Publications by authors named "Kevin F Kennedy"

213 Publications

Impact of Age on Outcomes after Transcatheter Aortic Valve Implantation.

Eur Heart J Qual Care Clin Outcomes 2022 May 9. Epub 2022 May 9.

Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030.

Aims: Usage of transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is increasing across age groups. However, literature on age-specific TAVI outcomes is lacking. The purpose of this study is to assess the risks of procedural complications, mortality, and readmission in patients undergoing TAVI across different age groups.

Methods And Results: The Nationwide Readmissions Database (NRD) was used to identify 84,017 patients undergoing TAVI from 2016-2018. Patients were stratified into four age groups: younger than 70, 70 to 79, 80 to 89, and older than 90. Complications, mortality, and readmission rates were compared between groups in a proportional hazards regression model. Risk of post-procedural stroke, acute kidney injury, and pacemaker or implantable cardioverter defibrillator implantation increased with incremental age grouping. Compared to patients younger than 70, patients aged 70 to 79 had no significant difference in mortality, whereas patients aged 80 to 89 and older than 90 had an increased mortality risk (odds ratio (OR) 1.39; CI 1.14-1.70; p = .001, and OR 1.68; CI 1.33-2.12; p < .001, respectively). Patients aged 80 to 89 and older than 90 had increased overall readmission as compared to patients younger than 70 (HR 1.09; CI 1.03-1.14; p = 0.001 and HR 1.33; CI 1.25-1.41; p < .001, respectively). Cardiac readmissions followed the same trend.

Conclusions: Patients aged 80 to 89 and greater than 90 undergoing TAVI have increased risk of readmission, complications, and mortality compared to patients younger than 70.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjqcco/qcac021DOI Listing
May 2022

Prognostic Relationship Between Coronary Artery Calcium Score, Perfusion Defects, and Myocardial Blood Flow Reserve in Patients With Suspected Coronary Artery Disease.

Circ Cardiovasc Imaging 2022 04 13;15(4):e012599. Epub 2022 Apr 13.

Saint Luke's Mid America Heart Institute, Kansas City, MO (K.K.P., P.A.P.-O., F.S.P., B.W.S., A.I.M., R.C.T., K.F.K., P.S.C., J.A.S., T.M.B.).

Background: Coronary artery calcium score (CACS) is an anatomic measure of calcified atherosclerosis. Myocardial perfusion defects and reduced myocardial blood flow reserve (MBFR) are physiological measures of ischemia and coronary circulatory health. We aimed to assess the relative prognostic importance of MBFR, perfusion defects, and CACS in patients with suspected coronary artery disease.

Methods: A total of 5983 consecutive patients without known history of coronary artery disease or cardiomyopathy, who underwent a CACS and Rb positron emission tomography myocardial perfusion imaging between 2010 and 2016, were followed for all-cause death (n=785) over median of 3 years. Prognostic value was assessed using multivariable Cox regression models, and incremental risk discrimination for imaging variables was evaluated by comparing model c-indices after adjusting for clinical risk factors (RF).

Results: Mean age was 67.1 years, 60% were female, and 83% were symptomatic. CACS was 0 in 22%, abnormal perfusion in 19%, and MBFR <2 in 53.3%. When added to RF, the model with MBFR had the best fit (c=0.78, <0.0001). Addition of CACS to model with RF and perfusion (c=0.77) offered modest improvement in discrimination over the model with RF and perfusion (c=0.76, =0.02). Adding CACS to a model with RF, perfusion, and MBFR did not provide incremental prognostic value (c=0.785 for both, =0.16). CACS and MBFR both had independent prognostic value in patients with normal and abnormal myocardial perfusion imaging. Even among patients with CACS of 0, MBFR <2 was present in 37.8%, being associated with higher risk of death (hazard ratio per 0.1↓, 1.10 [1.04-1.15]; <0.001), but perfusion defects were not.

Conclusions: Use of anatomic testing such as CACS of 0 to avoid myocardial perfusion imaging in symptomatic patients could lead to missing microvascular dysfunction in 4 out of 10 patients, a finding associated with a high mortality risk. Higher CACS was independently associated with the risk of death but did not provide incremental prognostic value over positron emission tomography with MBFR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCIMAGING.121.012599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9018603PMC
April 2022

Use of a Smart-Phone Mobile Application is Associated With Improved Compliance and Reduced Length of Stay in Patients Undergoing Primary Total Joint Arthroplasty of the Hip and Knee.

J Arthroplasty 2022 Mar 25. Epub 2022 Mar 25.

Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Background: Patient compliance with perioperative protocols is paramount to improving outcomes and reducing adverse events in total joint arthroplasty (TJA) of the hip and knee. Given the widespread use of smartphones, mobile applications (MAs) may present an opportunity to improve outcomes in TJA. We aim to determine whether the use of a mobile application platform improves compliance with standardized pre-operative protocols and outcomes in TJA.

