Publications by authors named "Mohamed O Mohamed"

40 Publications

Sex-Based Differences in Prevalence and Outcomes of Common Acute Conditions Associated with Type 2 Myocardial Infarction.

Am J Cardiol 2021 Feb 20. Epub 2021 Feb 20.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. Electronic address:

Little is known about the association between acute prevalent conditions in patients with type 2 Myocardial Infarction (T2MI) and clinical outcomes, particularly between sexes. Using the Nationwide Inpatient Sample (2015-2017), we examined outcomes of T2MI in patients stratified by prevalent associated conditions (renal failure, decompensated heart failure, infection, acute respiratory failure, cardiac arrhythmias, bleeding) and sex. Multivariable logistic regression was performed to assess the odds ratios (OR) of in-hospital all-cause mortality in each of the study groups. A total of 38,715 T2MI patients were included in the analysis, of which 47.9% (n=18,540) were females. Renal failure was the most common prevalent condition in both sexes (males: 60%; females: 52.6%). Acute respiratory failure was associated with the greatest odds of mortality (OR 5.46, 95% confidence interval (CI) 5.02-5.94) when compared to other conditions: renal failure (OR 2.20 95% CI 2.01-2.40), infections (OR 2.96 95% CI 2.72-3.21), major bleeding (OR 1.71 95% CI 1.52-1.93), arrhythmias (OR 1.30 95% CI 1.19-1.43) and decompensated heart failure (OR 0.71, 95% CI 0.65-0.77). However, there was no difference in mortality between sexes for all acute conditions except renal failure (females OR: 1.02, 95% CI 1.02-1.02, p=0.011). In conclusion, in-hospital mortality after T2MI differs according to the underlying acute condition, with acute respiratory failure being associated with the highest rate of mortality. No significant differences in mortality were observed between sexes amongst all prevalent acute conditions, with the exception of renal failure which was marginally higher in females.
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http://dx.doi.org/10.1016/j.amjcard.2021.02.011DOI Listing
February 2021

Percutaneous coronary intervention and 30-day unplanned readmission with chest pain in the United States (Nationwide Readmissions Database).

Clin Cardiol 2021 Feb 16. Epub 2021 Feb 16.

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.

Percutaneous coronary intervention (PCI) improves anginal chest pain in most, but not all, treated patients. PCI is associated with unplanned readmission for angina and non-specific chest pain within 30-days of index PCI. Patients with an index hospitalization for PCI between January-November in each of the years 2010-2014 were included from the United States Nationwide Readmissions Database. Of 2 723 455 included patients, the 30-day unplanned readmission rate was 7.2% (n = 196 581, 42.3% female). This included 9.8% (n = 19 183) with angina and 11.1% (n = 21 714) with non-specific chest pain. The unplanned readmission group were younger (62.2 vs 65.1 years; P < 0.001), more likely to be females (41.0% vs 34.2%; P < 0.001), from the lowest quartile of household income (32.9% vs 31.2%; P < 0.001), have higher prevalence of cardiovascular risk factors or have index PCI performed for non-acute coronary syndromes (ACS) (OR:3.46, 95%CI 3.39-3.54). Factors associated with angina readmissions included female sex (OR:1.28, 95%CI 1.25-1.32), history of ischemic heart disease (IHD) (OR:3.28, 95%CI 2.95-3.66), coronary artery bypass grafts (OR:1.79, 95%CI 1.72-2.86), anaemia (OR:1.16, 95%CI 1.11-1.21), hypertension (OR:1.13, 95%CI 1.09, 1.17), and dyslipidemia (OR:1.10, 95%CI 1.06-1.14). Non-specific chest pain compared with angina readmissions were younger (mean difference 1.25 years, 95% CI 0.99, 1.50), more likely to be females (RR:1.13, 95%CI 1.10, 1.15) and have undergone PCI for non-ACS (RR:2.17, 95%CI 2.13, 2.21). Indications for PCI other than ACS have a greater likelihood of readmission with angina or non-specific chest pain at 30-days. Readmissions are more common in patients with modifiable risk factors, previous history of IHD and anaemia.
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http://dx.doi.org/10.1002/clc.23543DOI Listing
February 2021

Effect of primary percutaneous coronary intervention on in-hospital outcomes among active cancer patients presenting with ST-elevation myocardial infarction: a propensity score matching analysis.

