Significant Difference In In-hospital Mortality Research Articles

Analysis and results of early revascularization in non-ST segment elevation acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena Introduction The time to diagnostic coronary angiography in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) is considered one of the main prognostic factors in patients at higher risk. Purpose Our aim is to know whether early coronary angiography modifies the prognosis of high-risk patients with NSTEACS and to compare it with performing this procedure later. Methods We include patients admitted to the coronary unit of a 3rd level hospital from January-2015 to December-2021 due to NSTEACS. We plan to examine whether the clinical characteristics of patients in whom early coronary angiography (ECA) is performed, the one performed in the first 24 hours from the onset of symptoms, differ from those in whom it is performed later. Likewise, we analyze the clinical results obtained according to the strategy. Results 811 patients were included (73.4% men and 26.6% women), with an average age of 65, in which 229 (28.2%) of them underwent early coronary angiography. Initially, we found more smokers (44.5% vs 32.8, p = 0.006), a higher frequency of risk electrocardiographic changes (ST decrease> 2 mm in 2 contiguous leads, transient ST segment elevation, left main stem pattern) (p = 0.000), greater need for inotropic drugs (14.5% vs 9.6%, p = 0.045), worse Killip-Kimball (KK) during hospital stay (p = 0.002), as well as higher frequency of cardiogenic shock (p = 0.005) among the patients in whom ECA was performed. Although in-hospital mortality was higher in patients who underwent ECA, no statistically significant difference was found. No differences were obtained in the other cardiovascular risk factors, previous history of acute myocardial infarction, heart failure, stroke, coronary revascularization, initial KK presentation, or post-catheterization LVEF. Conclusions In our study, we observed that in patients admitted for NSTEACS, we performed ECA more frequently in patients with a worse prognosis (pathological alterations in the initial ECG, greater frequency of support with inotropics and worse KK during hospital admission), without observing significant differences in in-hospital mortality or in post-catheterization LVEF. The results suggest that ECA improves the prognosis in the group with the worst clinical profile.

Methicillin‐resistant Staphylococcus aureus among elderly patients with community-acquired pneumonia

IntroductionThe 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend methicillin‐resistant Staphylococcus aureus (MRSA) coverage for patients with prior sputum isolation of MRSA. This study aimed to determine the impact of MRSA coverage on in-hospital mortality in elderly patients with CAP among whom MRSA was isolated. MethodsConsecutive elderly patients who were admitted for CAP and had positive sputum culture for MRSA were retrospectively included, and the association between MRSA coverage and in-hospital mortality was analyzed. ResultsTwenty (18%) of 111 patients received MRSA coverage. Although patients who received MRSA coverage tended to have more frequent prior isolation of MRSA compared to those who did not, no significant difference in in-hospital mortality was observed between both groups (2/20, 10% vs. 8/91, 9%). MRSA coverage was not associated with in-hospital mortality (odds ratio: 1.15; 95% CI: 0.23–5.89, p = 0.864); however, advanced age, hemoglobin level, a high A-DROP score, and C-reactive protein levels were associated with in-hospital mortality. MRSA coverage may not improve the prognosis of elderly patients with CAP who had positive sputum culture for MRSA. ConclusionsA randomized control study is required to determine the efficacy of MRSA coverage on the management of CAP in elderly patients.

Midterm Outcomes of One-Stage Hybrid Aortic Arch Repair for Stanford Type A Aortic Dissection: A Single Center's Experience

This study sought to identify the midterm outcomes of one-stage hybrid aortic arch repair (HAAR) in patients with Stanford type A aortic dissection (TAAD). Between January 2010 and December 2015, 75 consecutive patients with TAAD involving the aortic arch who underwent one-stage type Ⅱ HAAR at our institution were identified. During this period, 496 consecutive patients with TAAD underwent traditional total aortic arch replacement (TAR) with frozen elephant trunk. The preoperative, perioperative, and postoperative data of all patients were compared. A propensity score-matching analysis was applied to adjust for baseline risk factors. Five hundred and seventy-one patients were included for analysis (428 men; mean age, 48.9 ± 11.1 years). For all patients, the mean follow-up time was 41.1 ± 22.1 months, in-hospital mortality was 4.7%, and the 5-year survival rate was 89.5%. Midterm outcomes between the propensity-matched groups were compared (59 HAAR vs TAR pairs). HAAR group showed shorter cardiopulmonary bypass time (105-159 minutes vs 158-230 minutes, P < 0.001), aortic cross-clamping time, postoperative ventilation time, and intensive care unit stays (33-108 hours vs 45-131 hours, P = 0.010) than the TAR group. There were no significant differences in in-hospital mortality, rate of stroke and rate of paraplegia between the 2 groups, however, better 5-year survival rate was found in HAAR group (94.9% vs 75.8%, Log-rank P = 0.005). As compared to propensity matched cohort of TAR patients, HAAR shows good midterm outcomes for patients with TAAD. Further randomized study was needed to clarify the optimal management strategy of TAAD.

Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians.

We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians. From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians. The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23). The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.

Clinical outcomes of patients with hepatic insufficiency undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

BackgroundTranscatheter aortic valve implantation (TAVI) is currently a common treatment in high-risk aortic stenosis patients, but the impact of hepatic insufficiency on prognosis after TAVI is debatable and whether TAVI is superior to surgical aortic valve replacement (SAVR) in patients with hepatic insufficiency is uncertain.ObjectiveTo investigate the effect of abnormal liver function on the outcome and safety after TAVI and whether TAVI is superior to SAVR in patients with hepatic insufficiency.MethodsPubMed, Embase, the Cochrane Library and Web of Science were systematically searched from inception up to 26 November 2021. Studies were eligible if mortality and complications after TAVI in patients with and without hepatic insufficiency, or mortality and complications for TAVI versus SAVR in patients with hepatic insufficiency were reported. The Newcastle–Ottawa scale (NOS) was used to evaluate the quality of each study. This meta-analysis was registered with PROSPERO (CRD42021253423) and was carried out by using RevMan 5.3 and Stata 14.0.ResultsThis meta-analysis of 21 studies assessed a total of 222,694 patients. Hepatic insufficiency was associated with higher short-term (in-hospital or 30-day) mortality [OR = 1.62, 95% CI (1.18 to 2.21), P = 0.003] and 1–2 years mortality [HR = 1.64, 95% CI (1.42 to 1.89), P < 0.00001] after TAVI. Between TAVI and SAVR in patients with hepatic insufficiency, there was a statistically significant difference in in-hospital mortality [OR = 0.46, 95% CI (0.27 to 0.81), P = 0.007], the occurrence rate of blood transfusions [OR = 0.29, 95% CI (0.22 to 0.38), P < 0.00001] and the occurrence rate of acute kidney injury [OR = 0.55, 95% CI (0.33 to 0.91), P = 0.02].ConclusionsTAVI patients with hepatic insufficiency may have negative impact both on short-term (in-hospital or 30-day) and 1–2-years mortality. For patients with hepatic insufficiency, TAVI could be a better option than SAVR.

Sex-related differences in the trends and outcomes of trans-septal transcatheter mitral valve replacement: Insights from the National Readmissions Database.

There is a paucity of data regarding the sex-related differences in the trends and outcomes of trans-septal transcatheter mitral valve replacement (TS-TMVR). The Nationwide Readmissions Database (2015-2018) was queried for admissions for TS-TMVR. Propensity matched analysis was conducted to compare outcomes with hospitalizations for TS-TMVR among women versus men. The main study outcome was in-hospital mortality. Our final analysis included 2063 hospitalizations for TS-TMVR; of whom, 58.1% were women. The proportion of women among those undergoing TS-TMVR increased from 50% in 2015 to 60.2% in 2018 (Ptrend = 0.04). Compared with men, women undergoing TS-TMVR were slightly younger, and had a distinct profile of comorbidities. After matching, there was no significant difference in in-hospital mortality among women versus men undergoing TS-TMVR (7.8% vs. 6.1%, OR = 1.30; 95% CI: 0.79-2.13). Subgroup analyzes showed an interaction toward higher mortality with women versus men among patients with CKD (Pinteraction = 0.07). There were no significant differences between women and men in in-hospital complications or length of stay after TS-TMVR. Compared with men, women undergoing TS-TMVR were more likely to be discharged to a nursing facility (17.7% vs. 11.5%, p = 0.01) and had higher rates of 30-day readmissions (22.4% vs. 13.6%, p = 0.01). This nationwide analysis showed an increase in the proportion of women among patients undergoing TS-TMVR during the study years. There were no differences in in-hospital mortality, in-hospital complications, or length of stay between both sexes following TS-TMVR. Women were more likely to be discharged to nursing facilities and had higher rates of readmission at 30 days even after propensity matching.

