Recurrent Hospitalizations Research Articles

Use of Levosimendan in Patients with Advanced Heart Failure: An Update.

Levosimendan is an inodilator drug that, given its unique pharmacological actions and safety profile, represents a viable therapeutic option in patients with heart failure with reduced ejection fraction in the advanced stage of the disease (advHFrEF). Pulsed levosimendan infusion in patients with advHFrEF improves symptoms and clinical and hemodynamic status, prevents recurrent hospitalizations, and enables optimization of guidelines-directed medical therapy. Furthermore, considering its proprieties on right ventricular function and pulmonary circulation, levosimendan could be helpful for the prevention and treatment of the right ventricular dysfunction post-implanting a left ventricular assist device. However, to date, evidence on this issue is scarce and has yielded mixed results. Finally, preliminary experiences indicate that treatment with levosimendan at scheduled intervals may serve as a "bridge to transplant" strategy in patients with advHFrEF. In this review, we summarized the clinical pharmacology of levosimendan, the available evidence in the treatment of patients with advHFrEF, as well as a hypothesis for its use in patients with advanced heart failure with preserved ejection fraction.

A case of chronic hyponatremia secondary to SIADH treated with low dose Tolvaptan to prevent recurrent hospital admission and proven cost effective

A case of chronic hyponatremia secondary to SIADH treated with low dose Tolvaptan to prevent recurrent hospital admission and proven cost effective

Effects of empagliflozin on cardiovascular and renal outcomes in heart failure with reduced ejection fraction according to age: a secondary analysis of EMPEROR-Reduced.

Empagliflozin improves cardiovascular and renal outcomes in patients with heart failure (HF) and reduced ejection fraction (HFrEF), but its efficacy and safety across patient's age is not well established. We assessed the effects of empagliflozin (10mg daily) versus placebo, on top of standard HF therapy, in symptomatic HFrEF patients with a left ventricular ejection fraction ≤40% and increased natriuretic peptides stratified by age (<65, 65-74, ≥75 years). The primary endpoint was a composite of cardiovascular death or HF hospitalization. Key secondary endpoints included first and recurrent HF hospitalizations and slope of change in estimated glomerular filtration rate (eGFR); the latter was supported by an analysis of a renal composite endpoint (chronic dialysis or renal transplantation or profound and sustained reduction in eGFR). Of 3730 patients, 38% were <65 years, 35% were 65-74 years and 27% were ≥75 years. Compared with placebo, empagliflozin reduced the primary endpoint consistently across the three age groups (hazard ratio 0.71 [95% confidence interval 0.57-0.89] for <65 years, 0.72 [0.57-0.93] for 65-74 years, 0.86 [0.67-1.10] for ≥75 years, interaction p-trend test=0.24). The effects of empagliflozin were also consistent across age groups for key secondary endpoints of first and recurrent HF hospitalization (p-trend=0.30), the rate of decline in eGFR (p-trend=0.78) and the renal composite (p-trend=0.94). Adverse events (AEs), serious AEs and AEs leading to drug discontinuation increased with age in both treatment arms, but empagliflozin did not increase their incidence over placebo within each age group. The efficacy and safety of empagliflozin in improving cardiovascular and renal outcomes in HFrEF was consistent across the spectrum of age, including older patients (aged ≥75).

Heart failure with preserved ejection fraction: Calculating the risk of future heart failure events and death.