Eur Heart J Acute Cardiovasc Care 2021 Feb 4. Epub 2021 Feb 4.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK.

Aims: Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI.

Methods And Results: All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group.

Conclusion: Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.
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http://dx.doi.org/10.1093/ehjacc/zuaa032DOI Listing
February 2021

Incidence and predictors of postoperative ischemic stroke after coronary artery bypass grafting.

Int J Clin Pract 2021 Feb 3:e14067. Epub 2021 Feb 3.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Newcastle, UK.

Background: Data on the incidence and outcomes of ischemic stroke in patients undergoing coronary artery bypass grafting (CABG) in the current era are limited. The goal of this study was to examine contemporary trends, predictors, and outcomes of ischemic stroke following CABG in a large nationally representative database over a 12-year-period.

Methods: The National Inpatient Sample was used to identify all adult (≥18 years) patients who underwent CABG between 2004 and 2015. The incidence and predictors of post-CABG ischemic stroke were assessed and in-hospital outcomes of patients with and without post-CABG stroke were compared.

Results: Out of 2 569 597 CABG operations, ischemic stroke occurred in 47 279 (1.8%) patients, with a rising incidence from 2004 (1.2%) to 2015 (2.3%) (P < .001). Patient risk profiles increased over time in both cohorts, with higher Charlson comorbidity scores observed amongst stroke patients. Stroke was independently associated with higher rates of in-hospital mortality (3-fold), longer lengths of hospital stay (~6 more days), and higher total hospitalisation cost (~$80 000 more). Age ≥60 years and female sex (OR 1.33, 95% CI 1.31-1.36) were the strongest predictors of stroke (both P < .001). Further, on-pump CABG was not an independent predictor of stroke (P = .784).

Conclusion: In this nationally representative study we have shown that the rates of postoperative stroke complications following CABG have increased over time to commensurate with a parallel increase in overall baseline patient risks. Given the adverse impact of stroke on in-hospital morbidity and mortality after CABG, further studies are warranted to systematically delineate factors contributing to this striking trend.
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http://dx.doi.org/10.1111/ijcp.14067DOI Listing
February 2021

Outcomes of COVID-19 Positive Acute Coronary Syndrome Patients; a multisource Electronic Healthcare Records Study from England.

J Intern Med 2021 Jan 19. Epub 2021 Jan 19.

Keele Cardiovascular Research Group, Institute for Prognosis Research, School of Primary Care, Keele University, Stoke On Trent, United Kingdom of Great Britain and Northern Ireland.

Background: Patients with underlying cardiovascular disease and Coronavirus disease 2019 (COVID-19) infection are at increased risk of morbidity and mortality.

Objectives: This study was designed to characterise the presenting profile and outcomes of patients hospitalized with acute coronary syndrome (ACS) and COVID-19 infection.

Methods: This observational cohort study was conducted using multisource data from all acute NHS hospitals in England. All consecutive patients hospitalized with diagnosis of ACS with or without COVID-19 infection between 1 March- 31 May 2020 were included. The primary outcome was in-hospital and 30-day mortality.

Results: A total of 12,958 patients were hospitalized with ACS during the study period, of which 517 (4.0%) were COVID-19 positive and were more likely to present with non-ST elevation acute myocardial infarction. COVID-19 ACS group were generally older, Black Asian and Minority ethnicity, more comorbid and had unfavourable presenting clinical characteristics such as elevated cardiac troponin, pulmonary oedema, cardiogenic shock and poor left ventricular systolic function compared with non-COVID-19 ACS group. They were less likely to receive an invasive coronary angiography (67.7% vs 81.0%), percutaneous coronary intervention (PCI) (30.2% vs 53.9%) and dual antiplatelet medication (76.3% vs 88.0%). After adjusting for all the baseline differences, patients with COVID-19 ACS had higher in-hospital (adjusted odds ratio (aOR) 3.27 95% confidence interval (CI) 2.41-4.42) and 30-day mortality (aOR 6.53 95%CI 5.1-8.36) compared to the non COVID-19 ACS group.

