Similar In-hospital Mortality Research Articles

Abstract 133: Impact of COPD on Patients With Cardiovascular Disease

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and the third leading cause of death in the US. Little is known about the impact of COPD on pts with cardiovascular disease, although it is a common coexisting condition. Methods: We used a statewide, all-payer hospital discharge database in Hawaii to identify pts discharged from 2011-13 with a primary diagnosis of acute myocardial infarction (AMI) or heart failure (HF). We compared characteristics and outcomes of pts with and without a secondary diagnosis of COPD. Multivariable logistic regression was used to assess associations between COPD and 30d readmission and inhospital mortality. Results: Overall, 6,581 pts accounted for 10,080 HF admissions and 6,520 pts accounted for 7,556 AMI admissions. COPD was noted in 11.5% of HF, 6.2% of AMI and 8.8% of pts with HF or AMI. After controlling for potential confounders, COPD was independently associated with 30d readmission for HF (OR=1.16, 95% CI: 1.00-1.33) and HF or AMI (OR=1.26, 95% CI: 1.11-1.42), with a trend for AMI alone (OR=1.19, 95% CI: 0.93-1.53). There was a trend for higher mortality with COPD for HF (OR-1.09, 95% CI: 0.80-1.50), AMI (OR=1.26, 95% CI: 0.91-1.75), and HF or AMI (OR=1.10, 95% CI: 0.87-1.37). Conclusion: Among pts hospitalized for HF or AMI, having COPD was associated with higher 30d readmission but similar inhospital mortality. As <10% were diagnosed with COPD, further work is needed to determine if it is under-reported in this population.

Abstract W MP105: Regionalization of Care and Increased Burden on Specialized Stroke Centers

Introduction: Many patients are transferred to specialized stroke centers for advanced ischemic stroke (AIS) care, especially after tPA. We sought to determine differences in the baseline characteristics and outcomes between AIS cases presenting directly to our academic stroke center as compared to those transferred from outside facilities (OSH). Methods: Using our institutional GWTG stroke registry, we analyzed 1,726 AIS cases (01/09 - 02/14). Univariate and multivariable models explored differences in patients presenting directly at our center as compared to transferred from OSH. Results: 46% percent of all AIS were transferred patients. Compared to those presenting directly at our center, transferred patients were older, more often Caucasian, with more vascular risk factors. They had worse median NIHSS, more often had limb weakness or aphasia and received IV tPA. In-hospital mortality was nearly double in transferred patients. Transfer-in patients had a longer hospital length of stay and were more often discharged to inpatient rehab. Independent predictors of in-hospital mortality were increasing age, A. fib, coronary artery disease and initial NIHSS. Transfer status was not independently associated with in-hospital mortality. Conclusions: Transferred patients differed significantly from those presenting directly, they have more stroke risk factors and present with severe strokes. Accepting such patients increase the burden at specialized stroke centers. Despite having more severe strokes on arrival, transfer patients had similar in-hospital mortality after adjusting for stroke severity (NIHSS) lending support to the concept of regionalized stroke care.

Incidental Dural Tear in Cervical Spine Surgery

This was a retrospective study. To report the incidence of incidental dural tear (DT) in cervical spine surgery, risk factors, and in-hospital patient outcomes on a national level. DT during cervical spine surgery is not as common as that during lumbar spine surgery; however, DT is still a difficult complication. Clinical data were obtained from the US Nationwide Inpatient Sample for 2009. Patients who underwent cervical spine surgery were identified and divided into those with and without DT according to the International Classification of Diseases, 9th revision, Clinical Modification codes. The patient and health care system-related demographic data were retrieved. The incidence of DT and patient outcomes were analyzed. A multivariate logistic regression analysis was performed to identify the risk factors for DT. The incidence of DT was 0.45% (855/190,021). The multivariate analysis revealed that a diagnosis of myelopathy and ossification of the posterior longitudinal ligament; posterior approach, anterior and posterior approach; and insurance status were the significant risk factors for DT. Comparison between patients with and without DT showed that those with DT had significantly higher overall in-hospital complications (21.6% vs. 7.3%), longer hospital stays (6.0 vs. 3.2 d), a lower proportion who were discharged home routinely (66.3% vs. 83.9%), increased total hospital costs ($96,424 vs. $62,416), and similar in-hospital mortality (0.6% vs. 0.4%). The incidence of DT in cervical spine surgery was 0.45% in the United States. The risk of DT was highest with a primary diagnosis of the ossification of the posterior longitudinal ligament (58.4 times). DT significantly increased the rate of in-hospital complications and health care burden.