We sought to develop a clinical model to identify heart failure patients with preserved ejection fraction (HFpEF) at highest risk for acute HF events or death. Between 2010 and 2019, 422 patients with HFpEF were followed. Acute HF events occurred in 190 patients (45%), including 110 (58%) with recurrent hospitalizations. Those with recurrent events had worse 6-min walk test (p < 0.001), higher brain N-terminal prohormone natriuretic peptide (NT-proBNP, p < 0.001), and higher New York Heart Association functional class (NYHA, p < 0.001). Overall survival rates in patients with 1 HF event vs > 1 HF events were: at 1-year 91.6 vs. 91.8%, at 3-years 84.7 vs. 68.3% and at 5-years 67.4 vs. 42.7%, respectively (p < 0.04). The Hfpef survivAL hOspitalization (HALO) score revealed best predictive capability for all-cause mortality combining the variables age (p = 0.08), BMI (p = 0.124), NYHA class (p = 0.004), need for diuretic therapy (p = 0.06), left atrial volume index (p = 0.048), systolic pulmonary artery pressure (p = 0.013), NT-proBNP (p = 0.076), and number of prior hospitalizations (p = 0.006). HALO score predicted future HF hospitalizations in an ordinal logistic regression model (OR 3.24, 95% CI: 2.45-4.37, p < 0.001). The score performance was externally validated in 75 HFpEF patients, confirming a strong survival prediction (HR 2.13, 95% CI: 1.30-3.47, p = 0.002). We developed a model to identify HFpEF patients at increased risk of death and HF hospitalization. NYHA class and recurrent HF hospitalizations were the strongest drivers of outcome.

Impact of renal artery stenosis on acute kidney injury and outcomes after heart failure hospitalization

BackgroundRenal artery stenosis (RAS) is known to co-exist with heart failure (HF), however the impact of RAS on rates of acute kidney injury during an acute HF hospitalization, and adverse events after acute HF hospitalizations has not been well studied. MethodsWe performed a retrospective cohort study of subjects hospitalized for acute HF at a tertiary academic care center. We identified subjects who had a renal artery duplex ultrasound or other diagnostic study for RAS to categorize heart failure subjects as RAS+ or RAS-. AKI was defined as a rise from admission to peak creatinine of >0.3 mg/dL or >1.5 fold. In-hospital outcomes including rates of AKI were ascertained. Adverse outcomes over a two-year follow up period were also ascertained. ResultsA total of 93 subjects with acute HF hospitalization met the inclusion criteria and were enrolled in this study; 27 (29%) were identified as RAS+. At admission, subjects with RAS had higher rates of diabetes and prior PCI. During the HF hospitalization, subjects with RAS were more likely to develop AKI. No significant differences were identified in baseline or hospital medication use among subjects with versus without RAS. Importantly, the rate of ACE-I/ARB use was low in both groups and no significant difference in ACE-I/ARB use was demonstrated. Subjects with RAS had higher rates of recurrent HF hospitalization during the follow-up period. ConclusionsRAS is prevalent among subjects with acute HF, associated with higher rates of AKI during HF hospitalization, and associated with higher rates of recurrent HF hospitalization during follow-up.

Association of Area-Level Heat and Social Vulnerability With Recurrent Hospitalizations Among Individuals With Rheumatic Conditions.

Climate and social vulnerability contribute to morbidity and health care utilization. We examined associations between the neighborhood Social Vulnerability Index (SVI) and the Heat Vulnerability Index (HVI) and recurrent hospitalizations among individuals with rheumatic conditions. Using a Massachusetts multihospital centralized clinical data repository, we identified individuals ≥18 years of age with a rheumatic condition who received rheumatology care within 3 years of April 2021. We defined the index date as 2 years before the last encounter and the baseline period as 1 year pre-index date. Addresses were geocoded and linked by census tract to the SVI and the HVI. We used multilevel, multinomial logistic regression to examine the odds of 1-3 and ≥4 hospitalizations (reference=0) over 2 years post index date by vulnerability index, adjusting for age, gender, race/ethnicity, insurance, and comorbidities. Among 14,401 individuals with rheumatic conditions, the mean ± age was 61.9 ± 15.7 years, 70% were female, 79% White, 7% Black, and 2% Hispanic. There were 8,251 hospitalizations; 11,649 individuals (81%) had 0 hospitalizations, 2,063 (14%) had 1-3, and 689 (5%) had ≥4. Adjusting for individual-level factors, individuals living in the highest versus lowest SVI areas had 1.84 times higher odds (95% confidence interval [95% CI] 1.43-2.36) of ≥4 hospitalizations. Individuals living in the highest versus lowest HVI areas had 1.64 times greater odds (95% CI 1.17-2.31) of ≥4 hospitalizations. Individuals with rheumatic conditions living in areas with high versus low social and heat vulnerability had significantly greater odds of recurrent hospitalizations. Studies are needed to determine modifiable factors to mitigate risks.