Conclusion: COVID-19 infection was present in 4% of patients hospitalized with an ACS in England and is associated with lower rates of guideline recommended treatment and significant mortality hazard.
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http://dx.doi.org/10.1111/joim.13246DOI Listing
January 2021

Sex differences in distribution, management and outcomes of combined ischemic-bleeding risk following acute coronary syndrome.

Int J Cardiol 2020 Dec 31. Epub 2020 Dec 31.

Keele Cardiovascular Research Group, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom.

Background: Risk factors for further bleeding and ischemic events after acute coronary syndrome (ACS) often overlap. Little is known about sex-based differences in the management and outcomes of ACS patients according to their combined bleeding-ischemic risk.

Methods: All ACS hospitalizations in the United Kingdom (2010-2017) were retrospectively analyzed, stratified by sex and bleeding-ischemic risk combination (using CRUSADE and GRACE scores). Multivariable logistic regression was performed to examine association between risk-groups and 1) receipt of guideline-recommended management and 2) in-hospital outcomes.

Results: Of 584,360 patients, a third of males (32.3%) and females (32.6%) were in the dual high-risk group (High CRUSADE- High GRACE). In comparison to the dual low-risk group (Low CRUSADE-Low GRACE), the dual high-risk patients of both sexes were 59-83% less likely to receive inpatient revascularisation (PCI or CABG) and 50% less likely to receive dual antiplatelet therapy (DAPT) on discharge, with a significant increase in odds of MACE (~8 to 9-fold), all-cause and cardiac mortality (25 to 35-fold), and bleeding (78-91%). The greatest difference in management and clinical outcomes between sexes was found in the dual-high risk group where females were less likely to receive guideline-recommended therapy (revascularisation and DAPT), compared to males, and were more likely to experience MACE, all-cause and cardiac mortality.

Conclusion: ACS patients with dual high-risk for bleeding and recurrent ischemia, especially females, are less likely to receive guideline-recommended therapy and experience significantly worse outcomes. Novel strategies are needed to effectively manage this highly prevalent, complex patient group and address the under-treatment of females.
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http://dx.doi.org/10.1016/j.ijcard.2020.12.063DOI Listing
December 2020

In-Hospital and 30-Day Mortality After Percutaneous Coronary Intervention in England in the Pre-COVID and COVID Eras.

J Invasive Cardiol 2021 Mar 22;33(3):E206-E219. Epub 2020 Dec 22.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK.

Background: Public reporting of percutaneous coronary intervention (PCI) outcomes is a performance metric and a requirement in many healthcare systems. There are inconsistent data on the causes of death after PCI, and the proportion of these deaths that are attributable to cardiac causes.

Methods: All patients undergoing PCI in England between January 1, 2017 and May 10, 2020 (n = 273,141) were retrospectively analyzed according to their outcome from the date of PCI: no death, in-hospital death, postdischarge death, and total 30-day death. The present study examined short-term primary causes of death after PCI in a national cohort before and during COVID-19.

Results: The overall rates of in-hospital and 30-day death were 1.9% and 2.8%, respectively. The rate of 30-day death declined between 2017 (2.9%) and February 2020 (2.5%), mainly due to lower in-hospital death (2.1% vs 1.5%), before rising again from March 1, 2020 (3.2%) due to higher rates of postdischarge mortality. Only 59.6% of 30-day deaths were due to cardiac causes, with the most common causes being acute coronary syndrome, cardiogenic shock, and heart failure, and this persisted throughout the study period. In the 30-day death group, 10.4% after March 1, 2020 were due to confirmed COVID-19.