Abstract TMP64: Outcomes After Mechanical Thrombectomy In Patients With Left Ventricular Assist Devices

Background: Left ventricular assist devices (LVADs) are an established durable and lifesaving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population but LVO trials largely excluded patients on mechanical circulatory support and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all adult patients hospitalized with acute ischemic stroke (AIS). The presence of LVAD, the use of MT, and additional covariates were extracted. Descriptive statistics and multivariable regression models were used to compare outcomes following MT in patients with and without LVADs. Results: Of the 798,059 AIS hospitalizations identified, 366 occurred in patients with LVADs. LVAD patients were younger (mean age 59.6 [13.2] vs 70.1 [14.3], p &lt;0.001), and were less often female (23.0% vs 50.9%, p &lt;0.001). In the general stroke population 2% were treated with MT vs 6% in LVAD-associated AIS. Post-stroke mortality was higher among LVAD patients (18.4% vs 6.22, p=0.000). However, among patients receiving MT, there was no significant difference in in-hospital mortality between LVAD and non-LVAD patients (23.1% vs 12.5%, p=0.104). In crude analysis and after adjusting for potential confounders there was no difference in odds of discharge to home after treatment with MT (Figure). Conclusion: Our data suggests MT is not a futile treatment approach in patients with LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Assessing the impact of the national traffic safety campaign: a nationwide cohort study in Japan

ObjectivesThis study aimed to examine the difference in mortality from serious road traffic injuries during the National Traffic Safety Campaign compared with other periods and identify the common mechanisms of...

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study.

Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. Therapeutic/Care Management, Level III.

Impact of COVID-19 on Acute MI and Percutaneous Coronary Intervention Rates and Outcomes in South East Asia and the Middle East

Background: Previous studies have reported mixed findings regarding the effects of COVID-19 on percutaneous coronary intervention (PCI) and acute MI (AMI) procedural volumes and case fatalities, as well as on ST-elevation MI (STEMI) door-to-balloon time (DTB). This study characterised the effects of COVID-19 on AMI and PCI volumes and mortality outcomes in countries from Asia and the Middle East, which faced repeated waves of COVID-19. Methods: Pooled data on AMI and PCI case volumes were collected in 4-weekly blocks from Malaysia, Singapore and Abu Dhabi from 2019 (pre-COVID-19) and 2020 (during COVID-19). These were compared against reported COVID-19 case numbers. Case fatality rates, STEMI patient demographics and STEMI DTB times were compared between the pre- and during COVID-19 periods. Results: During the COVID-19 pandemic, there was a comparative reduction in non-STEMI (NSTEMI) cases in Singapore (from 814 to 722; p=0.025) and Malaysia (from 925 to 604; p&lt;0.001), but not in Abu Dhabi (from 144 to 188; p=0.010). PCI volumes fell significantly in Singapore (from 13,089 to 11,449; p=0.020), but not in Malaysia or Abu Dhabi. STEMI volume remained similar before and during COVID-19. There were no significant differences in in-hospital mortality for NSTEMI, STEMI or PCI between the two periods. Conclusion: COVID-19 resulted in a fall in NSTEMI and PCI cases, potentially as a result of patients deferring contact with healthcare institutions. With appropriate protocols and systems, it is possible to provide coronary intervention services in the middle of a pandemic without compromising on mortality or DTB outcomes.