Amiodarone vs Dronedarone for Atrial Fibrillation: A Retrospective Cohort Study

BackgroundAtrial fibrillation is one of the most common arrhythmias, but the optimal drug choice for a rhythm-control strategy remains uncertain. MethodsThis article reports on a retrospective cohort claims database study conducted using the Truven Health Market Scan Commercial Claims and Encounters and Medicare Supplemental databases. Patients with a new diagnosis of atrial fibrillation, and a discharge date between 2011 and 2015, were included. The exposure variables of interest were a discharge prescription for amiodarone or dronedarone. The average treatment effect for the composite of total mortality or a repeat cardiovascular (CV)-related hospitalization was the primary outcome. Sensitivity analyses with other treatment effect metrics were performed. Baseline covariate imbalances between the groups were adjusted using propensity-score methods with inverse probability weighting. ResultsA total of 1735 patients were discharged on amiodarone, and 338 were discharged on dronedarone, with a median follow-up time of 357 days. A total of 43 (12.7%) CV-related hospitalizations occurred in the dronedarone group, and 146 (8.4%) occurred in the amiodarone group (risk difference 4.3%, 95% confidence interval [CI] 0.4%-8.3%, P = 0.02). A total of 4 (1.2%) deaths occurred in the dronedarone group, and 31 (1.8%) deaths occurred with amiodarone (risk difference -0.6%, 95% CI -2.1%-0.9%, P = 0.6). After adjusting for baseline covariates, the dronedarone hazard ratio for the composite endpoint was 1.47 (95% CI 1.01-2.12). This result was generally robust to sensitivity analyses. ConclusionIn this incident cohort of patients hospitalized for atrial fibrillation, compared to those discharged on amiodarone, patients who received a dronedarone discharge prescription had an increase in the composite endpoint of recurrent CV-related hospitalization and death, over a median 1-year follow-up period.

Ambient particulate matter pollution of different sizes associated with recurrent stroke hospitalization in China: A cohort study of 1.07 million stroke patients

BackgroundTo estimate the associations between ambient particulate matter (PM) pollution of different sizes (PM1, PM2.5, and PM10) and risk of rehospitalization among stroke patients, as well as the attributable burden in China. MethodsWe built a cohort of 1,066,752 participants with an index stroke hospitalization in Sichuan, China from 2017 to 2019. Seven-day and annual average exposures to PM pollution prior to the date of the index hospitalization were linked with residential address using a bilinear interpolation approach. Cox proportional hazard models were constructed to assess the association between ambient PM and the risk of rehospitalization. The burden of stroke rehospitalization was estimated using a counterfactual approach. Results245,457 (23.0 %) participants experienced rehospitalization during a mean of 1.15 years (SD: 0.90 years) of follow-up. Seven-day average concentrations of PM were associated with increased risk of rehospitalization: the hazard ratios (HRs) per 10 μg/m3 were 1.034 (95 % confidence interval [CI]: 1.029–1.038) for PM1, 1.033 (1.031–1.036) for PM2.5, and 1.030 (1.028–1.031) for PM10; the hazard ratios were larger for annual average concentrations: 1.082 (1.074–1.090) for PM1, 1.109 (1.104–1.114) for PM2.5, and 1.103 (1.099–1.106) for PM10. The associations were stronger in participants who were female, of minority ethnicity (non-Han Chinese), who suffered from an ischemic stroke, and those admitted under normal conditions. Population attributable fractions for stroke rehospitalization ranged from 4.66 % (95 % CI: 1.69 % to 7.63 %) for the 7-day average of PM1 to 17.05 % (14.27 % to 19.83 %) for the annual average of PM10; the reducible average cost of rehospitalization per participant attributable to PM ranged from 492.09 (178.19 to 806) RMB for the 7-day average of PM1 to 1801.65 (1507.89 to 2095.41) RMB for the annual average of PM10. ConclusionsAmbient PM pollution may increase the risk of rehospitalization in stroke patients and is responsible for a significant burden of stroke rehospitalization.

