Abstract Background Older women presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to receive revascularization and have worse outcomes relative to their male ...counterparts. Objectives This study sought to determine temporal trends and sex differences in revascularization and in-hospital outcomes of younger patients with STEMI. Methods We used the 2004 to 2011 Nationwide Inpatient Sample databases to identify all patients age 18 to 59 years hospitalized with STEMI. Temporal trends and sex differences in revascularization strategies, in-hospital mortality, and length of stay were analyzed. Results From 2004 to 2011, of 1,363,492 younger adults (age <60 years) with acute myocardial infarction, 632,930 (46.4%) had STEMI. Younger women with acute myocardial infarction were less likely than men to present with STEMI (adjusted odds ratio OR: 0.74; 95% confidence interval CI: 0.73 to 0.75). Younger women with STEMI were less likely to receive reperfusion as compared with younger men (percutaneous coronary intervention adjusted OR: 0.74; 95% CI: 0.73 to 0.75) (coronary artery bypass grafting adjusted OR: 0.61; 95% CI: 0.60 to 0.62) (thrombolysis adjusted OR: 0.80; 95% CI: 0.78 to 0.82). From 2004 to 2011, use of percutaneous coronary intervention for STEMI increased in both younger men (63.9% to 84.8%; ptrend < 0.001) and women (53.6% to 77.7%; ptrend < 0.001). In-hospital mortality was significantly higher in younger women compared with men (4.5% vs. 3.0%; adjusted OR: 1.11; 95% CI: 1.07 to 1.15). There was an increasing trend in risk-adjusted in-hospital mortality in both younger men and women during the study period. Length of stay decreased in both younger men and women (ptrend < 0.001). Conclusions Younger women are less likely to receive revascularization for STEMI and have higher in-hospital mortality as compared with younger men. Use of percutaneous coronary intervention for STEMI and in-hospital mortality have increased, whereas length of stay has decreased in both sexes over the past several years.
Abstract Background Choosing an antithrombotic regimen post coronary intervention in patients with concomitant indication for anticoagulation is a challenge commonly encountered by clinicians. ...Methods We performed a meta-analysis of observational studies and randomized controlled trials comparing outcomes of triple therapy (dual antiplatelet therapy and anticoagulant) with dual therapy (single antiplatelet therapy and anticoagulant) in patients on long-term anticoagulants after percutaneous coronary intervention. Major bleeding was the primary outcome. Random effects overall risk ratios were calculated using the DerSimonian and Laird model. Results Nine observational studies and 2 randomized controlled trials with a total of 7,276 patients met our selection criteria. At a mean follow up of 10.8 months major bleeding was higher in triple therapy cohort compared to dual therapy (6.6% versus 3.8%, RR 1.54, CI- 1.2-1.98, P<0.01). No difference was observed between the two groups for all-cause mortality (RR 0.98, 95% CI 0.68-1.43, P=0.93), major adverse cardiac events (RR 1.03, 95% CI 0.8-1.32, P=0.83), thromboembolic events (RR 1.02, 95% CI 0.49-2.10, P=0.96), myocardial infarction (RR 0.85, 95% CI 0.67-1.09, P=0.21), stent thrombosis (RR 0.77, 95% CI 0.46-1.3, P=0.33) and target vessel revascularization (RR 0.87, 95% CI 0.66-1.15, P=0.33). Conclusion In patients receiving anticoagulant therapy, a strategy of single antiplatelet therapy confers a benefit of less major bleeding with no difference in all-cause mortality, cardiovascular mortality, major adverse cardiac events, myocardial infarction, stent thrombosis or thromboembolic event rate compared with dual antiplatelet therapy.
Background
Transcatheter aortic valve replacement (TAVR) is typically performed under general anesthesia (GA). However, there is increasing data supporting the safety of performing TAVR under local ...anesthesia/conscious sedation (LA). We performed a meta‐analysis to gain better understanding of the safety and efficacy of LA versus GA in patients with severe aortic stenosis undergoing TAVR.