Abstract W MP3: Endovascular Therapy in Large Vessel Occlusion Strokes with ASPECTS of 5-7 May Result in Reduced Infarct Volumes and Better Functional Outcomes

Introduction: Intra-arterial therapy (IAT) for large vessel occlusions strokes (LVOS) has been increasingly utilized. The benefit of endovascular reperfusion in patients with mid-range ASPECTS remains to be established. Materials and methods: Retrospective analysis of LVOS patients with ASPECTS 5-7 treated with IAT (n=86) or medical therapy alone (±IV t-PA; n=15) at two academic centers from 2009-2012. Definitions employed: Symptomatic ICH: any parenchymal hematoma; Successful reperfusion: modified TICI≥2B; Good and acceptable clinical outcomes: 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes were calculated based on 24-hour post-procedure CT or MRI scans. Results: Mean age (67±14 vs. 67±19 years) and baseline NIHSS (20±5 vs. 20±6) were similar in the IAT and medical treatment groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic ICH occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The IAT rates of 90-day good and acceptable outcomes were 20% (17/86) and 33% (28/86), respectively. Successful reperfusion in IAT patients was associated with smaller FIV (p=0.015) and higher rates of good (p=0.02) and acceptable (p=0.03) outcomes. The median final infarct volume was significant lower with IAT vs. medical therapy (80ml [IQR, 38-122] vs. 190ml [121-267], p=0.015). There was a strong trend towards a higher hemicraniectomy requirement in medically vs. endovascularly treated patients (20% versus 6%, p=0.06) despite similar in-hospital mortality (20% versus 26.7 %, p=0.75). Conclusions: Despite a low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in smaller final infarct volumes leading to a reduction in the need for hemicraniectomy and decreasing the degree of overall disability. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability. Prospective studies utilizing shift in outcome measures are warranted to confirm these results.

Juxtarenal Aortic Aneurysm Treated with Chimney Technique

Endovascular aneurysm repair (EVAR) compares favorably to open surgical repair of abdominal aortic aneurysm (AAA). For anatomically challenging aortic aneurysms such as inadequate sealing zone, chimney graft stent has been developed involving renal, visceral or internal iliac branches by placing parallel stents to the main stent graft to preserve blood flow to aortic branches [1,2]. Early and mid-term results of chimney technique have reported similar-in hospital mortality and less morbidity than surgical treatment but long term data also needs to be determined for concerns about patency and endoleak [3,4].

Impact Of Sex On Clinical Characteristics And In-Hospital Outcomes In A Multi-Ethnic Southeast Asian Population Of Patients Hospitalized For Acute Heart Failure.

Objectives:To study sex differences in clinical characteristics and outcomes among multi-ethnic Southeast Asian patients with hospitalized heart failure (HHF).Background:HHF is an important public health problem affecting man and women globally. Reports from Western populations suggest striking sex differences in risk factors and outcomes in HHF. However, this has not been studied in a multi-ethnic Asian population.Methods:Using the population-based resources of the Singapore Cardiac Data Bank, we studied 5,703 consecutive cases of HHF admitted across hospitals in the Southeast Asian nation of Singapore from 1st January, 2008 through 31st December, 2009.Results:Women accounted for 46% of total admissions and were characterized by older age (73 vs. 67 years; p<0.001), higher prevalence of hypertension (78.6 vs. 72.1%; p<0.001) or atrial fibrillation (22.2 vs. 18.1%; p<0.001), and lower prevalence of coronary artery disease (33.8 vs. 41.0%; p<0.001) or prior myocardial infarction (14.9 vs. 19.8%; p<0.001). Women were more likely than men to have HHF with preserved ejection fraction (42.5% versus 20.8%, p < 0.001). Women were less likely than men to receive evidencebased therapies at discharge, both in the overall group and in the sub-group with reduced ejection fraction. Women had longer lengths of stay (5.6 vs. 5.1 days; p<0.001) but similar in-hospital mortality and one-year rehospitalization rates compared to men. Independent predictors of mortality or rehospitalization in both men and women included prior myocardial infarction and reduced ejection fraction. Among women alone, additional independent predictors were renal impairment, atrial fibrillation, and diabetes. Prescription of beta-blockers and ACE-inhibitors at discharge was associated with better outcomes.Conclusion:Among multi-ethnic Asian patients with HHF, there are important sex differences in clinical characteristics and prognostic factors. These data may inform sex-specific strategies to improve outcomes of HHF in Southeast Asians.