Effects of race on the outcome of COVID-19 in hospitalized patients

Background and aimsRecent reports indicate that African Americans have higher mortality rates from SARS-CoV-2 coronavirus disease 19 (COVID-19) compared to Caucasians, with more marked differences in the Midwest region of the US. This study was performed to study differences in COVID-19 related mortality and hospital length of stay (LOS) between African Americans and Caucasians in Midwest setting, and identify factors associated with mortality and LOS. MethodsData were collected from the electronic health records (EHR) of patients admitted to hospitals in Midwest region of the US. EHR of 471 COVID-19 patients were reviewed. ResultsApproximately 63% were African Americans and 34% Caucasians. One hundred sixteen variables were tested. There was no significant difference in hospital mortality between African Americans and Caucasians (OR 1, 95% CI 0.48–1.94). Older age, Chronic kidney disease, mental status change, mechanical ventilation, vasopressor support, high neutrophil count, elevated AST and ALT, high lung involvement severity score and elevated CRP were associated with mortality in a univariate analysis (P < 0.05). Multivariable modeling indicated that mechanical ventilation was the only factor that predicted mortality (OR 6, 95% CI: 2.94–12.48). The LOS did not differ in African Americans and Caucasians. The use of oxygen via high flow nasal cannula (Survival Estimate 1.6, 95% CI: 1.20–2.26), low estimated glomerular filtration rate (Survival Estimate 1.4, 95% CI: 1.05–1.82) and mechanical ventilation (Survival Estimate 3.5, 95% CI: 2.72–4.37) were predictors of LOS. ConclusionThis study performed in Midwest setting in the US showed that race did not affect in-hospital mortality and LOS. Our analysis demonstrated new predictors of LOS.

Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases

BackgroundThe advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial. MethodsWe searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment. ResultsFive randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32–2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31–11.15), persistent SIRS (OR 2.83; 95% CI 1.58–5.04), renal failure (OR 2.58; 95% CI 1.90–3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51–9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60–3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis. ConclusionsCompared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.

Characteristics of abdominal hemorrhage in patients with severe acute pancreatitis and its influence on outcomes

To explore the risk factors of abdominal hemorrhage (AH) in patients with severe acute pancreatitis (SAP) and its impact on outcome. The clinical data of 231 SAP patients admitted to Diagnosis and Treatment Center for SAP of Guizhou Province from January 1, 2015 to December 31, 2019 were retrospectively analyzed. These patients were divided into AH group and non-AH group. The general information, etiology, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, organ failure, complications, interventions, bleeding time, bleeding site and outcome were compared between the two groups. Binary multivariate Logistic regression analysis was used to explore the risk factors of AH in SAP patients and whether the time and location of AH were risk factors affecting the outcome. A total of 231 patients were enrolled in the analysis, including 198 patients without AH and 33 with AH (14.3%). There was no significant difference in gender, age or etiology between the two groups. The scores of APACHE II and SOFA in AH group were significantly higher than those in non-AH group [APACHE II score: 18 (12, 24) vs. 13 (9, 19), SOFA score: 9 (5, 15) vs. 5 (4, 11), both P < 0.01]. The incidences of acute kidney injury (AKI), gastrointestinal dysfunction, coagulation disorders, necrotic infection, pseudocyst and gastrointestinal fistula in AH group were significantly higher than those in non-AH group (66.7% vs. 47.0%, 36.4% vs. 7.1%, 18.2% vs. 6.6%, 66.7% vs. 9.1%, 66.7% vs. 34.3%, 9.1% vs. 1.5%, all P < 0.05). The proportions of requiring mechanical ventilation (MV) and surgical intervention in AH group were significantly higher than those in non-AH group (69.7% vs. 43.4, 48.5% vs. 14.6%, both P < 0.01). The length of intensive care unit (ICU) stay and hospital stay in AH group were significantly longer than those in non-AH group [length of ICU stay (days): 13 (8, 19) vs. 7 (3, 16), length of hospital stay: 24 (13, 40) vs. 17 (12, 24), both P < 0.01], and the hospital mortality was significantly higher (60.6% vs. 9.6%, P < 0.01). Multivariate Logistic regression analysis showed that APACHE II score [odds ratio (OR) = 1.157, 95% confidence interval (95%CI) was 1.030-1.299, P = 0.014], infectious necrosis (OR = 12.211, 95%CI was 4.063-36.697, P < 0.01), pseudocyst (OR = 3.568, 95%CI was 1.238-10.283, P = 0.019) and requiring MV (OR = 0.089, 95%CI was 1.354-6.625, P = 0.007) were the risk factors of AH in SAP patients. In 33 AH patients, there was no significant difference in hospital mortality between early hemorrhage (occurred within 2 weeks of onset) and late hemorrhage (occurred 2 weeks after onset) groups [66.7% (8/12) vs. 57.1% (12/21), P > 0.05]. All 4 patients in the unspecified bleeding site group died during hospitalization; half or more patients died in the pseudocyst/abscess bleeding (14 cases), mesenteric/intestinal bleeding (13 cases) and gastric variceal bleeding (2 cases) groups (7 cases, 8 cases and 1 case respectively), and there were significant differences among the groups (P < 0.05). Multivariate Logistic regression analysis showed that neither bleeding time (OR = 0.989, 95%CI was 0.951-1.028, P = 0.574) nor bleeding site (OR = 2.009, 95%CI was 0.822-4.907, P = 0.126) was the risk factor of death in patients with SAP combined with AH. Both early and late bleeding significantly increased the length of hospital stay and mortality of SAP patients. APACHE II score, infectious necrosis and pseudocyst were the risk factors of AH in SAP patients. Neither bleeding time nor bleeding site was the risk factors of death in patients with SAP combined with AH. However, it still needed to be confirmed by a large sample clinical study.

