HF.

474 Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians With Subdural Hematomas

INTRODUCTION: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017-2019 was queried to identify patients &gt;79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS &lt;13, pupil non-reactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS &lt;13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. CONCLUSION: Poor GCS, pupil non-reactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients &gt;80 years with SDH. Pre-existing CHF may further predict withdrawal of lifesustaining measures.

Robotic Off-Pump Totally Endoscopic Coronary Artery Bypass in Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas

Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n= 150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Sepsis Fluid Metric Compliance and its Impact on Outcomes of Patients with Congestive Heart Failure, End-Stage Renal Disease or Obesity.

Emergency physicians express concern administering a 30-cc/kg fluid bolus to septic shock patients with pre-existing congestive heart failure (CHF), end-stage renal disease (ESRD), or obesity, due to the perceived risk of precipitating a fluid overload state. Our aim was to determine whether there is a difference in fluid administration to septic shock patients with these pre-existing conditions in the emergency department (ED). Secondary objectives focused on whether compliance impacts mortality, need for intubation, and length of stay. We conducted a retrospective chart review of 470,558 ED patient encounters at a single urban academic center during a 5-year period. Of 847 patients with septic shock, 308 (36.36%) had no pre-existing condition and 199 (23.49%), 17 (2.01%), and 154 (18.18%) had the single pre-existing condition of CHF, ESRD, and obesity, respectively, and 169 (19.95%) had multiple pre-existing conditions. Weight-based fluid compliance was achieved in 460 patients (54.31%). There was a lower likelihood of compliance among patients with CHF (adjusted odds ratio [aOR] 0.35; 95% confidence interval [CI] 0.24-0.52; p < 0.001), ESRD (aOR 0.11, 95% CI 0.04-0.32; p < 0.001), and obesity (aOR 0.29, 95% CI 0.19-0.44; p < 0.001) compared with patients with no pre-existing conditions. Compliance decreased further in patients with multiple pre-existing conditions (aOR 0.49, 95% CI 0.33-0.72; p < 0.001). Compliance was not associated with mortality in patients with CHF and ESRD, but was protective in patients with obesity and those with no pre-existing conditions. Septic shock patients with pre-existing CHF, ESRD, or obesity are less likely to achieve compliance with a 30-cc/kg weight-based fluid goal compared with those without these pre-existing conditions.

An Evaluation of the Use of Aggressive Fluid Resuscitation in the Early Treatment of Sepsis Patients.

IntroductionFluid resuscitation is a critical aspect of the sepsis protocol with the usual initial dose being 30 mL per kilogram. Although this dose is well accepted in patients with normal cardiac function, there is some significant variation in clinical practice concerning the optimal fluid resuscitation in septic patients with underlying congestive heart failure (CHF). Many different approaches have been tried to best treat these patients by using lesser volumes of fluid. The purpose of this retrospective study is to attempt to better define optimal fluid resuscitation in congestive heart failure patients and whether standard fluid resuscitation exacerbates CHF in these cases.MethodsThis was a retrospective study involving patients admitted to the Emergency Department (ED) during the time period of September of 2016 through March of 2019 with a primary diagnosis of sepsis and pre-existing CHF. Data collected from the data warehouse and patient charts included demographics, total amount of fluid received in the ED and outcome data. Evidence of fluid overload (chest X-ray [CXR] evidence, rising B-type natriuretic peptide [BNP], or use of diuretics), was evaluated with respect to in-hospital mortality, white blood cell (WBC) count and comorbidities (chronic obstructive pulmonary disease [COPD], hypertension and coronary artery disease).ResultsThere were 422 patients included in the cohort. Of the 422, 113 (26.8%) patients showed evidence of fluid overload on CXR during hospital stay and received diuretics and therefore considered in the CHF exacerbation group. The patients that experienced CHF exacerbation were significantly older (mean ± SD, 70.9 ± 11.8 years versus 67.4 ± 15.1 years, p=0.014). Patients with exacerbation also received more fluid (median and interquartile range, 3.0, 2:5.5 L versus 2.0, 1:4.3 L, p=0.017). The receiver operating characteristic curve analysis for fluid to predict exacerbation resulted in an area under the curve of 0.59 with a 95% confidence interval (CI) of 0.52 to 0.65, p=0.012. The Youden Index was used to determine an optimal cutoff value of 2.6 L. The percentage of patients in the exacerbation group above the threshold was significantly higher (57.3%) than those without exacerbation (43.3%), p=0.019. Following multivariate analysis, age greater than 60 (odds ratio [OR]: 2.5; CI: 1.4-4.6, p=0.003) and fluid cutoff of 2.6 L (OR: 1.9; CI: 1.2-3.1, p=0.007) were both found to be independent predictors of CHF exacerbation. There was no significant difference in mortality based on the total fluid received in the ED.ConclusionThe findings of this study showed that septic patients with pre-existing CHF who received more than 2.6 L of fluid in the ED were 90% more likely to develop symptoms of CHF exacerbation with no evidence of lowering mortality compared to the group that received less than 2.6 L. Our data supports the practice of limiting total fluid resuscitation in CHF to 2.6 L and reconfirms the idea that fluid resuscitation for patients with CHF needs to be individualized.