Conclusions: In this nationwide study, we show that 40% of 30-day deaths are due to non-cardiac causes. Non-cardiac deaths have increased even more from the start of the COVID-19 pandemic, with 1 in 10 deaths from March 2020 being COVID-19 related. These findings raise a question of whether public reporting of PCI outcomes should be cause specific.
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March 2021

Impact of pre-existent vascular and poly-vascular disease on acute myocardial infarction management and outcomes: An analysis of 2 million patients from the National Inpatient Sample.

Int J Cardiol 2021 Mar 30;327:1-8. Epub 2020 Nov 30.

Keele Cardiovascular Research Group, Keele University, UK; Royal Stoke Hospital, Stoke on Trent, UK; Department of Cardiology, Thomas Jefferson University, USA. Electronic address:

Background: Patients with pre-existing vascular disease are known to have worse outcomes after acute myocardial infarction (AMI). However, there is limited data for outcomes stratified by type and number of vascular territories involved.

Methods: Using the Nationwide Inpatient Sample (2015-2017), we examined outcomes of AMI in patients with pre-existent vascular disease stratified by number as well as types of diseased beds including all five major vascular sites: cardiac, cerebrovascular, renal, aortic and peripheral vascular disease (PVD). Multivariable logistic regression was used to determine the adjusted odds ratios (aOR) of adverse outcomes and invasive procedure utilization.

Results: Out of 2,184,614 AMI admissions, 49.7% had pre-existent vascular disease. The odds of major adverse cardiovascular and cerebrovascular events (MACCE), mortality, ischemic stroke and major bleeding incrementally increased and was highest in those with ≥3 vascular sites involved (aOR for MACCE 1.16, CI 1.13-1.19; mortality 1.3, CI 1.26-1.34; stroke 1.15, CI 1.1-1.2; major bleeding 1.21, CI 1.16-1.25). Amongst those with a single pre-existent diseased vascular bed, the adjusted odds of MACCE appeared to be higher in those with PVD (1.28, CI 1.26-1.31), aortic disease (1.24, CI 1.19-1.29), and cerebrovascular disease (1.22, CI 1.2-1.25). Patients with pre-existent vascular disease had a lower overall likelihood of undergoing invasive revascularization procedures.

Conclusions: Approximately half of the population presenting with AMI have pre-existent vascular disease. There is an incremental increase in adverse outcomes with increasing number of diseased vascular beds, with further differences in outcomes and utilization of invasive procedures based on sub-types of sites involved.
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http://dx.doi.org/10.1016/j.ijcard.2020.11.051DOI Listing
March 2021

Acute Myocardial Infarction in Autoimmune Rheumatologic Disease: A Nationwide Analysis of Clinical Outcomes and Predictors of Management Strategy.

Mayo Clin Proc 2021 02 26;96(2):388-399. Epub 2020 Nov 26.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK; Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA. Electronic address:

Objectives: To examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014.

Methods: All AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD.

Results: Of 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography-0.87; 0.84 to 0.91; PCI-0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication.

Conclusion: In a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.
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http://dx.doi.org/10.1016/j.mayocp.2020.04.044DOI Listing
February 2021

Trends, management and outcomes of acute myocardial infarction in chronic liver disease.

Int J Clin Pract 2020 Nov 21:e13841. Epub 2020 Nov 21.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom.

Aims: There are limited data on the management and outcomes of chronic liver disease (CLD) patients presenting with acute myocardial infarction (AMI), particularly according to the subtype of CLD.

Methods: Using the Nationwide Inpatient Sample (2004-2015), we examined outcomes of AMI patients stratified by severity and sub-types of CLD. Multivariable logistic regression was performed to assess the adjusted odds ratios (aOR) of receipt of invasive management and adverse outcomes in CLD groups compared with no-CLD.