Trends in Body Mass Index and Association With Outcomes in Pediatric Patients on Continuous Flow Ventricular Assist Device Support.

Data are limited regarding body mass index (BMI) in pediatric patients supported by ventricular assist devices (VAD) and associated clinical outcomes and complications. We performed a retrospective single-center cohort study including patients aged ≤21 years on durable continuous-flow VAD support for ≥30 days from 2009 to 2020. Patients were classified based on BMI percentile at implant using the US Centers for Disease Control and Prevention criteria: underweight (<5th percentile), healthy weight (5th-<85th percentile, reference group), overweight (85th-<95th percentile), and obese (≥95th percentile). Primary outcomes were hospital mortality and length of stay (LOS) after implant. Secondary outcomes included infectious complications and pump thrombosis. Seventy-two patients (58 HeartWare, 13 HeartMateII, 1 HeartMate3) were included. At implant, the study cohort comprised 13% underweight, 53% healthy weight, 18% overweight, and 17% obese. BMI increased across all categories during support, with 29% gaining BMI categories. No patients with obesity reduced their BMI category. At explant, the study cohort comprised 1% underweight, 54% healthy weight, 22% overweight, and 22% obese. There was no significant difference in hospital mortality, postoperative LOS, or pump thrombosis. Patients who were overweight had more frequent non-VAD infections. Patients with obesity required longer duration on VAD support and were less likely to be transplanted. We concluded that pediatric patients on VAD support who are overweight or have obesity do not improve their BMI and instead have significant increase. Larger studies are needed to assess the impact of abnormal BMI on VAD complications in pediatric patients.

The association of statins use with survival of patients with COVID-19

BackgroundStatins are frequently prescribed for patients with dyslipidemia and diabetes mellitus. These comorbidities are highly prevalent in coronavirus disease 2019 (COVID-19) patients. Statin's beneficial effect on mortality in COVID-19 infection has been reported in several studies. However, these findings are still inconclusive. MethodsWe conducted a retrospective observational study among 6,095 patients with laboratory confirmed COVID-19 hospitalized in Mount Sinai Health System between March 1st 2020 and May 7th 2020. Patients were stratified into two groups: statin use prior to or during hospitalization (N = 2,423) versus no statins (N = 3,672). We evaluated in-hospital mortality as a primary outcome using propensity score matching and inverse probability treatment weighted (IPTW) analysis. In additional analysis, we compared continuous use of statins (N = 1,108) with no statins, continuous use of statins with discontinuation of statins (N = 644), and discontinuation of statins with no statins. ResultsAmong 6,095 COVID-19 patients, statin use prior to or during hospitalization group were older (70.8 ± 12.7 years versus 59.2 ± 18.2 years, p<0.001) and had more comorbidities compared to no statins group. After matching by propensity score (1,790 pairs), there were no significant differences in-hospital mortality between patients with statins and those without [28.9% versus 31.0%, p = 0.19, odds ratio (OR) 95% confidence interval (CI): 0.91 (0.79–1.05)]. This result was confirmed by IPTW analysis [OR (95% CI): 0.96 (0.81–1.12), p = 0.53]. In the additional analysis comparing continuous use of statins with no statins group, in-hospital mortality was significantly lower in continuous use of statins compared to no statins group [26.3% versus 34.5%, p<0.001, OR (95% CI): 0.68 (0.55–0.82)] after matching by propensity score (944 pairs), as well as IPTW analysis [OR (95% CI): 0.77 (0.64–0.94), p = 0.009]. Finally, comparison of continuous use of statins with discontinuation of statins showed lower in-hospital mortality in continuous use of statins group [27.9% versus 42.1%, p<0.001, OR (95% CI): 0.53 (0.41–0.68)]. ConclusionsUse of statins prior to or during hospitalization was not associated with a decreased risk of in-hospital mortality, however, continuous use of statins was associated with lower in-hospital mortality compared to no statin use and discontinuation of statins.