Methods: A non-randomized, prospective cohort study was conducted in adult patients undergoing primary elective TJA to determine whether the use of an MA with timed reminders starting 5 days pre-operatively, to perform a chlorhexidine gluconate (CHG) shower and oral hydration protocol improves compliance with these protocols.

Outcome Measures: compliance, length of stay (LOS), surgical site infection (SSI), 90-day readmission.

Results: App-users had increased adherence to the hydration protocol (odds ratio [OR] = 3.17 [95% confidence interval {CI} = 1.42, 7.09: P = .003]). App-use was associated with shorter LOS (Median Interquartile ranges [IQR] 2.0 days [1.0, 2.0 days]) for App-users vs 2.0 days ([1.0, 3.0] for non-App users, P = .031), younger age, (63.3 vs 67.9 years, P = .0001), Caucasian race (OR = 3.32 [95% CI = 1.59, 6.94 P = .0009]) and male gender (48.2% vs 35.0%, P = .02). There was no difference in adherence to chlorhexidine gluconate (CHG), readmission, or surgical site infection (SSI) (2.2% App-users vs 2.9% non-App users; P = .74).

Conclusion: Use of a mobile application was associated with increased compliance with a hydration protocol and reduced LOS. App-users were more likely to be younger, male and Caucasian. These disparities may reflect inequity of access to the requisite technology and warrant further study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.03.068DOI Listing
March 2022

Predictors of in-hospital de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention.

Cardiovasc Revasc Med 2022 Feb 3. Epub 2022 Feb 3.

Department of Cardiovascular Medicine, Warren Alpert Medical School of Brown University/Lifespan Health System, Providence, RI, USA.

Background: Ticagrelor or prasugrel are recommended to reduce ischemic events in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). However, in clinical practice, patients are often switched from a potent P2Y12 inhibitor to clopidogrel prior to or at discharge ('de-escalation'). We sought to assess the incidence and predictors of de-escalation.

Methods: Consecutive patients who received either a ticagrelor or prasugrel loading dose for AMI PCI at two tertiary centers between Jan 2015-Mar 2019 who survived to discharge were included. Data were obtained from the electronic health record and institutional NCDR CathPCI data. Patients who were de-escalated to clopidogrel were compared with those who remained on potent P2Y12 inhibitors through the time of discharge.

Results: Of the1818 patients in the cohort, 1146 (63%) were de-escalated. Patients in the de-escalation group were older, more often Black, had lower prevalence of co-morbidities, less often had private insurance, and had less complex PCI. After adjustment, older age remained positively associated (OR 1.2, CI 1.08-1.34, p = .001) and Caucasian race (OR 0.5, CI 0.33-0.77, p = .002), prior MI (OR 0.7, CI 0.5-0.97, p = .032), bifurcation lesion (OR 0.71, CI 0.53-0.95, p = .019), and greater number of stents (OR 0.82, CI 0.75-0.91, p = .0001) were negatively associated with de-escalation. In de-escalated patients, the rationale was not documented in 75.9% of cases.

Conclusions: De-escalation occurred frequently in patients with AMI and was associated with both non-clinical and clinical factors. Medical decision making was poorly documented and represent an area for improvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2022.01.029DOI Listing
February 2022

Relationship Between Myocardial Perfusion Imaging Abnormalities on Positron Emission Tomography and Anginal Symptoms, Functional Status, and Quality of Life.

Circ Cardiovasc Imaging 2022 02 15;15(2):e013592. Epub 2022 Feb 15.

Saint Luke's Mid America Heart Institute, Kansas City, MO (K.K.P., F.S.P., T.M.B., K.F.K., P.A.P.-O., A.I.M., B.W.S., R.C.T., I.M.S., P.G.J., J.A.S.).

Background: Myocardial perfusion imaging (MPI) identifies abnormalities that occur early in the ischemic cascade leading to angina. Our aim was to study the association between ischemic measures on positron emission tomography MPI and patients' health status; their symptoms, function, and quality of life.

Methods: Health status was collected using the Seattle Angina Questionnaire (SAQ-7, 0-100, higher=better) and Rose Dyspnea Score (RDS) on 1515 outpatients with known or suspected coronary artery disease presenting for clinically indicated pharmacological Rb positron emission tomography MPI from July 2018 to July 2019. Adjusted multivariable ordinal regression models were used to assess the association between MPI findings of ischemia and the SAQ physical limitation, angina frequency, quality of life, summary score, and the RDS.

Results: The mean SAQ and RDS scores of the cohort (mean age 71.7 years, 55% male, 37.6% prior myocardial infarction or revascularization) were 73.8±28.6 (physical limitation), 87.4±21.7 (angina frequency), 79.0±26.1 (quality of life), 81.3±19.0 (summary score), and 2±2 (RDS). No perfusion, flow or function abnormalities were significantly associated with SAQ angina frequency scores. Low left ventricular ejection fraction reserve (≤0%), low global and regional myocardial blood flow reserve (<2) were independently associated with worse SAQ Physical Limitation score, SAQ summary score, and RDS (30% to 57% greater odds; all ≤0.01), but reversible perfusion defects were not.