Prognostic implications of biventricular and left radial strain in heart failure

Abstract Background Chronic heart failure (CHF) is associated with the high ventricular filling pressures with subsequent negative impact on the left (LV) and right ventricular (RV), and left atrium (LA) mechanics, and pulmonary vasculature. All these could lead to poor long-term outcome. Purpose Assess the prognostic implications of LA, LV and RV mechanical dysfunction, and pulmonary hypertension, in CHF based on advanced echocardiographic technology. Methods A total of 2110 CHF patients were retrospectively reviewed and enrolled for the analyses. The 2D-Speckle tracking echocardiographic analysis was used to measure the peak LV, RV and LA longitudinal strain. The long-term outcomes were evaluated for all-cause CVS outcomes and recurrent hospitalization. Results For the 941eligible patients [mean age: 61±4; 62% male sex], 244 reached the combined endpoint. Population was divided into three groups based on the mean pulmonary artery systolic pressure (mPASP): Group 1, 25&amp;lt;mPASP≤40 mmHg; Group 2, 40&amp;lt;mPASP≤55 mmHg and Group 3, &amp;gt;mPASP 55 mmHg. Mean follow-up was 2.5±0.6 years. The higher mPASP was demonstrated in those with higher left atrial volume ndex (LAVI), NYHA ≥II class, pulmonary diseases, presence of at least moderate mitral and/or tricuspid regurgitation (TR) grades, significantly lower LVEF, lower strain values (LA, LV, RV), and tricuspid annular plane systolic excursion (TAPSE), p&amp;lt;0.001). High mPASP, lower LVEF and RV dysfunction were independent predictors of survival after multiple adjustments using different models. Conclusions Multiple factors are associated with poor outcomes in CHF; particularly the presence of RV dysfunction, severe PH and severely impaired, which would guide further manage of CHF and to consider other treatment options including device therapy or even transplantation. All these factors could strongly influence the risk stratification of patients with CHF Funding Acknowledgement Type of funding sources: None.

Sex-based differences in treatment outcomes in HFpEF: a systematic review

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is the prevailing heart failure phenotype among women. Disease-modifying treatment in HFpEF has proved a challenge and little is known on sex-based differences in treatment outcomes in HFpEF. Purpose This systematic review aimed to identify drug and non-drug exercise randomized controlled trials that stratified treatment outcome by sex. Methods A systematic literature search of PubMed for randomised controlled trials that assessed treatment outcomes by sex (pre-specified, secondary, post-hoc analysis) for HFpEF was performed until January 2021. Results This systematic review included 36 drug and 2 exercise RCTs. There was an increased benefit in reducing the composite outcome of first and recurrent HF hospitalisation and cardiovascular death among women (HR 0.73, 95% CI 0.59–0.90) compared to men (HR 1.03, 95% CI, 0.84–1.25, p-interaction = 0.017) treated with sacubitril-valsartan. However, women (HR 1.41, 95% CI 1.02–1.97) had higher risk of new-onset AF compared to men (HR 0.79, 95% CI 0.55,1.14, p-interaction 0.019) taking sacubitril-valsartan, and men (Δ2.8, 95% CI 1.3–4.3) were more likely to show improvements in the KCCQ-CSS compared to women (Δ-0.6, 95% CI −2.1,0.8, p-interaction=0.003). There may be benefit among women treated with sacubitril-valsartan in lowering blood pressure and characteristic impedance. A superior risk reduction in all-cause mortality was reported in women treated with spironolactone (HR 0.66, 95% CI 0.48–0.90) when compared with men (HR 1.06, 95% CI 0.81–1.39, p-interaction=0.024). No differences in treatment outcomes by sex were reported with SGLT2 inhibitors or with exercise interventions in HFpEF. Conclusions Women may respond to HFpEF treatment differently than men. Identifying sex-based differences in treatment outcomes should be prioritised in future research and taken into consideration in the development of guidelines for the management of HFpEF. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart Foundation

Ratio between left and right ventricular end-diastolic volumes and outcomes in patients with heart failure and preserved ejection fraction