Methods and Results
We comprehensively searched EMBASE, PubMed, and Web of Science. Effect sizes were summarized using risk ratios (RRs) difference of the mean (DM), and 95% CIs (confidence intervals) for dichotomous and continuous variables respectively. Twenty‐six studies and 10,572 patients were included in the meta‐analysis. The use of LA for TAVR was associated with lower overall 30‐day mortality (RR, 0.73; 95% CI, 0.57–0.93; P = 0.01), use of inotropic/vasopressor drugs (RR, 0.45; 95% CI, 0.28–0.72; P < 0.001), hospital length of stay (LOS) (DM, −2.09; 95% CI, −3.02 to −1.16; P < 0.001), intensive care unit LOS (DM, −0.18; 95% CI, −0.31 to −0.04; P = 0.01), procedure time (DM, −25.02; 95% CI, −32.70 to −17.35; P < 0.001); and fluoroscopy time (DM, −1.63; 95% CI, −3.02 to −0.24; P = 0.02). No differences were observed between LA and GA for stroke, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, acute kidney injury, paravalvular leak, vascular complications, major bleeding, procedural success, conduction abnormalities, and annular rupture.
Conclusion
Our meta‐analysis suggests that use of LA for TAVR is associated with a lower 30‐day mortality, shorter procedure time, fluoroscopy time, ICU LOS, hospital length of stay, and reduced need for inotropic support.
Abstract Ranolazine was developed as an antianginal agent and was approved by the Food and Drug Administration in 2006 for use in chronic stable angina pectoris. Experimental and clinical studies ...have shown that it also has antiarrhythmic properties based on the frequency-dependent blockade of peak sodium channel current (peak INa ) and rapidly activating delayed rectifier potassium current (IKr ) in the atria and blockade of late phase of the inward sodium current (late INa ) in the ventricles. Recent clinical studies have revealed the efficacy of ranolazine in prevention of atrial fibrillation in patients with acute coronary syndromes, prevention as well as conversion of postoperative atrial fibrillation after cardiac surgery, conversion of recent-onset atrial fibrillation and maintenance of sinus rhythm in recurrent atrial fibrillation. Ranolazine has also been shown to reduce ventricular tachycardia and drug-refractory implantable cardioverter defibrillator shocks. The antiarrhythmic effect of ranolazine is preserved in the setting of chronic heart failure and clinical studies have demonstrated its safety in patients with heart failure. This review discusses the available preclinical and clinical data on the antiarrhythmic effects of this novel antianginal agent.
ABSTRACT
Background
Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may ...depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions.
Objective
To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs.
Design, Setting, and Participants
The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria.
Main Measures
The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs.
Key Results
Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints.
Conclusion
Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.
The safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain.
Utilizing Get With The ...Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC.
A total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC. Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p<0.01). After adjustment for clinical covariates, the likelihood of 1 year mortality was higher in those on OAC (aHR: 1.22, 95% CI 1.05-1.41, p<0.01), while no significant differences were noted for ICH (aHR: 1.34, 95% CI 0.69-2.59, p=0.38) and recurrent ischemic stroke (aHR: 0.78, 95% CI 0.54-1.15, p = 0.21). The likelihood of all-cause bleeding (aHR: 1.59, 95% CI 1.29-1.96, p<0.01) and all-cause re-hospitalization (aHR: 1.14, 95% CI 1.02-1.27, p = 0.02) was higher for those on OAC.
Initiation of OAC after an ischemic stroke in older patients with HF in the absence of atrial fibrillation is associated with death, bleeding and re-hospitalization without an associated reduction in recurrent ischemic stroke. If validated, these findings raise caution for prescribing OAC to such patients.
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Background
Prior studies have found that smokers undergoing thrombolytic therapy for ST‐segment elevation myocardial infarction have lower in‐hospital mortality than nonsmokers, a phenomenon called ...the “smoker's paradox.” Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention.