Results: Of 7 024 723 AMI admissions, 54 283 (0.8%) had a CLD diagnosis. CLD patients were less likely to undergo coronary angiography (CA) and percutaneous coronary intervention (PCI) (aOR 0.62, 95%CI 0.60-0.63 and 0.59, 95%CI 0.58-0.60, respectively), and had increased odds of adverse outcomes including major adverse cardiovascular and cerebrovascular events (1.19, 95%CI 1.15-1.23), mortality (1.30, 95%CI 1.25-1.34) and major bleeding (1.74, 95%CI 1.67-1.81). In comparison to the non-severe CLD sub-groups, patients with all forms of severe CLD had the lower utilization of CA and PCI (P < .05). Among severe CLD patients, those with alcohol-related liver disease (ALD) had the lowest utilization of CA and PCI; patients with ALD and other CLD (OCLD) had more adverse outcomes than the viral hepatitis sub-group (P < .05).

Conclusions: CLD patients presenting with AMI are less likely to receive invasive management and are associated with worse clinical outcomes. Further differences are observed depending on the type as well as severity of CLD, with the worst management and clinical outcomes observed in those with severe ALD and OCLD.
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http://dx.doi.org/10.1111/ijcp.13841DOI Listing
November 2020

Safety and efficacy of coronary intravascular lithotripsy for calcified coronary arteries- a systematic review and meta-analysis.

Expert Rev Cardiovasc Ther 2021 Jan 9;19(1):89-98. Epub 2020 Dec 9.

Department of Internal Medicine, Detroit Heart center/Wayne State University , Detroit, MI, USA.

: Intravascular lithotripsy (IVL) clinical efficacy and safety in the treatment of calcified coronary artery disease (CAC) is not well known. We sought to assess IVL safety and efficacy in CAC. : A comprehensive online databases search were performed to identify intravascular lithotripsy studies in patients with coronary artery disease. The primary outcome was IVL related change in the mean pre and post-procedural diameter of the coronary artery. : A total of 4 studies with 282 patients were included. The mean pre-IVL coronary diameter for all patients was 1.01 mm, while the mean post-IVL coronary diameter was 2.70 mm. The mean pre-post IVL diameter difference of coronary arteries on the pooled analysis was significantly lower by 4.08 mm (95% CI -4.94 to -3.30, p ≤ 0.00001). The Overall increase in the post-IVL lumen diameter was significantly higher than the pre-IVL diameter with a mean difference of -4.16 (95% CI -5.08 to -3.24, p = 0.000001). However, compared to pre-IVL, there was a significant reduction in the overall mean difference of luminal calcium angle after IVL of the stented coronary arteries (0.09, 95% CI 0.002-0.16, p = 0.01). : Intravascular lithotripsy can offer a significant improvement in the vessel lumen to facilitate coronary stent delivery and deployments in severely calcified coronary arteries.
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http://dx.doi.org/10.1080/14779072.2021.1845143DOI Listing
January 2021

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality.

Eur Heart J Qual Care Clin Outcomes 2020 Oct 20. Epub 2020 Oct 20.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom.

Background: Limited data exists on the impact of COVID-19 on national changes in cardiac procedure activity, including patient characteristics and clinical outcomes before and during the COVID-19 pandemic.

Methods And Results: All major cardiac procedures (n = 374,899) performed between 1st January and 31st May for the years 2018, 2019 and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression was performed to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period.Overall, there was a deficit of 45,501 procedures during the COVID period compared to the monthly averages (March-May) in 2018-2019. Cardiac catheterisation and device implantations were the most affected in terms of numbers (n = 19,637 and n = 10,453) whereas surgical procedures such as MVR, other valve replacement/repair, ASD/VSD repair and CABG were the most affected as a relative percentage difference (Δ) to previous years' averages. TAVR was the least affected (Δ-10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterisation (OR 1.25 95% confidence interval (CI) 1.07-1.47, p = 0.006) and cardiac device implantation (OR 1.35 95% CI 1.15-1.58, p < 0.001).