Conclusions: Impaired augmentation of left ventricular ejection fraction and myocardial blood flow with stress is associated with significant angina-associated functional limitation, health status, and dyspnea in patients who underwent positron emission tomography MPI, but not the frequency of their angina. Future studies should evaluate whether therapies that improve stress-induced abnormalities in systolic function and myocardial flow may improve patients' health status.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCIMAGING.121.013592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8869837PMC
February 2022

Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest.

J Card Surg 2022 Apr 13;37(4):818-824. Epub 2022 Feb 13.

Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.

Objective: The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out-of-hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA.

Methods: The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgently and placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno-venous ECMO were excluded. Predictors of mortality were assessed using multivariable analyses.

Results: There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST-elevation myocardial infarction (39.1%), non-ST-elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality.

Conclusion: Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jocs.16307DOI Listing
April 2022

Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis.

Intensive Care Med 2022 Feb 18;48(2):213-224. Epub 2021 Dec 18.

Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Purpose: This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO).

Methods: We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs.

Results: Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49-1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08-1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55-7.97]) and medical bleeding, including intracranial (5.71 [4.02-8.09]), pulmonary (2.02 [1.54-2.67]), and gastrointestinal (1.54 [1.2-1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis.

Conclusions: Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00134-021-06593-xDOI Listing
February 2022

Outpatient Management of Heart Failure During the COVID-19 Pandemic After Adoption of a Telehealth Model.

JACC Heart Fail 2021 12 6;9(12):916-924. Epub 2021 Oct 6.

Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA. Electronic address:

Objectives: This study sought to determine whether the increased use of telehealth was associated with a difference in outcomes for outpatients with heart failure.

Background: The COVID-19 pandemic led to dramatic changes in the delivery of outpatient care. It is unclear whether increased use of telehealth affected outcomes for outpatients with heart failure.

Methods: In March 2020, a large Midwestern health care system, encompassing 16 cardiology clinics, 16 emergency departments, and 12 hospitals, initiated a telehealth-based model for outpatient care in the setting of the COVID-19 pandemic. A propensity-matched analysis was performed to compare outcomes between outpatients seen in-person in 2018 and 2019 and via telemedicine in 2020.

Results: Among 8,263 unique patients with heart failure with 15,421 clinic visits seen from March 15 to June 15, telehealth was employed in 88.5% of 2020 visits but in none in 2018 or 2019. Despite the pandemic, more outpatients were seen in 2020 (n = 5,224) versus 2018 and 2019 (n = 5,099 per year). Using propensity matching, 4,541 telehealth visits in 2020 were compared with 4,541 in-person visits in 2018 and 2019, and groups were well matched. Mortality was similar for telehealth and in-person visits at both 30 days (0.8% vs 0.7%) and 90 days (2.9% vs 2.4%). Likewise, there was no excess in hospital encounters or need for intensive care with telehealth visits.

Conclusions: A telehealth model for outpatients with heart failure allowed for distanced encounters without increases in subsequent acute care or mortality. As the pressures of the COVID-19 pandemic abate, these data suggest that telehealth outpatient visits in patients with heart failure can be safely incorporated into clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jchf.2021.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8494054PMC
December 2021

Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction.

JAMA 2021 Nov;326(19):1940-1952

Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island.

Importance: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19.

Objective: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection.

Design, Setting, And Participants: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449).

Exposures: Active COVID-19 infection present during the same encounter.

Main Outcomes And Measures: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year.

Results: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001).

Conclusions And Relevance: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2021.18890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8596198PMC
November 2021

Impact of Transcatheter Aortic Valve Replacement on Hospitalization Rates: Insights From Nationwide Readmission Database.

J Am Heart Assoc 2021 11 29;10(21):e022910. Epub 2021 Oct 29.

Cardiovascular Disease Saint Luke's Mid America Heart Institute Kansas City MO.

Background Hospitalization rates after transcatheter aortic valve replacement (TAVR) remain high, given the age and comorbidities of patients undergoing TAVR. To better understand the impact of TAVR on hospitalization, we sought to compare hospitalization rates before and after TAVR and to examine if underlying patient comorbidities are associated with a differential effect of TAVR on hospitalizations. Methods and Results We used the Nationwide Readmissions Database to identify patients who underwent TAVR. As Nationwide Readmissions Database data do not cross over calendar years, we limited our index admission to hospitalizations during April to September of each calendar year to allow 90 days of observation before and after TAVRs. We calculated the daily risk of all-cause hospitalization and used a mixed-effects logistic regression model to explore interactions between patient characteristics, TAVR, and hospitalization risk. Among 39 249 patients who underwent TAVR in 2014 to 2017 (median age, 82 years [interquartile range, 76-87 years]; 45.7% women), 32.0% had at least one hospitalization in the 90 days before TAVR compared with 23.2% in the 90 days post-TAVR (relative reduction, 27.5%; <0.001). In the mixed-effects logistic regression model, TAVR was associated with decreased all-cause hospitalization rate after TAVR in all comorbidity subgroups. However, younger patients and those with heart failure and reduced ejection fraction appeared to have more robust reduction in hospitalizations. Conclusions Although patients who are treated with TAVR have high rates of rehospitalization, TAVR is associated with an overall reduction in all-cause hospitalizations regardless of underlying patient comorbidities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.121.022910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8751839PMC
November 2021

Correlation of Hepatic Steatosis Among Cohabitants Using Hounsfield Unit From Coronary Computed Tomography.