Impact of congestive heart failure and role of cardiac biomarkers in COVID-19 patients: A systematic review and meta-analysis

BackgroundCoronavirus disease 2019 (COVID-19) has been reported to cause worse outcomes in patients with underlying cardiovascular disease, especially in patients with acute cardiac injury, which is determined by elevated levels of high-sensitivity troponin. There is a paucity of data on the impact of congestive heart failure (CHF) on outcomes in COVID-19 patients. MethodsWe conducted a literature search of PubMed/Medline, EMBASE, and Google Scholar databases from 11/1/2019 till 06/07/2020, and identified all relevant studies reporting cardiovascular comorbidities, cardiac biomarkers, disease severity, and survival. Pooled data from the selected studies was used for metanalysis to identify the impact of risk factors and cardiac biomarker elevation on disease severity and/or mortality. ResultsWe collected pooled data on 5967 COVID-19 patients from 20 individual studies. We found that both non-survivors and those with severe disease had an increased risk of acute cardiac injury and cardiac arrhythmias, our pooled relative risk (RR) was — 8.52 (95% CI 3.63–19.98) (p < 0.001); and 3.61 (95% CI 2.03–6.43) (p = 0.001), respectively. Mean difference in the levels of Troponin-I, CK-MB, and NT-proBNP was higher in deceased and severely infected patients. The RR of in-hospital mortality was 2.35 (95% CI 1.18–4.70) (p = 0.022) and 1.52 (95% CI 1.12–2.05) (p = 0.008) among patients who had pre-existing CHF and hypertension, respectively. ConclusionCardiac involvement in COVID-19 infection appears to significantly adversely impact patient prognosis and survival. Pre-existence of CHF, and high cardiac biomarkers like NT-pro BNP and CK-MB levels in COVID-19 patients correlates with worse outcomes.

Insulin-like growth factor-binding protein 7 and risk of congestive heart failure hospitalization in patients with atrial fibrillation

The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker. The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication. We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed. Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend <.001). In a subgroup of 2812 patients without pre-existing CHF at baseline, the corresponding aHRs were 1.0, 0.90 (0.47-1.72), 1.69 (0.94-3.04), and 3.48 (1.94-6.24) (P for trend <.001). Patients with IGFBP-7 and NT-proBNP levels above the biomarker-specific median had a higher risk of incident CHF hospitalization (aHR 5.20; 3.35-8.09) compared to those with only 1 elevated marker (elevated IGFBP-7 aHR 2.17; 1.30-3.60); elevated NT-proBNP aHR 1.97; 1.17-3.33); or no elevated marker (reference). Higher plasma levels of IGFBP-7 were strongly and independently associated with CHF hospitalization in AF patients. The prognostic information provided by IGFBP-7 was additive to that of NT-proBNP.