Conclusion: Cardiac procedural activity has significantly declined across England during the COVID-19 pandemic, with a deficit in excess of 45000 procedures, without an increase in risk of mortality for most cardiac procedures performed during the pandemic. Major restructuring of cardiac services is necessary to deal with this deficit, which would inevitably impact long-term morbidity and mortality.
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http://dx.doi.org/10.1093/ehjqcco/qcaa079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665465PMC
October 2020

Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure.

Int J Cardiol 2021 Feb 3;324:205-213. Epub 2020 Oct 3.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom; Norwich Medical School, University of East Anglia, Norwich, United Kingdom. Electronic address:

Background: Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood.

Method: National Inpatient Sample (NIS) AIS admissions (January 2004-September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET).

Results: 69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75-85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively.

Conclusions: We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.
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http://dx.doi.org/10.1016/j.ijcard.2020.09.076DOI Listing
February 2021

Sex Differences in Mortality Rates and Underlying Conditions for COVID-19 Deaths in England and Wales.

Mayo Clin Proc 2020 10 23;95(10):2110-2124. Epub 2020 Jul 23.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. Electronic address:

Objective: To address the issue of limited national data on the prevalence and distribution of underlying conditions among COVID-19 deaths between sexes and across age groups.

Patients And Methods: All adult (≥18 years) deaths recorded in England and Wales (March 1, 2020, to May 12, 2020) were analyzed retrospectively. We compared the prevalence of underlying health conditions between COVID and non-COVID-related deaths during the COVID-19 pandemic and the age-standardized mortality rate (ASMR) of COVID-19 compared with other primary causes of death, stratified by sex and age group.

Results: Of 144,279 adult deaths recorded during the study period, 36,438 (25.3%) were confirmed COVID deaths. Women represented 43.2% (n=15,731) of COVID deaths compared with 51.9% (n=55,980) in non-COVID deaths. Overall, COVID deaths were younger than non-COVID deaths (82 vs 83 years). ASMR of COVID-19 was higher than all other common primary causes of death, across age groups and sexes, except for cancers in women between the ages of 30 and 79 years. A linear relationship was observed between ASMR and age among COVID-19 deaths, with persistently higher rates in men than women across all age groups. The most prevalent reported conditions were hypertension, dementia, chronic lung disease, and diabetes, and these were higher among COVID deaths. Pre-existing ischemic heart disease was similar in COVID (11.4%) and non-COVID (12%) deaths.

Conclusion: In a nationwide analysis, COVID-19 infection was associated with higher age-standardized mortality than other primary causes of death, except cancer in women of select age groups. COVID-19 mortality was persistently higher in men and increased with advanced age.
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http://dx.doi.org/10.1016/j.mayocp.2020.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377724PMC
October 2020

Place and causes of acute cardiovascular mortality during the COVID-19 pandemic.

Heart 2021 01 28;107(2):113-119. Epub 2020 Sep 28.

Leeds Institute for Data Analytics, University of Leeds, Leeds, UK

Objective: To describe the place and causes of acute cardiovascular death during the COVID-19 pandemic.

Methods: Retrospective cohort of adult (age ≥18 years) acute cardiovascular deaths (n=5 87 225) in England and Wales, from 1 January 2014 to 30 June 2020. The exposure was the COVID-19 pandemic (from onset of the first COVID-19 death in England, 2 March 2020). The main outcome was acute cardiovascular events directly contributing to death.

Results: After 2 March 2020, there were 28 969 acute cardiovascular deaths of which 5.1% related to COVID-19, and an excess acute cardiovascular mortality of 2085 (+8%). Deaths in the community accounted for nearly half of all deaths during this period. Death at home had the greatest excess acute cardiovascular deaths (2279, +35%), followed by deaths at care homes and hospices (1095, +32%) and in hospital (50, +0%). The most frequent cause of acute cardiovascular death during this period was stroke (10 318, 35.6%), followed by acute coronary syndrome (ACS) (7 098, 24.5%), heart failure (6 770, 23.4%), pulmonary embolism (2 689, 9.3%) and cardiac arrest (1 328, 4.6%). The greatest cause of excess cardiovascular death in care homes and hospices was stroke (715, +39%), compared with ACS (768, +41%) at home and cardiogenic shock (55, +15%) in hospital.