Cureus 2021 Sep 8;13(9):e17834. Epub 2021 Sep 8.

Gastroenterology and Hepatology, University of Missouri Kansas City School of Medicine, Kansas City, USA.

Background Individuals living in the same household are exposed to common risk factors. We hypothesized that living with someone who has fatty liver disease increases the risk of having the same disease. Methods This was a retrospective study that included pairs of men and women who shared the same residential addresses, underwent screening non-contrast computed tomography for coronary calcium scoring and had Hounsfield Unit density for liver and spleen in the field of view available for measurement. The primary goal was to determine the association between hepatic steatosis and living in the same household. Secondary end-points compared to body mass index, triglyceride levels, type 2 diabetes mellitus (T2DM) and hypertension. Results Out of 1,362 cohabitant pairs, there were 202 couples with either the male or female having hepatic steatosis and 10 cohabitant pairs with both the male and female having hepatic steatosis. In 1,150 cohabitant pairs out of 1,362, neither man nor woman had hepatic steatosis. Pearson correlation coefficient (r) for hepatic steatosis between cohabitant pairs was 0.122 (p-value: < 0.001), suggesting that no correlation was found. Elevated triglyceride levels were prevalent among cohabitant pairs with hepatic steatosis, when compared to pairs without hepatic steatosis (p-value < 0.05). Female gender and having a diagnosis of hepatic steatosis also showed a strong association with higher body mass index, T2DM and hypertension (p-value < 0.05). Conclusion Despite the assumption of exposure to similar environmental factors, our results did not show any correlation of hepatic steatosis among the cohabitants.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.17834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502746PMC
September 2021

Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry.

Catheter Cardiovasc Interv 2021 12 27;98(7):1363-1372. Epub 2021 Sep 27.

University of Missouri-Kansas City, Kansas City, Missouri, USA.

Objectives: To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention.

Background: Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding.

Methods: We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement.

Results: Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%).

Conclusions: Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.29961DOI Listing
December 2021

Hospitalizations and Outcomes of T1MI Observed Before and After the Introduction of MI Subtype Codes.

J Am Coll Cardiol 2021 09;78(12):1242-1253

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. Electronic address:

Background: International Classification of Disease (ICD)-10 coding of type 1 myocardial infarction (MI) is used for reimbursement, value-based programs, and clinical research.

Objectives: This study sought to determine whether the introduction of ICD-10 codes for type 2 and types 3-5 MI was associated with changes in hospitalizations for ICD-10 codes now attributed to type 1 MI.

Methods: Using the Nationwide Readmissions Database, we identified patients with ICD-10 codes now attributed to type 1 MI between January 2016 and December 2018. Patients were stratified according to the timing of their event in relation to the introduction of the type 2 and types 3-5 MI codes on October 1, 2017.

Results: There were 2,680,323 hospitalizations for ICD-10 codes now attributed to type 1 MI; after adjustment for seasonality, there was a 13.7% decline in hospitalizations after the introduction of the new subtype codes. Patients with ICD-10 codes now attributed to type 1 MI after the coding change were less likely to be female, had lower prevalence of several cardiovascular and noncardiovascular comorbidities, and had higher rates of coronary angiography and revascularization. After introduction of the new codes, there was a positive deflection in the slope of risk-adjusted in-hospital mortality (0.007%; P <0.001) and a negative deflection in risk-adjusted 30-day readmission (-0.002%; P = 0.05) for patients with ICD-10 codes now attributed to type 1 MI.

Conclusions: The introduction of ICD-10 codes for type 2 and types 3-5 MI was associated with a decrease in hospitalizations for ICD-10 codes now attributed to type 1 MI and changes in the observed characteristics and treatment patterns of these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2021.07.034DOI Listing
September 2021

Trends and predictors of 30-day readmissions in subjects with eosinophilic esophagitis: results from a national cohort.

Dis Esophagus 2022 Feb;35(2)

Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.

Background: Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition causing recurrent dysphagia and may predispose patients to repeated hospitalizations. We assessed temporal trends and factors affecting readmissions in patients with EoE.