Electrocardiographic characteristics of 5-year atrial tachy-arrhythmia free patients after catheter ablation for atrial fibrillation

Abstract Background Predictors are not well known for long-lasting sinus rhythm after atrial fibrillation catheter ablation (AFCA). Purpose We investigated the pre-procedural clinical factors associated with the patients with 5-year long-term atrial fibrillation (AF) free after AFCA. Methods Among 2,085 patients who underwent de novo AFCA, 934 patients (58±11 years, 73.1% male, 66.0% paroxysmal AF), who underwent guidelines-based rhythm follow-up longer than 5-years, were included in this study. We compared 340 patients who never showed AF recurrence for 5-years and 594 patients with AF/ atrial tachycardia (AT) recurrence at least a single episode. Cut-off values of pericardial fat volume and electrocardiogram (ECG) parameters were obtained by Youden index. Results 1. The patients with AF-free for 5-years (AF-Free-5yrs) had higher proportion of paroxysmal AF (p&amp;lt;0.001), lower body mass index (p=0.020), and lower proportion of pre-existing congestive heart failure (p=0.035), and smaller LA size (p&amp;lt;0.001) than those who experienced recurrence. 2. The patients with AF-Free-5yrs showed lower pericardial fat volume (105.9±47.5 vs. 121.2±53.cm3, p&amp;lt;0.001) and shorter PR interval (181.5±29.6 vs. 190.5±33.1ms, p&amp;lt;0.001) and P wave duration in lead II (PWDII, 121.1±18.0 vs. 129.4±18.8ms, p&amp;lt;0.001) rather than those of counter-part. 3. Multivariate regression analysis revealed that paroxysmal AF at the procedure, lower pericardial fat volume (OR 0.995, 95% CI [0.991–0.998], p=0.004), short PR interval (OR 0.994, 95% CI [0.988–1.000], p=0.038), and PWDII (OR 0.986, 95% CI [0.978–0.995], p=0.002) were independently associated with the AF-Free-5yrs. 3. Among the patients with persistent AF, PWDII was significantly shorter in AF-Free-5yrs group. (123.7±22.6 vs. 133.5±19.5, p&amp;lt;0.001), and PWDII &amp;lt;127.1ms was independently associated with AF-Free-5yrs (OR 3.114, 95% CI [1.819–5.331], p&amp;lt;0.001). Conclusions Pericardial fat volume (&amp;lt;113.7cm3) and PR interval (&amp;lt;196 ms) in pre-procedural ECG was independently associated with an excellent 5-year rhythm outcome after AFCA, and PWDII (&amp;lt;127.1 ms) predicted super-responders especially after persistent AF ablation. Funding Acknowledgement Type of funding source: None

52: Major adverse cardiovascular and cerebrovascular events associated with female pelvic reconstructive surgery

To evaluate national trends in major adverse cardiovascular and cerebrovascular events (MACCE) in women undergoing pelvic reconstructive surgery (PRS). Data from the Healthcare Cost and Utilization Project National Inpatient Sample was used to identify women undergoing PRS between 2012 to 2016. Patient- and hospital-level demographic, procedural, and comorbidity data were collected. Patients were stratified into those with and those without MACCE. MACCE was defined as all-cause mortality (ACM), cardiac arrest (CA), acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Descriptive statistics are expressed as medians and interquartile ranges (IQR). Pairwise analysis was performed between groups using Wilcoxon rank-sum or Fisher’s exact test as appropriate. Multivariable logistic regression was used to identify independent risk factors for MACCE. During the study period 53,540 patients underwent PRS. The rate of MACCE was 4.8 per 1,000 surgeries. The most common form of MACCE was AMI (3.7 per 1,000), followed by AIS (0.6 per 1,000), CA (0.4 per 1,000), and ACM (0.3 per 1,000). Patients experiencing MACCE were older (median 69 years, IQR: 58-76 vs 58, 46-68, p<0.001), more likely to have a household income in the 1st quartile (28.5% vs 22.9%, p=0.03), and more likely to have Medicare as their primary insurer (60.9% vs 33.6%, p<0.001). Patients experiencing MACCE were a more likely to have major pre-existing cardiovascular comorbidities, coagulopathy, neurologic disease (ND), and diabetes (Table 1). Additionally, patients experiencing MACCE were more likely to undergo robotic colpopexy (20.7% vs 9.6%, p<0.001), vaginal colpopexy (32.0% vs 28.5%, p=0.04), bilateral salpingo-oophorectomy (25.8% vs 19.6%, p=0.03) and to receive a blood transfusion (8.2% vs 2.5%, p<0.001); and less likely to undergo hysterectomy (39.5% vs 48.8%, p=0.01) and bilateral salpingectomy (3.5% vs 6.8%, p=0.03). On logistic regression, pre-existing coagulopathy was the strongest predictor of MACCE, (aOR=5.53, 95% CI: 2.39-12.78), followed by blood transfusion (aOR=4.84, 95% CI: 1.89-12.45), congestive heart failure (CHF) (aOR=3.61, 95% CI: 1.56-8.37), ND (aOR=3.14, 95% CI: 1.23-8.06), and electrolyte abnormalities (aOR=1.99, 95% CI: 1.05-3.99). MACCE after PRS is a rare event with AMI being the most common manifestation. Pre-existing ND, CHF, coagulopathy, electrolyte disturbances, and perioperative transfusions are strongly associated with MACCE.