Outcomes of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with previous coronary bypass surgery.

This study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion. The outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era. Data was extracted from a large, regional STEMI system's prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012. Previous CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; p= 0.82) and 1-year (10.8% vs. 9.1%; p= 0.36) mortality, but 5-year (24.9% vs. 14.2%; p< 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, p= 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; p= 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; p= 0.71). Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

Race-based differences in length of stay among patients undergoing pancreatoduodenectomy

Race-based disparities in operative morbidity and mortality have been demonstrated for various procedures, including pancreatoduodenectomy (PD). Race-based differences in hospital length-of-stay (LOS), especially related to provider volume at the surgeon and hospital level, remain poorly defined. Using the 2003-2009 Nationwide Inpatient Sample, we determined year-specific PD volumes for surgeons and hospitals and grouped them into terciles. Patient race (white, black, or Hispanic), age, sex, and comorbidities were examined. Median length of stay was calculated, and multivariable logistic regression was used to examine factors associated with increased LOS. Among 4,319 eligible individuals, 3,502 (81.1%) were white, 423 (9.8%) were black, and 394 (9.1%) were Hispanic. Overall median LOS was 12 days (range, 0-234). Median annual surgeon volume was 8 (interquartile range [IQR], 2-19; range, 1-54). Annual hospital volume ranged from 1 to 129 (median, 19; IQR, 7-55). White patients were more likely to have been treated at medium- to high-volume hospitals (odds ratio [OR] 1.53, P < .001) and by medium- to high-volume surgeons (OR 1.62, P < .001) than black or Hispanic patients. After PD, white, black, and Hispanic patients demonstrated similar in-hospital mortality (5.1%, 5.7% and 7.2% respectively P = .250). After adjustment, black (OR 1.36, P = .010) and Hispanic (OR 1.68, P < .001) patients were more likely to have a greater LOS after PD. Black and Hispanic PD patients were less likely than white patients to be treated at higher-volume hospitals and by higher-volume surgeons. Proportional mortality and LOS after PD were greater among black and Hispanic patients.

Nationwide Comparative Impact of Thoracic Endovascular Aortic Repair of Acute Uncomplicated Type B Aortic Dissections

Thoracic endovascular aortic repair (TEVAR) for acute uncomplicated type B aortic dissection (TBAD) remains controversial. This study aims to evaluate the impact of TEVAR on mortality, morbidity, length of stay (LOS), and discharge status in patients with acute uncomplicated TBAD. We analyzed the National Inpatient Sample from 2009 and 2010. Patients were categorized according to the type of treatment: TEVAR or medical management. Outcomes, including mortality, stroke, myocardial infarction (MI), acute renal failure, discharge disposition, and LOS, were compared between the treatment groups. We identified 4706 patients with TBAD. Mean age was 67 years and 55% were male. Treatment options included TEVAR in 504 and medical management in 4202. The overall adjusted in-hospital mortality was similar for both the groups (8.5% for TEVAR vs 10.3% for medical management, P = .224). The TEVAR carried higher risk of stroke (odds ratio [OR] = 1.61, 95% confidence interval [CI] = [1.14-2.27]; P = .0073). The TEVAR was associated with prolonged LOS (12 vs 5.6 days, P < .0001) and patients were less likely to be discharged home (OR 0.73, 95% CI 0.54-0.99; P = .013). When stratified by age, all outcomes were similar between the 2 groups, with the exception of longer LOS with TEVAR. Thoracic endovascular aortic repair for acute uncomplicated TBAD was associated with similar in-hospital mortality, MI, and renal failure as compared to medical management. The TEVAR had higher rate of stroke up to the age 70 years and longer LOS. Because extending TEVAR to less complicated patients could only decrease TEVAR mortality rates, these findings support the more widespread use of TEVAR to treat patients with uncomplicated TBAD.