Methods: Patients with primary diagnosis of EoE and/or a complication (dysphagia, weight loss, and esophageal perforation) from EoE between 2010 and 2017 were identified from the National Readmissions Database using the International Classification of Diseases codes. The primary outcome was incidence of EoE related 30-day readmission. Independent risk factors for readmissions were evaluated using multivariable logistic regression analysis. Secondary outcomes were temporal trends of readmissions and healthcare costs.

Results: Of the 2,676 (mean age 45 ± 17.8 years, 1,667 males) index adult admissions, 2,103 (79%) patients underwent an upper endoscopy during the admission. The mean length of stay (LOS) was 3 ± 3.7 days. The 30-day readmission rate was steady at 6.8% from 2010 to 2017 and majority of the readmissions occurred by day 10 of index discharge. Age > 70 years was associated with a higher trend in 30-day readmission (P < 0.001). Longer LOS, history of smoking and the presence of eosinophilic gastroenteritis predicted readmission. Conversely, a history of foreign body impaction and upper endoscopy (including esophageal dilation) at index admission were negatively associated with readmission. Mean hospital charges significantly increased from $24,783 in 2010 to $40,922 in 2017.

Conclusion: Readmissions due to EoE are more likely to occur in the first 10 days of discharge and at a lesser rate when upper endoscopies are performed at the index admission.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doab060DOI Listing
February 2022

Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database.

Am J Gastroenterol 2021 12;116(12):2367-2373

Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Missouri, USA.

Introduction: A gastrostomy is generally performed in patients who are unable to maintain volitional intake of food. We compared outcomes of percutaneous endoscopic gastrostomy (PEG) and interventional radiologist-guided gastrostomy (IRG) using an integrated nationwide database.

Methods: Using the VA Informatics and Computing Infrastructure database, patients who underwent PEG or IRG from 2011 through 2021 were selected using Current Procedural Terminology and International Classification of Diseases codes. The primary outcome was the comparative incidence of adverse events between PEG and IRG. Secondary outcomes included all-cause mortality. Comorbidities were identified using International Classification of Diseases codes, and adjusted odds ratio (OR) for adverse events were calculated using multivariate logistic regression analysis.

Results: A total of 23,566 (70.7 ± 10.2 years) patients underwent PEG and 9,715 (69.6 ± 9.7 years) underwent IRG. Selected frequent indications for PEG vs IRG were as follows: stroke, 6.8% vs 5.3%, P < 0.01; aspiration pneumonia, 10.9% vs 6.8%, P < 0.001; feeding difficulties, 9.8% vs 6.3%, P < 0.01; and upper aerodigestive tract malignancies 58.8% vs 79.8%, P < 0.01. Across all subtypes of malignancies of the head and neck and foregut, the proportion of patients undergoing IRG was greater than those undergoing PEG (P < 0.001). The all-cause 30-day mortality and overall incidence of adverse events were significantly lower for PEG compared with those for IRG (PEG vs IRG): all-cause 30-day mortality, 9.35% vs 10.3% (OR 0.80; 95% confidence interval [CI] 0.74-0.87; P < 0.01); perforation of the colon, 0.12% vs 0.24% (OR 0.50; 95% CI 0.29-0.86; P = 0.04); peritonitis, 1.9% vs 2.7% (OR 0.68; 95% CI 0.58-0.79; P < 0.01); and hemorrhage 1.6% vs 1% (OR 1.47; 95% CI 1.18-1.83; P < 0.01).

Discussion: In a large nationwide database of more than 33,000 gastrostomy procedures, PEG was associated with a lower incidence of adverse outcomes and the 30-day mortality than IRG.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/ajg.0000000000001504DOI Listing
December 2021

Educational intervention to improve quality of care in Barrett's esophagus: the AQUIRE randomized controlled trial.

Gastrointest Endosc 2022 02 6;95(2):239-245.e2. Epub 2021 Sep 6.

Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA.

Background And Aims: Despite quality measures in upper endoscopy (EGD) for Barrett's esophagus (BE), considerable variability remains in practice among gastroenterologists. This randomized controlled trial evaluated the role of structured intensive training on the quality of EGD in BE.

Methods: In this multicenter study, 8 sites (from the GI Quality Consortium) were cluster randomized (1:1) to receive AQUIRE (A Quality Improvement program in cancer care during Endoscopy) training (intervention) or continue local standard practices (control). The primary outcome was compliance with the Seattle biopsy protocol. Secondary outcomes were change in knowledge of BE detection and sampling assessed by questionnaire and dysplasia detection rate (DDR) before and after completion of the 6-month study period.

Results: The intervention sites (n = 4) had 31 gastroenterologists and the control sites (n = 4) had 34. There was a significant improvement in the compliance rates with the Seattle biopsy protocol from baseline to the end of the study in the intervention sites (64.8%-73.2%, P = .002) but not in the control sites (69.5%-69.4%, P = .953). The accurate response rate on the questionnaire at the intervention sites increased from 73% at baseline to 88% after AQUIRE training (difference, 14.8%; standard deviation, 18.7; P = .008). DDR did not change significantly from baseline to 6 months in either the control or intervention groups (P = .06).