Abstract Background Reference left and right ventricular (LV/RV) volumes normalized to age and gender have been published. However, the relative dilation of the LV compared to the RV in patients with heart failure (HF) symptoms and its prognostic association have not been evaluated. Purpose The present study investigated the relative dilation of the LV compared to the RV among patients with HF and preserved LV ejection fraction (HFpEF). We explored the association between LV/RV ratio (defined as the ratio between LV end-diastolic volume index [LVEDVi] and RV end-diastolic volume index [RVEDVi]) and outcomes. Methods Clinical and imaging data from consecutive ambulatory patients diagnosed with HFpEF between April 2011 and November 2021, and undergoing a cardiac magnetic resonance examination were retrieved. The endpoints were 1) all-cause death or first HF hospitalization, and 2) cardiovascular death or first HF hospitalization, 3) repeated HF hospitalizations. Results A total of 159 patients (median age 58 years [interquartile range 49–69], 64% men) were included. Median LVEF was 60% (54–70%), and the LV/RV ratio was 1.21 (1.07–1.40). Over a 3.5-year follow-up (1.5–5.0), all-cause death or first HF hospitalization occurred in 23 patients (15%) and cardiovascular death or first HF hospitalization in 22 (14%). Spline curve analysis showed a bimodal relationship between LV/RV and both outcomes, with a steep increase in risk &amp;lt;1.0 and ≥1.4 (Figure 1). Accordingly, patients with either LV/RV &amp;lt;1.0 or ≥1.4 had a much shorter survival free from both endpoints than patients with LV/RV 1.0–1.3 (Figure 2). An LV/RV &amp;lt;1 was associated with a higher risk of all-cause death or first HF hospitalization (hazard ratio [HR] 5.95, 95% confidence interval [CI] 1.67–21.28; p=0.006) and a higher risk of cardiovascular death or first HF hospitalization (HR 5.68, 95% CI 1.58–20.35; p=0.008). Furthermore, an LV/RV ≥1.4 was associated with a higher risk of all-cause death or first HF hospitalization (HR 4.10, 95% CI 1.58–10.61; p=0.004) and a higher risk of cardiovascular death or first HF hospitalization (HR 3.71, 95% CI 1.41–9.79; p=0.008). Nine patients (6%) had more than 1 HF hospitalization. The crude incidence of HF hospitalizations was much higher in patients with an LV/RV &amp;lt;1.0 (16.6 per 100 patient/years) or ≥1.4 (10.29 per 100 patient/years) than in those with LV/RV 1–1.3 (1.88 per 100 patient/years). Multivariable binomial negative regression showed significant association between LV/RV and recurrent HF hospitalizations after adjustment by age, gender and New York Heart Association class: LV/RV &amp;lt;1.0 vs. 1.0–1.3, incidence rate ratio 9.0 per 100 patient/years (4.1–19.6), p&amp;lt;0.001; LV/RV ≥1.4 vs. 1.0–1.3, incidence rate ratio 5.3 per 100 patient/years (1.5–8.4), p=0.009. Conclusions Among patients with HFpEF, an RVEDVi larger than the LVEDVi, or an LVEDVi ≥40% larger than the RVEDVi were significantly associated with worse outcomes. Funding Acknowledgement Type of funding sources: None.

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Abstract Background Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit. Purpose This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice. Methods This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI &amp;gt;5% prior to ablation, mean systolic/diastolic blood pressure &amp;gt;125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) &amp;gt;6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed. Results The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI &amp;gt;5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c &amp;gt;6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1. Conclusion Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c &amp;gt;6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

S1309 Can Sarcopenia Diagnosed by Hand Grip Strength Provide a Better MELD-Na Cutoff in Predicting Complications of Cirrhosis?