Comparison of Direct Oral Anticoagulants for Acute Hospital Mortality in Venous Thromboembolism.

The choice of direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) is at the physician's discretion; however, it is useful to know the differences in the clinical data of DOACs to help physicians choose. We aimed to compare the mortality associated with the use of rivaroxaban, edoxaban, and apixaban in clinical practice. We identified 38,245 patients with first hospitalization for VTE from the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). We classified patients into three groups by DOAC (rivaroxaban and edoxaban group, rivaroxaban and apixaban group, and edoxaban and apixaban group) and compared the in-hospital mortality and bleeding risk by propensity score (PS) matching in each group. After PS matching, patients with rivaroxaban use had significantly lower total in-hospital mortality (1.2% vs. 2.1%; odds ratio [OR] 0.55, p=0.012) and in-hospital mortality within 21 days (0.4% vs. 1.0%; OR 0.41, p=0.020) and 28 days (0.7% vs. 1.3%; OR 0.53, p=0.042) than patients with apixaban use. In the subanalysis, significant differences were only observed in patients younger than 80 years of age, patients with pulmonary embolism, and patients without heart failure. There was no significant difference in in-hospital mortality in the other groups and in the rate of bleeding events among the three groups. On PS-matched analysis, there was a difference in in-hospital mortality, especially in the rivaroxaban and apixaban group. Identifying the clinical characteristics of patients associated with each DOAC, as well as prognosis, will be useful in determining treatment strategies for VTE.

Impact of hospital volume of valve operations on the utilization and outcomes of surgery for patients with infective endocarditis

Valve surgery is indicated and can be life-saving in patients with infective endocarditis (IE). We evaluated the impact of hospital valvular surgery volume on utilization and outcomes of surgery for IE. National Inpatient Sample (NIS) database was used for IE hospitalizations from 2008 to 2015. Hospitals were divided into quartiles based on valve surgery volume with quartile 1 (Q1) indicating lowest volume and quartile 4 (Q4) highest volume. Primary outcome was utilization of valve surgery in patients hospitalized with IE and secondary outcomes were in-hospital mortality and length of stay for IE patients undergoing valve surgery. Volume-outcome relationship was analysed both as categorical (quartiles) and continuous variable (restricted cubic splines). A total of 36 471 hospitalizations for IE were identified using the NIS database from 2008 to 2015 of which 17.33% underwent any valve surgery. Utilization rates of valve surgery for IE were significantly higher in Q4 hospitals (Q1: 6.73%; Q2: 10.39%; Q3: 14.91%; Q4: 2321%). Amongst the admissions for IE endocarditis undergoing valve surgery, there was no significant difference in in-hospital mortality when analysed as a categorical variable (as quartiles). However, when analysed as a continuous variable we note significant variation in outcomes across the Q4 hospitals, with highest volume centres having reduced mortality rates and length of stay. Hospital valvular surgery volume has direct impact on utilization and outcomes of surgery for IE. Given rising rates of IE and ongoing intravenous drug pandemic, there is need for regionalization of care for IE patients and development of 'endocarditis centres of excellence' for improved patient outcomes.

Intensive care unit versus high-dependency care unit for patients with acute heart failure: a nationwide propensity score-matched cohort study