Conclusions: This study confirms the capacity of a structured educational intervention to improve utilization of a standard biopsy protocol and knowledge of standards of care in BE but without significant change in DDR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2021.08.026DOI Listing
February 2022

North American lower-extremity revascularization and amputation during COVID-19: Observations from the Vascular Quality Initiative.

Vasc Med 2021 12 25;26(6):613-623. Epub 2021 Jun 25.

Division of Cardiology, Alpert Medical School of Brown University, Providence, RI, USA.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic's impact on vascular procedural volumes and outcomes has not been fully characterized.

Methods: Volume and outcome data before (1/2019 - 2/2020), during (3/2020 - 4/2020), and following (5/2020 - 6/2020) the initial pandemic surge were obtained from the Vascular Quality Initiative (VQI). Volume changes were determined using interrupted Poisson time series regression. Adjusted mortality was estimated using multivariable logistic regression.

Results: The final cohort comprised 57,181 patients from 147 US and Canadian sites. Overall procedure volumes fell 35.2% (95% CI 31.9%, 38.4%, < 0.001) during and 19.8% (95% CI 16.8%, 22.9%, < 0.001) following the surge, compared with presurge months. Procedure volumes fell 71.1% for claudication (95% CI 55.6%, 86.4%, < 0.001) and 15.9% for chronic limb-threatening ischemia (CLTI) (95% CI 11.9%, 19.8%, < 0.001) but remained unchanged for acute limb ischemia (ALI) when comparing surge to presurge months. Adjusted mortality was significantly higher among those with claudication (0.5% vs 0.1%; OR 4.38 [95% CI 1.42, 13.5], = 0.01) and ALI (6.4% vs 4.4%; OR 2.63 [95% CI 1.39, 4.98], = 0.003) when comparing postsurge with presurge periods.

Conclusion: The first North American COVID-19 pandemic surge was associated with a significant and sustained decline in both elective and nonelective lower-extremity vascular procedural volumes. When compared with presurge patients, in-hospital mortality increased for those with claudication and ALI following the surge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1358863X211021918DOI Listing
December 2021

Reasons for discordance between positron emission tomography (PET) myocardial perfusion imaging (MPI) results and subsequent management.

J Nucl Cardiol 2021 Jun 24. Epub 2021 Jun 24.

University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.

Background: Referral patterns to coronary angiography following positron emission tomography (PET) myocardial perfusion imaging (MPI) and reasons for non-referral following abnormal PET MPI are largely unknown.

Methods: Referral rates to coronary angiography within 90 days post PET MPI were determined. A random subset of 100 patients with severe (≥ 10%) ischemia on MPI between 2014-16 who were not referred for angiography were examined to better understand reasons as to why patients with high-risk MPI findings did not undergo coronary angiography.

Results: Among 19,282 unique patients, overall rate of 90-day coronary angiography was 18.5% (3574/19282). Among patients with severe ischemia, 64.1% (1930/3011) underwent angiography within 90 days; the rate was lower in those with mild-moderate (20.6% [1010/4898]) and no ischemia (5.6% [634/11373]). In the random sample of 100 patients, the most common physician reasons for non-referral were uncertainty regarding whether the test results were responsible for the patient's presenting symptoms, renal failure, and patient age, frailty, or cognitive status, while patient preference for medical management was by far the most common patient reason.

Conclusion: Referral rates for coronary angiography after PET correlate with severity of ischemia. However, there appear to be opportunities to reconsider testing for instances when results will not change clinical management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12350-021-02695-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702573PMC
June 2021

Comparison of Outcomes of Pediatric Catheter Ablation by Anesthesia Strategy: A Report From the NCDR IMPACT Registry.

Circ Arrhythm Electrophysiol 2021 07 17;14(7):e009849. Epub 2021 Jun 17.

Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.).

[Figure: see text].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.121.009849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641558PMC
July 2021

Trends in Use of Prescription Skin Lightening Creams.

Int J Environ Res Public Health 2021 05 25;18(11). Epub 2021 May 25.

Department of Dermatology, Boston University School of Medicine, Boston, MA 02118, USA.

The desire for an even skin tone pervades all cultures and regions of the world. Uniform skin color is considered a sign of beauty and youth. Pigmentation abnormalities can arise idiopathically with genetic predetermination, with injury and environmental exposures, and with advancing age, and can, therefore, be distressing to patients, leading them to seek a variety of treatments with professional assistance. In this short report, we describe the trends in the use of prescription lightening creams, particularly in patients with darker skin types residing in the US. Amongst 404 participants, skin hyperpigmentation had a moderate effect on patients' quality of life, and the most common diagnosis associated with the use of a prescription product was melasma (60.8%). The most common agent prescribed was hydroquinone (62.9%), followed by triple combination cream (31.4%). It is the dermatologist's duty to gauge the effect of the pigmentation disease on patients' life in order to counsel, tailor, and decide on the most appropriate treatment option.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijerph18115650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8197474PMC
May 2021

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock.