Introduction: Computerized Tomography (CT) measured Skeletal Muscle Index (SMI) is the best investigation to diagnose sarcopenia. However, in developing countries, it is not feasible due to cost and unavailability. Hand grip strength using hand grip dynamometry is a simple, economical and repeaTable bedside tool to assess sarcopenia in cirrhotics. MELD-Na score is a better marker for short term mortality and transplant allocation rather than predicting decompensation events in cirrhotics. In the present study, we showed that hand grip strength with MELD-Na score can correlate with complications of cirrhosis and predict survival. Methods: A total of 72 patients between December 2019 and June 2021 diagnosed with liver cirrhosis on the basis of imaging were included in our study. Hand grip strength was measured by hand grip dynamometer in the non-dominant hand in sitting position with semi-flexed arm. Mean of three values was taken as final reading. Cut-offs of < 26 kg for men and < 18 kg for women were taken from Asian Working Group for Sarcopenia 2014 consensus. Patients were followed up for a period of 6 months. Results: In our study, the prevalence of sarcopenia was 83.3%. The mean MELD-Na score was 20. Presence of sarcopenia correlated with complications like bleeding esophageal varices (p = 0.01), Hepatic Encephalopathy (HE) (p = 0.002) and Hepatorenal Syndrome (HRS) (p = 0.006). On univariate analysis, when MELD-Na was > 20.5, sarcopenia was significantly associated with HE [Odd’s Ratio (OR), 9.33; 95% confidence interval (CI), 1.86 - 46.68; p = 0.007], bleeding esophageal varices [OR, 4.29; 95% CI, 1.35 - 13.58; p = 0.01] and HRS [OR, 12.43; 95% CI, 1.46 -105.74; p = 0.02]. The MELD-Na score of more than 20.5 with sarcopenia predicted mortality with sensitivity 100%, specificity 65% and p = 0.038. The estimated survival of sarcopenics at 6 months with MELD-Na > 20.5 was 83.3%. Conclusion: Hand grip strength is a simple, non-expensive test to diagnose sarcopenia. In resource limited countries, it can be used instead of CT scan measured SMI. As a measure of sarcopenia, it shows a statistically significant association with decompensation events of cirrhosis. In patients not yet listed for transplant, hand grip strength measured sarcopenia along with MELD-Na score cut-off of 20.5 can be utilized to optimize medical treatment, to prevent decompensation, recurrent hospitalization and ensure good quality of life.

Effect of functional relaxation on the quality of life in patients with periprosthetic joint infection: Protocol for a randomised controlled trial

IntroductionPeriprosthetic joint infection (PJI) is a devastating complication in orthopaedic and trauma surgery, which puts a high burden on the patients involving recurrent hospitalisation, prolonged courses of antibiotic medication, severe...

Depression in Various Ethnic Groups of Pakistan after Primary Percutaneous Coronary Intervention

Background: Depression is very common among individuals recovering from a chronic illness with long-term or recurrent hospitalization. Post-myocardial infarction patients are at risk of developing depression and is considered to be a risk for elevated mortality.&#x0D; Aims and Objective: To determine the frequency of depression among various ethnic groups of patients post primary percutaneous coronary intervention for acute myocardial infarction.&#x0D; Material and Methods: �A cross-sectional study was conducted at the out-patients department of NICVD, Pakistan for a duration of six months from February 2021 to July 2021. Total 256 patients aged between 18 to 85 years, were diagnosed with STEMI, and had undergone PCI were included in the study. Patients with prior diagnosis of CAD or had prior history of psychological problems were excluded from the study. Patients were interviewed for depression by using Beck's depression inventory (BDI). Patients scoring &gt; 10 were labeled as having depression.&#x0D; Results: Out of 256 patients, 122 (48.8%) patients were screened positive for depressive symptoms.� Out of these, about 21.1% had mild depression, 16% had borderline clinical depression, 10.5% had moderate depression, while about 0.8% had severe depression. Age of 71 years and above, female gender, diabetes, hypertension, and sedentary lifestyle were all significantly correlated with increased risk of depression in post-MI patients with BDI scores of 17.64 � 7.9 (&lt;0.0001), 13.54 � 7.53 (0.015), 14.47 � 7.61 (p&lt;0.0001), 13.52 � 6.83 (p&lt;0.0001), and 16.69 � 7.57 (p&lt;0.0001), respectively.&#x0D; Conclusion: After percutaneous coronary intervention for MI, depression was found in almost half of the patients. However, as per our study, the risk for depression is independent of ethnic background.