Commercial Versus PARTNER Study Experience With the Transfemoral Edwards SAPIEN Valve for Inoperable Patients With Severe Aortic Stenosis

In patients with aortic stenosis who cannot have surgery, transcatheter aortic valve replacement using the Edwards SAPIEN valve has been shown to improve survival rate and is approved for commercial use in the United States. This study aims to assess the clinical profile, procedural characteristics, and in-hospital complications in patients treated with a commercial SAPIEN valve outside the clinical trial context. We retrospectively analyzed 69 consecutive patients who underwent transcatheter aortic valve replacement with a commercial SAPIEN valve compared with 55 Placement of AoRTic traNscathetER valves (PARTNER) trial patients from cohort B enrolled in the same institution by the same Heart Team. Compared with the commercial group, patients in the PARTNER cohort B had higher mean Society of Thoracic Surgeons score (10 ± 5 vs 9 ± 4, p= 0.04) and a lower rate of peripheral arterial disease (19% vs 44%, p= 0.004). Most patients in the commercial group had the procedure under conscious sedation (83% vs 66%, p= 0.03). Planned surgical cut down for vascular access was rare in the commercial group (1.4% vs 46%, p <0.001). The overall rates of major vascular complications, life-threatening or major bleeding, and blood transfusions were lower in commercial group (7.2% vs 27%, p= 0.003; 2.9% vs 16%, p= 0.01; and 28% vs 60%, p <0.001, respectively). In-hospital all-cause mortality (5.8% vs 9.1%, p= 0.51) and stroke rates (7.2% vs 14.5%, p= 0.19) were not statistically different between groups. The median length of hospitalization (p <0.001) and postprocedural length of stay (p= 0.01) was shorter in the commercial group. In conclusion, transfemoral commercial use of the Edwards SAPIEN valve for inoperable patients shows similar in-hospital mortality and stroke rates compared with PARTNER cohort B. The refinements in the procedure such as more conscious sedation, experience of the operators, and careful vascular planning in the commercial group led to lesser vascular and bleeding complications and shorter length of stay.

Obstructive sleep apnea as a risk factor after shoulder arthroplasty

Obstructive sleep apnea (OSA) has been identified as an important risk factor in perioperative orthopaedic surgery outcomes despite limited evidence. Screening systems are being instituted in increasing frequency to prevent morbidity and mortality. Our objective was to determine if patients with OSA have a higher likelihood of postoperative in-hospital complications, length of stay, or increased costs after shoulder arthroplasty. We utilized the Nationwide Inpatient Sample (NIS) to analyze 22988 patients undergoing TSA or hemiarthroplasty. Of these patients, 1983 (5.9%) were diagnosed with OSA. Multivariate analysis with logistic regression modeling was used to compare patients with and without OSA for various outcomes. Patients with obstructive sleep apnea had overall similar in-hospital mortality and complications including PE compared with those without OSA. OSA was not associated with increased postoperative charges ($39,741 in patients with OSA vs. $39,334 in those without OSA) and resulted in a shorter length of stay (mean, 2.61 vs. 2.91 days; P < .0001). This study does not support OSA as a significant risk factor for in-hospital morbidity and mortality following shoulder arthroplasty. Our results suggest that a diagnosis of OSA does not increase perioperative morbidity and mortality including perioperative complications. Given the results of this study, further research is warranted to attempt to keep patient screening costs down while optimizing outcomes.