JACC Cardiovasc Interv 2021 05 28;14(10):1067-1078. Epub 2021 Apr 28.

Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA.

Objectives: The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.

Background: The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.

Methods: Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.

Results: Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).

Conclusions: Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2021.02.021DOI Listing
May 2021

Association Between Hospital Cardiovascular Procedural Volumes and Transcatheter Mitral Valve Repair Outcomes.

Cardiovasc Revasc Med 2022 03 21;36:27-33. Epub 2021 Apr 21.

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known.

Methods: We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR).

Results: The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269).

Conclusion: In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2021.04.017DOI Listing
March 2022

Ultrasound-guided transthoracic needle biopsy of the lung: sensitivity and safety variables.

Eur Radiol 2021 Nov 21;31(11):8272-8281. Epub 2021 Apr 21.

Québec Heart and Lung Institute Research Center, Université Laval, Québec City, Québec, Canada.

Objectives: Variables affecting the performance of ultrasound-guided transthoracic needle biopsy (US-TTNB) are not well established. We examined clinical and imaging variables affecting the sensitivity and the complication rates of US-TTNB.

Methods: We retrospectively reviewed a consecutive series of 528 US-TTNBs performed from 2008 to 2017. Univariate analyses were used to assess the influence of clinical and imaging variables on sensitivity and complication rates. Multivariate logistic regression was used to account for possible confounding variables.

Results: In 397 malignant lesions, the sensitivity of US-TTNB was 72% (95% CI 68-77%; 285/397). The overall pneumothorax rate was 15% (95% CI 12-18%; 77/528), leading to a chest tube in 2% (95% CI 1-3%; 9/528). Multivariate analysis showed that increasing pleural contact length (up to 30 mm) was associated with increased sensitivity (OR 1.08 per mm; 95% CI 1.04-1.12; p < 0.001), and pleural contact length (OR 0.98 per mm; 95% CI 0.97-0.99; p = 0.013), lesion size (OR 0.98 per mm; 95% CI 0.96-0.99; p = 0.006), and core needle diameter of 18G (OR 0.47 as compared with 20G; 95% CI 0.26-0.83; p = 0.010) were associated with a decreased pneumothorax rate. Graphical inspection of cubic splines showed that the probability of a positive biopsy rose sharply with increasing pleural contact length up to 30 mm and was stable thereafter. A similar, but inverse, relationship was observed for the probability of a pneumothorax.

Conclusion: Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. Lesion size also predicts pneumothorax rates.

Key Points: • US-TTNB has a high sensitivity and a low complication rate for pleural and pulmonary lesions with pleural contact. • Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. • This study suggests that relying on US-TTNB may not be optimal for lesions < 10 mm for which the risk of pneumothorax is as high as the chance of obtaining diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-021-07888-9DOI Listing
November 2021

Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding.

World J Clin Cases 2021 Feb;9(5):1048-1057

Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States.

Background: Gastrointestinal bleeding (GIB) is a major concern in patients hospitalized with acute coronary syndrome (ACS) due to the common use of both antiplatelet medications and anticoagulants. Studies evaluating the safety of gastrointestinal endoscopy (GIE) in ACS patients with GIB are limited by their relatively small size, and the focus has generally been on upper GIB and esophago-gastroduod-enoscopy (EGD) only.

Aim: To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States.

Methods: The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014. The International Classification of Diseases Code, 9 Revision Clinical Modification was utilized for patient identification. Patients were further classified into two groups based on undergoing endoscopic procedures (EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy). Both groups were compared regarding demographic information, outcomes, and comorbi-dities. Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay. Chi-square test was used to compare categorical variables, while Student's -test was used to compare continuous variables. All analyses were performed using SAS 9.4 (Cary, NC, United States).

Results: A total of 35612318 patients with ACS were identified between January 2005 and December 2014. 269483 (0.75%) of the patients diagnosed with ACS developed concomitant GIB during the same admission. At least one endoscopic procedure was performed in 68% of the patients admitted with both ACS and GIB. Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality (3.8%) compared to the group not undergoing endoscopy (8.6 %, < 0.001). A shorter length of stay (LOS) was observed in patients who underwent GIE (mean 6.59 ± 7.81 d) compared to the group not undergoing endoscopy (mean 7.84 ± 9.73 d, < 0.001). Multivariate analysis showed that performing GIE was associated with lower mortality (odds ratio: 0.58, < 0.001) and shorter LOS (-0.36 factor, < 0.001).

Conclusion: Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS. Approximately two-thirds of patients with both ACS and GIB undergo GIE during the same hospitalization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12998/wjcc.v9.i5.1048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896652PMC
February 2021

Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction.

J Am Coll Cardiol 2021 02;77(7):848-857

Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. Electronic address:

Background: Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI.

Objectives: The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States.

Methods: Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared.

Results: There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission.