P1708Therapeutic hypothermia in cardiac arrest survivors with pre-existing heart failure is nephroprotective

Abstract Introduction The impact of therapeutic hypothermia on kidneys in cardiac arrest survivors with known congestive heart failure (CHF) is not known. Weak evidence suggests higher risk of acute kidney injury with hypothermia. Purpose The effect of hypothermia on organ function in cardiac arrest patients with preexisting CHF Methods This analysis includes 1417 comatose cardiac arrest survivors that achieved achieved return of spontaneous circulation on hospitalization and had a previous left ventricular ejection fraction (LVEF) assessment within last 1 year. Detailed chart review of these patients was performed. CHF was defined as either prior episode of congestive heart failure or presence of LVEF &lt;50%. Odds ratio (OR) and 95% confidence intervals (CI) for association of hypothermia and acute kidney injury as well as hemodialysis at discharge among patients with and without CHF were computed using multivariable adjusted logistic regression. Results Overall, 1417 cardiac arrest patients (mean age 62.5±14.6 years, 60.2% males, 67.2% white and 29.7% black) were included in this analysis, out of which 467 (33.0%) were treated with therapeutic hypothermia and known CHF was present in 624 (44%). AKI developed in 25.2% of CHF patients that were not treated with hypothermia while, only in 18.0% among CHF patients treated with hypothermia (OR 0.56; 95% CI 0.32–0.96, p=0.03). There was an decrease in trend of requiring hemodialysis at discharge among CHF patients treated with hypothermia compared with CHF patients that were not treated with hypothermia (8.1% vs. 19.62%, p=0.019) among CHF patients not treated with hypothermia. However, there was no significant result. Conclusions Hypothermia is associated with nephroprotective effects among patients with cardiac survivors with pre-existing CHF. Future research is needed to identify subgroups that derive benefit from therapeutic hypothermia after cardiac arrest.

Higher Mortality Rate in Moderate-to-Severe Thoracoabdominal Injury Patients with Admission Hyperglycemia Than Nondiabetic Normoglycemic Patients.

Background: Hyperglycemia at admission is associated with an increase in worse outcomes in trauma patients. However, admission hyperglycemia is not only due to diabetic hyperglycemia (DH), but also stress-induced hyperglycemia (SIH). This study was designed to evaluate the mortality rates between adult moderate-to-severe thoracoabdominal injury patients with admission hyperglycemia as DH or SIH and in patients with nondiabetic normoglycemia (NDN) at a level 1 trauma center. Methods: Patients with a glucose level ≥200 mg/dL upon arrival at the hospital emergency department were diagnosed with admission hyperglycemia. Diabetes mellitus (DM) was diagnosed when patients had an admission glycohemoglobin A1c ≥6.5% or had a past history of DM. Admission hyperglycemia related to DH and SIH was diagnosed in patients with and without DM. Patients who had a thoracoabdominal Abbreviated Injury Scale score <3, a polytrauma, a burn injury and were below 20 years of age were excluded. A total of 52 patients with SIH, 79 patients with DH, and 621 patients with NDN were included from the registered trauma database between 1 January 2009, and 31 December 2018. To reduce the confounding effects of sex, age, comorbidities, and injury severity of patients in assessing the mortality rate, different 1:1 propensity score-matched patient populations were established to assess the impact of admission hyperglycemia (SIH or DH) vs. NDN, as well as SIH vs. DH, on the outcomes. Results: DH was significantly more frequent in older patients (61.4 ± 13.7 vs. 49.8 ± 17.2 years, p < 0.001) and in patients with higher incidences of preexisting hypertension (2.5% vs. 0.3%, p < 0.001) and congestive heart failure (3.8% vs. 1.9%, p = 0.014) than NDN. On the contrary, SIH had a higher injury severity score (median [Q1–Q3], 20 [15–22] vs. 13 [10–18], p < 0.001) than DH. In matched patient populations, patients with either SIH or DH had a significantly higher mortality rate than NDN patients (10.6% vs. 0.0%, p = 0.022, and 5.3% vs. 0.0%, p = 0.043, respectively). However, the mortality rate was insignificantly different between SIH and DH (11.4% vs. 8.6%, odds ratio, 1.4; 95% confidence interval, 0.29–6.66; p = 0.690). Conclusion: This study revealed that admission hyperglycemia in the patients with thoracoabdominal injuries had a higher mortality rate than NDN patients with or without adjusting the differences in patient’s age, sex, comorbidities, and injury severity.