Frailty and Hospitalization Burden in Patients With Chronic Heart Failure

Frailty is associated with increased mortality and hospitalizations in patients with heart failure (HF). However, there is little evidence regarding the burden of morbidity. In this study, we aimed to assess the association between frailty and recurrent all-cause HF hospitalizations in patients with stable chronic HF. This was an observational and prospective study that enrolled HF outpatients followed in a specialized HF unit of a single tertiary care center from 2017 to 2019. Frailty was assessed by Fried criteria. Robustness, prefrailty, and frailty were defined as 0, 1 to 2, and ≥3, respectively. The independent association between frailty status and recurrent hospitalizations was assessed through Famoye's bivariate Poisson regression model, and risk estimates were expressed as incidence rate ratios (IRR). A total of 277 patients were included. The mean age was 74 ± 10 years, 118 were women (42.6%), and 131 patients (47.3%) had left ventricular ejection fraction ≥50. According to Fried's score 61 patients (22%) were robust, 95 patients (34%) were prefrail, and 121 patients (44%) were frail. After a median follow-up of 2.21 (1.6 to 2.8) years, 52 patients (19%) died. We registered 348 all-cause hospitalizations in 144 patients (52%) and 178 HF hospitalizations in 108 patients (39%). Compared with robust patients, frailty was associated with a higher risk of all-cause and HF recurrent hospitalizations in multivariable analysis (IRR 2.01, 95% confidence interval 1.14 to 3.57, p=0.017 and IRR 2.25, 95% confidence interval 1.16-4.36, p=0.016, respectively). In conclusion, in patients with chronic HF, frailty identifies patients with an increased risk of total and recurrent all-cause and HF hospitalizations.

Comparative effectiveness of Empagliflozin in reducing the burden of recurrent cardiovascular hospitalizations among older adults with diabetes in routine clinical care

BackgroundThe effect of sodium glucose cotransporter 2 inhibitors (SGLT2i) on the total (first and recurrent) burden of cardiovascular (CV) hospitalizations, including hospitalization for heart failure, myocardial infarction, and stroke, is poorly understood. ObjectiveTo assess the effect of empagliflozin, an SGLT2i, on total CV hospitalizations among older adults with T2D. MethodsUsing data from Medicare fee-for-service (08/2014-09/2017), we identified 1:1 propensity score-matched cohorts of patients with T2D initiating empagliflozin versus sitagliptin or empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA), balancing >140 baseline covariates. We compared the risk of first and recurrent hospitalizations with any CV condition as the primary discharge diagnosis (ICD-9: 390-459; ICD-10: I00-I99), hospitalizations for heart failure (HHF), and myocardial infarctions (MI) or stroke. We estimated treatment effects based on the Ghosh-Lin semiparametric model for recurrent events as primary and joint frailty model as secondary analysis. ResultsWe included 11,429 matched-pairs of empagliflozin and sitagliptin initiators and 17,502 matched-pairs of empagliflozin and GLP1-RA initiators with an average age of 72 years. Empagliflozin was associated with a reduced risk of total CV hospitalizations (0.80 [0.69-0.93] vs sitagliptin; 0.88 [0.77-1.00] vs GLP-1RA) and total HHF (0.70 [0.51-0.98] vs sitagliptin; 0.76 [0.56-1.03] vs GLP1-RA) over a mean follow up of 6.3 months. No differences between treatments were observed for MI or stroke. Results were consistent for joint frailty models. ConclusionEmpagliflozin, compared to sitagliptin or to a lesser extent GLP1-RA, was associated with a reduction in the burden of total CV hospitalizations and HHF in older patients with T2D.

Revision ureteroneocystostomy in pediatric renal transplant patients for symptomatic vesicoureteral reflux and its effect on recurrent hospitalizations