Characteristics and Outcomes Among Patients Transferred to a Regional Comprehensive Stroke Center for Tertiary Care

Many patients are transferred to comprehensive stroke centers for advanced acute ischemic stroke care, especially after intravenous tissue plasminogen activator. We sought to determine differences in the baseline characteristics and outcomes between patients with acute ischemic stroke presenting directly to our academic stroke center's front door versus transfers-in from another acute care hospital. Using our institutional Get With The Guidelines (GWTG)-Stroke registry, we analyzed all 3660 consecutively admitted patients with acute ischemic stroke (January 2005-June 2012). Univariate and multivariable models explored differences in front door versus transfer-in patients. Fifty percent of all patients with acute ischemic stroke were transfer-in. Compared with front door patients, transfer-in were younger (67±16 versus 71±15 years; P<0.001), had worse median initial National Institutes of Health Stroke Scale score (7.0 versus 4.0; P<0.001), more often had limb weakness (35% versus 27%; P<0.001) or aphasia (16% versus 11%; P<0.001), and received intravenous tissue plasminogen activator (29% versus 13%; P<0.001). Despite a trend toward higher in-hospital mortality in transfer-in patients, the difference was not statistically significant (13% versus 11%; P=0.08) between the 2 groups. Transfer-in patients had a longer hospital length of stay (5 versus 4 days; P<0.001) and were more often discharged to inpatient rehabilitation (48% versus 34%; P<0.001). Independent predictors of in-hospital mortality were increasing age (odds ratio [OR], 1.38 per decade [1.23-1.55]; P<0.001), atrial fibrillation (OR, 1.47 [1.12-1.93]; P=0.006), coronary artery disease (OR, 2.02 [1.53-2.67]; P<0.001), and initial National Institutes of Health Stroke Scale (OR, 1.20 per point [1.18-1.23]; P<0.001). Transfer status was not independently associated with in-hospital mortality (OR, 0.99 [0.76-1.29]; P=0.928). Despite having more severe strokes on arrival at our hospital, transfer-in patients had similar in-hospital mortality versus front door patients and were more likely to be discharged to rehabilitation. These outcomes lend support to the concept of regionalized stroke care and concentrating patients who are more disabled at more advanced stroke care centers.

Pre-hospital diagnosis and transfer of patients with acute myocardial infarction—a decade long experience from one of Europe's largest STEMI networks

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is essential. Although primary percutaneous coronary intervention (pPCI) is the preferred revascularization technique, it often involves longer primary transportation or secondary inter-hospital transfers and thus longer system related delays. The current ESC Guidelines state that PCI should be performed within 120minutes from first medical contact, and door-to-balloon time should be <60minutes in order to reduce long term mortality. STEMI networks should be established with regionalization of pPCI treatment to address the challenges regarding pre-hospital treatment, triage and transport of STEMI patients and collaborations between hospitals and Emergency Medical Services (EMS).We report on a regional decade long experience from one of Europe's largest STEMI networks located in Eastern Denmark, which serves a catchment area of 2.5 million inhabitants by processing ~4000 prehospital ECGs annually transmitted from 4 EMS systems to a single pPCI center treating 1100 patients per year.This organization has led to a significant improvement of the standard of therapy for acute myocardial infarction (MI) patients leading to historically low 30-day mortality for STEMI patients (<6%). About 70–80% of all STEMI patients are being triaged from the field and rerouted to the regional pPCI center. Significant delays are still found among patients who present to local hospitals and for those who are first admitted to a local emergency room and thus subject to inter-hospital transfer. In the directly transferred group, approximately 80% of patients can be treated within the current guideline time window of 120minutes when triaged within a 185km (~115 miles) radius. Since 2010, a Helicopter Emergency Medical Service has been implemented for air rescue. Air transfer was associated with a 20–30minute decrease from first medical contact to pPCI, at distances down to 90km from the pPCI center and with a trend toward better survival among air transported patients. The pPCI center also serves a small island in the Baltic Sea, where STEMI patients are rescued via air force helicopters. Based on data from more than 100 patients transferred over the past decade, we have found a similar in-hospital and long term mortality rate compared to the main island inhabitants.In conclusion, with the optimal collaboration within a STEMI network including local hospitals, university clinics, EMS and military helicopters using the same telemedicine system and field triage of STEMI patients, most patients can be treated within the time limits suggested by the current guidelines. These organizational changes are likely to contribute to the improved mortality rate for STEMI patients.

Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest

BackgroundArterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated. Methods and resultsObservational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score.We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2<35mmHg), 6705 (40.5%) into the normo- (35–45mmHg) and 6827 (41.3%) into the hypercapnia (>45mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p=0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p<0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p<0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p=0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p=0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p=0.52]). Cox-proportional hazards modelling supported these findings. ConclusionsHypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.