A risk score model of 30-day readmission in ulcerative colitis after colectomy or proctectomy.

IntroductionThe Center for Medicare and Medicaid Services established 30-day readmission rate as a key metric in measuring high-value, cost-conscious care; therefore, our aim is to develop a risk score for 30-day readmission in ulcerative colitis (UC) patients undergoing colectomy or proctectomy.MethodsThis study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file (2011–2015). Patients with UC undergoing colectomy or proctectomy were identified using ICD-9, 10, and CPT codes. Stepwise multivariate analyses were used to determine risk factors associated with readmission including pre-operative conditions, laboratory results, operative variables, and post-operative complications. For readmission risk score assessment, a weighted logistic regression model was built and validated using ACS NSQIP 2011–2014 and 2015 data, respectively.ResultsA total of 4797 patients were included with 963 (20%) patients readmitted within 30 days. Potentially modifiable risk factors included deep vein thrombosis, pulmonary embolism, renal insufficiency, wound infection, urinary tract infection, sepsis/septic shock, and pre-existing congestive heart failure. Ten percent of patients with a risk score between 0 and 9 were readmitted, 18.5% with a score between 10 and 19, 52.2% with a score between 20 and 29, and 59.6% in patients with a risk score >29.ConclusionsMultiple potentially preventable risk factors are associated with 30-day readmission following colectomy or proctectomy in UC patients. Higher risk scores are associated with increased risk of unplanned readmission.

Contrast-Induced Nephropathy After Cardiac Catheterization: Culprits, Consequences and Predictors

BackgroundContrast-induced nephropathy (CIN) is a common complication after radiocontrast exposure. MethodsA retrospective medical record review of 513 hospitalized patients who underwent cardiac catheterization from June-December 2014 was done, of which 38 patients with end-stage renal disease and 57 patients without preprocedural creatinine were excluded. Serum creatinine concentration before the procedure and each day for 3 days after the procedure was recorded. CIN was defined as an increase in serum creatinine concentration by ≥25% or ≥0.5mg/dL from the preprocedural value within 72hours of contrast exposure. ResultsA total of 418 patients (mean age: 69.1 ± 13.8 years, 55% males) were included in the study. Mean incidence of CIN was 3.7% (n = 16). CIN accounted for longer duration of hospitalization, lengthier intensive care unit admission, requirement of hemodialysis and higher mortality. Incidence of CIN was higher in the presence of preexisting atrial fibrillation (AF), congestive heart failure (CHF) and chronic kidney disease (CKD). When tested by univariate analysis, incidence of CIN was 13.8% in the AF group (P < 0.001), 8.6% in CHF group (P < 0.01) and 8.9% in CKD group (P < 0.002), compared with 2.3%, 1.9% and 2.4% in the absence of preexisting AF, CHF and CKD, respectively. On further testing using multivariate logistic regression model using AF, CHF and CKD as independent variables, development of CIN was strongly associated with preexisting AF with an odds ratio of 4.11, 95% CI: 1.40-12.07, P = 0.01. ConclusionIdentifying patients at risk is an important step in preventing CIN. Preexisting AF, independent of traditional risk factors, may increase the risk for CIN.

New-onset congestive heart failure (CHF) and cardiovascular disease (CVD) in older colorectal cancer (CRC) survivors: A population-based study.