Conclusions: Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2020.12.034DOI Listing
February 2021

Outcomes of Operator-Directed Sedation and Anesthesiologist Care in the Pediatric/Congenital Catheterization Laboratory: A Study Utilizing Data From the IMPACT Registry.

JACC Cardiovasc Interv 2021 02;14(4):401-413

Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objectives: The objective of this study was to assess contemporary use of operator directed sedation (ODS) and anesthesiologist care (AC) in the pediatric/congenital cardiac catheterization laboratory (PCCL), specifically evaluating whether the use of operator-directed sedation was associated with increased risk of major adverse events.

Background: The safety of ODS relative to AC during PCCL procedures has been questioned.

Methods: A multicenter, retrospective cohort study was performed studying procedures habitually performed with ODS or AC at IMPACT (Improving Adult and Congenital Treatment) registry hospitals using ODS for ≥5% of cases. The risks for major adverse events (MAE) for ODS and AC cases were compared, adjusted for case mix. Current recommendations were evaluated by comparing the ratio of observed to expected MAE for cases in which ODS was inappropriate (inconsistent with those guidelines) with those for similar risk AC cases, as well as those in which ODS or AC was appropriate.

Results: Of the hospitals submitting data to IMPACT, 28 of 101 met inclusion criteria. Of the 7,042 cases performed using ODS at these centers, 88% would be inappropriate. Use of ODS was associated with lower likelihood of MAE both in observed results (p < 0.0001) and after adjusting for case-mix (odds ratio: 0.81; p = 0.006). Use of AC was also associated with longer adjusted fluoroscopy and procedure times (p < 0.0001 for both). The observed/expected ratio for ODS cases with high pre-procedural risk (inappropriate for ODS) was significantly lower than that for AC cases with comparable pre-procedural risk. Across a range of pre-procedural risks, there was no stratum in which risk for MAE was lower for AC than ODS.

Conclusions: Across a range of hospitals, ODS was used safely and with improved efficiency. Clinical judgment better identified cases in which ODS could be used than pre-procedural risk score. This should inform future guidelines for the use of ODS and AC in the catheterization laboratory.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2020.10.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932684PMC
February 2021

Acute Kidney Injury Following In-Patient Lower Extremity Vascular Intervention: From the National Cardiovascular Data Registry.

JACC Cardiovasc Interv 2021 02;14(3):333-341

Cardiology Department, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Division of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA.

Objectives: The authors analyzed data from the NCDR (National Cardiovascular Data Registry) PVI Registry and defined acute kidney injury (AKI) as increased creatinine of ≥0.3 mg/dl or 50%, or a new requirement for dialysis after PVI.

Background: AKI is an important and potentially modifiable complication of peripheral vascular intervention (PVI). The incidence, predictors, and outcomes of AKI after PVI are incompletely characterized.

Methods: A hierarchical logistic regression risk model using pre-procedural characteristics associated with AKI was developed, followed by bootstrap validation. The model was validated with data submitted after model creation. An integer scoring system was developed to predict AKI after PVI.

Results: Among 10,006 procedures, the average age of patients was 69 years, 58% were male, and 52% had diabetes. AKI occurred in 737 (7.4%) and was associated with increased in-hospital mortality (7.1% vs. 0.7%). Reduced glomerular filtration rate, hypertension, diabetes, prior heart failure, critical or acute limb ischemia, and pre-procedural hemoglobin were independently associated with AKI. The model to predict AKI showed good discrimination (optimism corrected c-statistic = 0.68) and calibration (corrected slope = 0.97, intercept of -0.07). The integer point system could be incorporated into a useful clinical tool because it discriminates risk for AKI with scores ≤4 and ≥12 corresponding to the lower and upper 20% of risk, respectively.

Conclusions: AKI is not rare after PVI and is associated with in-hospital mortality. The NCDR PVI AKI risk model, including the integer scoring system, may prospectively estimate AKI risk and aid in deployment of strategies designed to reduce risk of AKI after PVI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2020.10.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076888PMC
February 2021

Risk of Colorectal Cancer and Cancer Related Mortality After Detection of Low-risk or High-risk Adenomas, Compared With No Adenoma, at Index Colonoscopy: A Systematic Review and Meta-analysis.

Gastroenterology 2021 05 29;160(6):1986-1996.e3. Epub 2021 Jan 29.

Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri.

Background & Aims: The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group.

Methods: We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups.

Results: Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06-1.51; I=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31-3.69; I=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72-3.20; I=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76-1.74; I=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30-4.75; I=38%) and no adenomas (OR, 2.69; 95% CI, 1.87-3.87; I=0).

Conclusions: The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.gastro.2021.01.214DOI Listing
May 2021

Comparison of Outcomes Among Patients With Cardiogenic Shock Admitted on Weekends Versus Weekdays.

Am J Cardiol 2021 04 6;144:20-25. Epub 2021 Jan 6.

Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri. Electronic address:

Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjcard.2020.12.061DOI Listing
April 2021
-->