P220 Evolving Set-Up Practises at a Respiratory Ward-Based Non-Invasive Ventilation (NIV) Unit

IntroductionNIV for acute hypercapnic respiratory failure (AHRF) in COPD, obesity related morbidity, chest wall and neuromuscular conditions has become widespread in the UK over the past decade. In terms of...

The management of acute myocardial infarction in the cardiological intensive care units in Italy: the ‘BLITZ 4 Qualità’ campaign for performance measurement and quality improvement

To assess and promote compliance of Italian cardiological intensive care units (CCUs) with evidence-based guidelines for the management of acute myocardial infarction (MI). The process of diagnosis and treatment of MI was prospectively evaluated in 163 CCUs by use of 30 indicators during two enrolment phases, each followed by a feedback of both local and general performance. Overall, 5854 patients with ST-segment elevation MI (STEMI) and 5852 with non-ST-segment elevation MI (NSTEMI) were consecutively enrolled. The target for each indicator was defined as compliance with the relevant recommendations in ≥90% of suitable patients and it was met for nine (30%) and 10 (33.3%) indicators in the first and second phases, respectively. Regardless of target, a significant improvement in compliance was observed in the second phase in 10 out of 30 indicators (33.3%). Use of pre-hospital ECG, expedite delivery of reperfusion therapy, dosage of antithrombotic drugs, and non-pharmacological implementation of secondary prevention were often off target. Similar in-hospital mortality was observed in phases I and II, both in patients with STEMI (4.0 vs. 4.2%, p=0.79) and NSTEMI (1.8 vs. 2.4%, p=0.11). Overall, 30-day mortality were 5.7% for patients with STEMI and 3.4% with NSTEMI. Performance indicators can accurately weigh the whole process of diagnosis and treatment of patients with MI and monitor the improvements in the quality of care. In our large population of consecutive patients, satisfactory 30-day outcomes were observed despite suboptimal adherence to guidelines for some indicators of recognised prognostic relevance.

Minimal traumatic aortic injuries: meaning and natural history

OBJECTIVE Minimal aortic injuries (MAIs) are being recognized more frequently due to the increasing use of high-resolution diagnostic techniques. The objective of this case series review was to report the clinical and radiological characteristics and outcomes of a series of patients with MAI. METHODS From January 2000 to December 2011, 54 major blunt trauma patients were admitted to our institution with traumatic aortic injuries. Nine of them presented with MAI, whereas the remaining 45 patients suffered a significant aortic injury (SAI). RESULTS MAIs accounted for 17% of the overall traumatic aortic injuries in our series. Major trauma patients with MAI and SAI were similar regarding the presence of severe associated non-aortic injuries and the expected mortality calculated by injury severity score, revised trauma score and trauma injury severity score. There were no statistically significant differences in in-hospital mortality between MAI (22.2%) and SAI (30.2%). No death in the MAI group was aortic related, whereas five deaths in the SAI group were caused by an aortic complication. The survival of MAI patients was 77.8% at 1 and 5 years. There was no late mortality among MAI patients. The survival of SAI patients was 69.7% at 1 year and 63.6% at 5 and 10 years. None of the seven surviving patients with MAI presented a progression of the aortic injury. In six patients, the intimal tear completely healed in imaging controls, whereas one patient developed a small saccular pseudoaneurysm. CONCLUSIONS Blunt traumas presenting MAI are as severe as traumas that associate SAI and present similar in-hospital mortality. In contrast to SAI traumas, in-hospital mortality due to MAI is not usually related to the aortic injury, so these injuries are more amenable to a conservative management. It is mandatory to perform a close imaging surveillance to detect early any potential adverse evolution of an MAI. Nevertheless, a balance must be struck between a close serial imaging surveillance and the potentially detrimental effects of obtaining high-resolution additional images.