BackgroundA structure and staffing model similar to that in general intensive care unit (ICUs) is applied to cardiac intensive care unit (CICUs) for patients with acute heart failure. However, there is limited evidence on the structure and staffing model of CICUs. The present study aimed to assess whether critical care for patients with acute heart failure in the ICUs is associated with improved outcomes than care in the high-dependency care units (HDUs), the hospital units in which patient care levels and costs are between the levels found in the ICU and general ward.MethodsThis nationwide, propensity score-matched, retrospective cohort study was performed using a national administrative inpatient database in Japan. We identified all patients who were hospitalized for acute heart failure and admitted to the ICU or HDU on the day of hospital admission from April 2014 to March 2019. Propensity score-matching analysis was performed to compare the in-hospital mortality between acute heart failure patients treated in the ICU and HDU on the day of hospital admission.ResultsOf 202,866 eligible patients, 78,646 (39%) and 124,220 (61%) were admitted to the ICU and HDU, respectively, on the day of admission. After propensity score matching, there was no statistically significant difference in in-hospital mortality between patients who were admitted to the ICU and HDU on the day of admission (10.7% vs. 11.4%; difference, − 0.6%; 95% confidence interval, − 1.5% to 0.2%). In the subgroup analyses, there was a statistically significant difference in in-hospital mortality between the ICU and HDU groups among patients receiving noninvasive ventilation (9.4% vs. 10.5%; difference, − 1.0%; 95% confidence interval, − 1.9% to − 0.1%) and patients receiving intubation (32.5% vs. 40.6%; difference, − 8.0%; 95% confidence interval, − 14.5% to − 1.5%). There were no statistically significant differences in other subgroup analyses.ConclusionsCritical care in ICUs was not associated with lower in-hospital mortality than critical care in HDUs among patients with acute heart failure. However, critical care in ICUs was associated with lower in-hospital mortality than critical care in HDUs among patients receiving noninvasive ventilation and intubation.

Abstract 14339: Disparities in Transcatheter Mitral Valve Repair in Racial Minorities - From the National Inpatient Sample

Introduction: Racial disparities in cardiovascular diseases and interventions have been widely reported in previous studies, Whether the racial disparities exist with transcatheter mitral valve repair (TMVr) is largely unknown. Hypothesis: The purpose of this study is to assess racial disparities in the utilization and outcome of TMVr procedure in the United States using the National Inpatient Sample (NIS) database. Methods: We analyzed NIS data from January 2013 to December 2017 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes and International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-CM codes. Multivariable analysis was done by using logistic regression model to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) to determine variability in mortality, home discharges, vascular complications, cardiac complications, pulmonary complications, post op stroke and acute kidney injury by race. Results: A total of 13,410 weighted hospitalizations for TMVr procedure were included in our analysis. Multiple logistic regression analysis showed no significant difference in hospital mortality among the three racial groups. Pulmonary complications were more likely in the African American (adjusted Odds Ratio [aOR], 1.326[95% CI, 1.03-1.706], p-value= 0.03) and Hispanic population (aOR, 1.362[95% CI, 1.034-1.794], p-value= 0.03) (Figure). Conclusions: No significant difference in hospital mortality was noted among Caucasian, African American and Hispanic patients undergoing TMVr, however, we report a higher rate of post procedure respiratory complications in the minority races compared to Caucasian race.

Abstract 14143: In-Hospital Outcomes of Left Ventricular Assist Device Implantation in Patients With Heart Failure and Connective Tissue Disease

Introduction: The use of left ventricular assist devices (LVAD) for patients with end-stage heart failure (HF), either as a bridge to transplant or destination therapy, continues to grow. Optimal patient selection is essential to decrease the risk of adverse events. The aim of our study was to evaluate outcomes of LVAD in patients with HF and connective tissue disease (HF-CT). Methods: Using the National Inpatient Database (NIS) we identified patients 18 years and older hospitalized for index LVAD procedure from 2016 to 2018. Patients were stratified according to CT disorder status. The primary outcome of interest was in-hospital mortality. Secondary outcomes included the need for renal replacement therapy (RRT), post-operative infection, stroke, and transfusion requirements. A multivariate regression analysis model was used to adjust for statistically significant differences in baseline characteristics between the groups. Results: A total of 30,206 patients underwent LVAD implant, of these 240 (0.8%) had CT disease. HF-CT patients were more likely to be female (47.5% vs 23.2%, p &lt; 0.001), less likely to have pulmonary hypertension (12.5% vs 21.1%, p = 0.001) and liver disease (2.2% vs 9.5%, p &lt; 0.001); and more likely to have anemia (18.4% vs 12.2%, p = 0.009). There was no significant difference in in-hospital mortality (8.3% vs 11.9%, p = 0.090). Unadjusted incidence of stroke (21.1% vs 7.4%, p = 0.002) and renal replacement therapy (2.1% vs 6.7%, p =0.090) was lower for HF-CT patients. However, this difference was not related to the presence of CT disease on multivariate analysis. Conclusions: While some studies have raised concerns of increased adverse events among patients with HF-CT undergoing LVAD implant, our analysis showed that in-hospital survival and short-term post-operative outcomes of HF-CT patients appear to be comparable to patients without CT disease. A clinical history of CT disease by itself should not preclude patients from undergoing LVAD implant.