Nearly 13,000 pediatric renal transplantations have been performed since 1987 with improving overall mortality and morbidity; however, graft infection remains a significant post-transplant concern. Recurrent urinary tract infections in pediatric patients with vesicoureteral reflux into their renal transplant can result in graft dysfunction, increased hospital cost, and impaired social and cognitive development due to time spent hospitalized. To evaluate the effect of revision ureteroneocystostomy on pediatric renal transplant patients with symptomatic vesicoureteral reflux in reducing hospitalizations and recurrent urinary tract infections. We retrospectively reviewed pediatric patients from 2002 through 2021 who underwent renal transplantation and required revision ureteroneocystostomy due to symptomatic vesicoureteral reflux. We analyzed the differences in days hospitalized, days hospitalized due to urinary tract infection, and treated urinary tract infections prior to and after revision ureteroneocystostomy. Ten patients requiring revision ureteroneocystostomy secondary to symptomatic vesicoureteral reflux were identified. There was no difference in the observation time between transplant to revision, and revision to last follow up (2.3 years (IQR 1.3-6.5) vs 1.7 years (IQR 1-6.7), p=0.4446). Overall, there was a significant decrease in the total number of hospitalization days (21.5 days (IQR 3-43) vs 5.5 days (IQR 0-9), p=0.006), total number of hospitalization days related to urinary tract infection (14.5 days (IQR 3-28) vs 0 days (IQR 0-3), p=0.008) and treated urinary tract infections (3.5 (IQR 3-6) vs 1 (IQR 0-2), p=0.019) following revision ureteroneocystostomy. The rate of hospitalization days for urinary tract infection was also significantly decreased following revision ureteroneocystostomy (7.15 per/year (IQR 0.4-11.75) vs 0 per/year (IQR 0-0.8), p=0.008). Symptomatic vesicoureteral reflux in pediatric transplant patients is difficult to manage and some patients will ultimately require surgery. There have been previous studies on the success of revision ureteroneocystostomy in treating reflux but no data on the reduction in hospitalizations associated with recurrent infections following the procedure. Limitations of this study are the small cohort size, retrospective nature, multi-surgeon study, and inherent selection bias due to evaluation of only surgical patients. Revision ureteroneocystostomy can limit the negative consequences of recurrent graft infections with reduction in hospitalization days and improved hospitalization rates due to urinary tract infections. The reduction in hospitalizations can greatly improve the cost of care along with quality of life for transplant patients and should be strongly considered in children with symptomatic vesicoureteral reflux who have failed conservative therapy.

A significant predictor of in-hospital and long-term mortality and progression in COVID-19 patients: The end-stage liver disease (MELD) score model.

The aim of this study is to investigate the relationship between the model for end‐stage liver disease (MELD) score and disease progression and mortality in COVID‐19 patients. The files of 4213 patients over the age of 18 who were hospitalized with the diagnosis of COVID‐19 between March 20, 2020 and May 1, 2021 were retrospectively scanned. Sociodemographic characteristics, chronic diseases, hemogram and biochemical parameters at the time they were diagnosed with COVID‐19 of the patients, duration of hospitalization, duration of intensive care unit (ICU), duration of intubation, in‐hospital mortality from COVID‐19 and outside‐hospital mortality for another reason (within the last 1 year) and recurrent hospitalization (within the last 1 year) were recorded. The MELD scores of the patients were calculated. Two groups were formed as MELD score < 10 and MELD score ≥ 10. The rate of ICU, in‐hospital mortality from COVID‐19 and outside‐hospital mortality from other causes, intubation rate, and recurrent hospitalization were significantly higher in the MELD ≥ 10 group. The duration of ICU, hospitalization, intubation were significantly higher in the MELD ≥ 10 group (p < 0.001). As a result of Univariate and Multivariate analysis, MELD score was found to be the independent predictors of ICU, in‐hospital mortality, intubation, and recurrent hospitalization (p < 0.001). MELD score 18.5 predicted ICU with 99% sensitivity and 100% specificity (area under curve [AUC]: 0.740, 95% confidence interval [CI]: 0.717–0.763, p < 0.001) also MELD score 18.5 predicted in‐hospital mortality with 99% sensitivity and 100% specificity (AUC: 0.797, 95% CI: 0.775–0.818, p < 0.001). The MELD score was found to be the independent predictors of in‐hospital mortality, ICU admission, and intubation in COVID‐19 patients.

Cardiovalve in mitral valve position—Additional solution for valve replacement

We report on a 72 years old male patient with recurrent heart failure hospitalizations caused by severe mitral regurgitation due to severe restriction of the posterior mitral leaflet treated with the transfemoral mitral valve replacement (TMVR) system Cardiovalve. Immediate interventional success was obtained resulting in a quick mobilization and discharge.