Sex differences in in-hospital mortality in acute decompensated heart failure with reduced and preserved ejection fraction

There are no sex-specific survival comparisons between patients with heart failure (HF) with reduced and those with preserved ejection fraction. Large registries noting women have better survival than men combined HF patients with reduced and preserved EF. Other registries that compared patients with reduced and preserved EF did not analyze their data by sex. We sought to evaluate sex/EF differences in mortality and risk factors for survival in hospitalized patients with HF. We included hospitals fully participating in Get With The Guidelines-Heart Failure that admitted HF patients with reduced (EF <40%) or preserved (EF ≥50%) EF. The primary end point was in-hospital mortality. Multivariate generalized estimating equation logistic models were used to compute odds ratios accounting for hospital clustering. The study cohort consisted of 51,428 patients with EF <40% (36% women, 64% men) and 37,699 patients with EF ≥50% (65% women, 35% men). Women compared with men with reduced and preserved EF were older and more likely to have hypertension, depression, or valvular heart disease and less likely to have coronary artery disease or peripheral vascular disease. There were no sex differences in in-hospital mortality (EF <40%, 2.69% women vs 2.89% men, P = .20; EF ≥50%, 2.61% women vs 2.62% men, P = .96), and risk factors such as age, systolic blood pressure, heart rate, and history of renal failure/dialysis were highly predictive of death for each sex/EF subgroup. In a large, multicenter registry, we found that despite differences in baseline characteristics, women and men with reduced and preserved EF have similar in-hospital mortality and risk factors predicting death.

Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine

An array of neuroprotective strategies has evolved to limit spinal cord injury during descending thoracic aneurysm and thoracoabdominal aortic aneurysm repair. This study prospectively assessed the neuroprotective impact of intrathecal papaverine added to other techniques in aortic aneurysm repairs. From January 2002 to January 2010, 398 consecutive patients underwent descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs at Cleveland Clinic, 68 under hypothermic circulatory arrest. We focused on the remaining 330, in whom a combination of neuroprotective adjuncts was used intraoperatively to mitigate spinal cord ischemia. These included distal aortic perfusion with moderate hypothermia, cerebrospinal fluid drainage, and intrathecal papaverine. Two patient groups were discriminated according to whether intrathecal papaverine was (n = 250) or was not (n = 80) administered. Postoperative outcomes were analyzed from a prospectively maintained clinical database. Preoperative patient characteristics and comorbidities were similar between groups. Extent of aortic disease was also similar: descending thoracic aneurysm (34% with papaverine vs 28%) and Crawford types I (25% vs 34%), II (27% vs 24%), III (13% vs 13%), and IV (2% vs 2.5%). Groups had similar in-hospital mortality (6.4% vs 11%; P = .11) and permanent stroke (4.4% vs 7.5%; P = .3). Permanent paraplegia (3.6% vs 7.5%; P = .01) and paraparesis (1.6% vs 6.3%; P = .01) were significantly lower in the intrathecal papaverine group. Adding intrathecal papaverine to the neuroprotective protocol for descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs may enhance spinal cord perfusion and provide additional spinal cord protection.

Timing of Preoperative Aspirin Discontinuation and Outcome After Elective Coronary Artery Bypass Graft Surgery

Whether aspirin should be discontinued before coronary artery bypass grafting is controversial. The potential benefits and harms associated with late use of aspirin (no discontinuation or discontinuation <3 days before surgery) were investigated in this retrospective, multicenter study. Retrospective, multicenter study. Two university hospitals and one central hospital. A consecutive series of 859 patients who underwent elective coronary artery bypass grafting from January 2008 through December 2010. Aspirin (100 mg/day) was used <3 days before surgery in 240 patients and was discontinued >3 days before surgery in 619 patients. In the overall series, similar in-hospital mortality, amount of postoperative blood loss, rate of re-exploration for excessive bleeding, and use of blood products were observed in the study groups. However, aspirin discontinuation >3 days before surgery tended to be associated with a higher postoperative stroke rate (1.9% v 0.4%, p = 0.13). Such a trend was observed after off-pump (1.9% v 0%, p = 0.58) and on-pump (2.0% v 0.6%, p = 0.46) surgery. Among 153 pairs matched by the propensity score, patients with aspirin discontinued >3 days before surgery had a significantly higher rate of postoperative stroke (5.9% v 0.7%, p = 0.02) and tended to have a higher risk of the composite adverse outcome endpoint (19.6% v 12.4%, p = 0.09). The postoperative release of troponin I was similar in the study groups. Late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion. These findings and the risk of cardiovascular events possibly occurring at the time of its discontinuation suggest that the use of aspirin until the day of elective coronary surgery may be beneficial.