Methods and Results
We used the 2003–2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction. Multivariable logistic regression was used to compare in‐hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in‐hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31–0.33, P<0.001). Although the association between smoking and lower in‐hospital mortality was partly attenuated after baseline risk adjustment, a significant residual association remained (adjusted odds ratio 0.60, 95% CI 0.58–0.62, P<0.001). This association largely persisted in age‐stratified analyses. Smoking status was also associated with shorter average length of stay (3.5 versus 4.5 days, P<0.001) and lower incidence of postprocedure hemorrhage (4.2% versus 6.1%; adjusted odds ratio 0.81, 95% CI 0.80–0.83, P<0.001) and in‐hospital cardiac arrest (1.3% versus 2.1%; adjusted OR 0.78, 95% CI 0.76–0.81, P<0.001).
Conclusions
In this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction, we observed significantly lower risk‐adjusted in‐hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST‐segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.
Previous studies have shown that obesity is paradoxically associated with improved outcomes in many cardiovascular (CV) disease states; however, whether obesity affects survival after in-hospital ...cardiac arrest (IHCA) has not been well examined. We queried the 2003 to 2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent cardiopulmonary resuscitation for IHCA. Obese patients were identified using the co-morbidity variable for obesity, as defined in Nationwide Inpatient Sample databases. Survival to hospital discharge was compared between obese and nonobese patients using multivariate regression models. Of 836,289 patients with IHCA, 67,216 (8.0%) were obese. Obese patients were younger and more likely to be women compared with nonobese patients. Despite being younger, obese patients had significantly higher prevalence of most CV co-morbidities such as dyslipidemia, coronary artery disease, previous myocardial infarction, heart failure, diabetes mellitus, hypertension, peripheral vascular disease, and chronic renal failure (p <0.001 for all). Obese patients were more likely to have ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (22.3% vs 20.9%; p <0.001). After multivariate risk adjustment, obese patients had improved survival to hospital discharge compared with nonobese patients (31.4% vs 24.1%; unadjusted odds ratio 1.44, 95% CI 1.42 to 1.47, p <0.001; adjusted odds ratio 1.15, 95% CI 1.13 to 1.17, p <0.001). Similar results were seen in patients with CV or non-CV conditions as the primary diagnosis and in those with ventricular tachycardia/ventricular fibrillation or pulseless electrical activity/asystole as the cardiac arrest rhythm. In conclusion, this large retrospective analysis of a nationwide cohort of patients with IHCA demonstrated higher risk-adjusted odds of survival in obese patients, consistent with an “obesity paradox.”
Half of all deaths in patients with chronic kidney disease (CKD) arise from cardiovascular causes. Congestive heart failure (CHF) is specifically more frequent with CKD. Cardiovascular therapies with ...proven benefit are often withheld from patients with renal disease for fear of adverse events. The renin-angiotensin-aldosterone system (RAAS) has been implicated as an important maladaptive neurohormonal pathway in heart failure. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to suppress it ineffectively. Current guidelines support the use of spironolactone for more comprehensive suppression of the RAAS in heart failure patients. Most supporting trials have however excluded patients with renal dysfunction resulting in a dearth of data to support use of spironolactone in CKD patients with CHF. Several small studies that prospectively interrogated the benefits of augmented RAAS blockade with spironolactone in CKD patients have shown improvement in predictors of cardiovascular mortality. More recently, improved mortality outcomes were demonstrated with the use of spironolactone in hemodialysis patients. Although reduction in glomerular filtration rate and hyperkalemia are potential adverse effects with its use, the available evidence suggests that it is uncommon and serious consequences can be avoided with close monitoring. Studies investigating the optimal spironolactone dosage in such a setting recommend starting with a low dose and careful uptitration. This review attempts to provide a comprehensive insight into the issues associated with the use of spironolactone in the setting of concomitant CHF and CKD.
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