10011 Background: CRC is primarily a disease of the elderly. The high burden of pre-existing comorbidities alone or in concert with cancer treatment place the older patients with CRC at increased risk of new-onset morbidities, specifically, CVD and CHF. However, the magnitude of risk of new-onset morbidity, and its association with pre-existing comorbidities or treatment remain unknown. Methods: Using SEER-Medicare data, we evaluated individuals diagnosed with incident stage I-III CRC at age ≥66y between 1/1/2000 and 12/31/2011 who had survived ≥2y after diagnosis (n = 57,256; 77% with colon cancer). We compared these to an age, sex-, and race-frequency matched comparison group of non-cancer Medicare patients (n = 104,731). We evaluated new-onset CHF and CVD using competing risk cumulative incidence functions and multivariable Cox regression models. Results: The median age at diagnosis was 77y (66-106y); 45% males; and 85% non-Hispanic white. Median follow-up was 8y (2-14y) from diagnosis of CRC. Treatment included surgery for 99%, chemotherapy for 31%, and radiation for 12%. New-onset morbidity: The 10y cumulative incidence of new-onset CHF and CVD were 43.6% and 58.9%, respectively. After controlling for pre-cancer comorbidities, CRC survivors were at increased risk of new-onset CHF (HR 1.29) and CVD (HR 1.74) (all p &lt; 0.001) compared to controls. Patients receiving radiation (HR 1.29) or 5-FU+oxaliplatin (HR 1.09) were at increased risk of CVD compared to those without those therapies (p &lt; 0.001). Pre-existing diabetes (HR 1.16) and CHF (HR 1.21) independently increased the risk of CVD (p &lt; 0.001). While 5FU+oxaliplatin did not increase the risk of CHF independently (HR 0.97), diabetic patients treated with 5-FU+oxaliplatin were at 1.71-fold increased risk of developing CHF (p &lt; 0.001) when compared with those without pre-existing diabetes. Conclusions: Older CRC survivors are at increased of developing CHF and CVD. Monitoring survivors with a history of exposure to 5FU+oxaliplatin or radiation, and improving management of pre-existing comorbidities may reduce the burden of long-term morbidity for older CRC survivors.

Subclinical Hypothyroidism and Survival: The Effects of Heart Failure and Race

Studies examining the association between subclinical hypothyroidism and mortality have yielded conflicting results. Emerging data suggest these associations may depend upon underlying congestive heart failure (CHF) and/or race, but this has not been empirically determined. Our objective was to examine the association between subclinical hypothyroidism and hypothyroidism overall with mortality according to pre-existing CHF and race. We examined the associations of subclinical hypothyroidism (TSH higher than assay upper limit of normal; total T4 within reference) and hypothyroidism overall (TSH higher than assay upper limit of normal; total T4 below lower limit of normal or within reference) with all-cause mortality among Third National Health and Nutrition Examination Survey participants stratified by CHF and race using multivariable Cox models. To confirm whether differences between strata were statistically significant, we tested for interaction on the basis of CHF (separately) and race by likelihood ratio testing. There were 14 130 (95.0%) euthyroid controls and 749 (5.0%) participants with hypothyroidism, 691 (4.6%) of whom had subclinical disease. Subclinical hypothyroidism vs euthyroidism was associated with greater mortality in those with CHF but not in those without: adjusted hazard ratios (HRs) (95% confidence intervals [CIs]) = 1.44 (1.01-2.06) and 0.97 (0.85-1.11), respectively (P interaction = .03). Similar findings were observed for hypothyroidism overall. Hypothyroidism overall vs euthyroidism was associated with greater mortality in Black participants (HR = 1.44 [95% CI = 1.03-2.03]) but not in non-Blacks (HR = 0.95 [95% CI = 0.83-1.08]) (P interaction = .03). Among participants with CHF, subclinical hypothyroidism and hypothyroidism overall are associated with greater death risk. Additional studies are needed to confirm findings and explore possible mechanisms for the differential hypothyroidism-mortality association across race.

What are the risks of oral contraceptives in patients with cardiovascular disease risk factors?

Evidence-Based Answer Women who smoke, have hypertension, hyperlipidemia, or factor V Leiden deficiency and take oral contraception (OC) are at increased risk of myocardial infarction (MI). Third-generation OCs and low-dose OCs are not associated with increased MI risk in women with or without other cardiovascular (CV) risk factors (SOR B, systematic review of cohort studies). OCs are contraindicated in women with preexisting congestive heart failure or CV disease, but may be used in otherwise healthy women with diabetes, hypertension, or hyperlipidemia (SOR C, evidence-based guidelines derived from consensus and expert opinion).