Conclusions And Relevance: The COVID-19 pandemic has resulted in an inflation in acute cardiovascular deaths, nearly half of which occurred in the community and most did not relate to COVID-19 infection suggesting there were delays to seeking help or likely the result of undiagnosed COVID-19.
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http://dx.doi.org/10.1136/heartjnl-2020-317912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523172PMC
January 2021

Early intervention or watchful waiting for asymptomatic severe aortic valve stenosis: a systematic review and meta-analysis.

J Cardiovasc Med (Hagerstown) 2020 Nov;21(11):897-904

Detroit Medical Center, DMC Heart Hospital, Detroit, Michigan, USA.

Background: The management of patients with severe but asymptomatic aortic stenosis is challenging. Evidence on early aortic valve replacement (AVR) versus symptom-driven intervention in these patients is unknown.

Methods: Electronic databases were searched, articles comparing early-AVR with conservative management for severe aortic stenosis were identified. Pooled adjusted odds ratio (OR) was computed using a random-effect model to determine all-cause and cardiovascular mortality.

Results: A total of eight studies consisting of 2201 patients were identified. Early-AVR was associated with lower all-cause mortality [OR 0.24, 95% confidence interval (CI) 0.13-0.45, P ≤ 0.00001] and cardiovascular mortality (OR 0.21, 95% CI 0.06-0.70, P = 0.01) compared with conservative management. The number needed to treat to prevent 1 all-cause and cardiovascular mortality was 4 and 9, respectively. The odds of all-cause mortality in a selected patient population undergoing surgical AVR (SAVR) (OR 0.16, 95% CI 0.09-0.29, P ≤ 0.00001) and SAVR or transcatheter AVR (TAVR) (OR 0.53, 95% CI 0.35-0.81, P = 0.003) were significantly lower compared with patients who are managed conservatively. A subgroup sensitivity analysis based on severe aortic stenosis (OR 0.24, 95% CI 0.11-0.52, P = 0.0004) versus very severe aortic stenosis (OR 0.20, 95% CI 0.08-0.51, P = 0.0008) also mirrored the findings of overall results.

Conclusion: Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early-AVR compared with conservative management. However, because of significant heterogeneity in the classification of asymptomatic patients, large scale studies are required.
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http://dx.doi.org/10.2459/JCM.0000000000001110DOI Listing
November 2020

Trends of repeat revascularization choice in patients with prior coronary artery bypass surgery.

Catheter Cardiovasc Interv 2020 Sep 5. Epub 2020 Sep 5.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, UK.

Objective: To examine rates and predictors repeat revascularization strategies (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) in patients with prior CABG.

Methods: Using the National Inpatient Sample, patients with a history of CABG hospitalized for revascularization by PCI or CABG from January 2004 to September 2015 were included. Regression analyses were performed to examine predictors of receipt of either revascularization strategy as well as in-hospital outcomes.

Results: The rate of redo CABG doubled between 2004 (5.3%) and 2015 (10.3%). Patients who underwent redo CABG were more comorbid and experienced significantly worse major adverse cardiovascular and cerebrovascular events (odds ratio [OR]: 5.36 95% CI 5.11-5.61), mortality (OR 2.84 95% CI 2.60,-3.11), bleeding (OR 5.97 95% CI 5.44-6.55) and stroke (OR 2.15 95% CI 1.92-2.41), but there was no difference in cardiac complications between groups. Thoracic complications were high in patients undergoing redo CABG (8%), especially in females. Factors favoring receipt of redo CABG compared to PCI included male sex, age < 80 years, and absence of diabetes and renal failure.

Conclusion: Reoperation in patients with prior CABG has doubled in the United States over a 12-year period. Patients undergoing redo CABG are more complex and associated with worse clinical outcomes than those receiving PCI.
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http://dx.doi.org/10.1002/ccd.29234DOI Listing
September 2020

Outcomes of Percutaneous Coronary Intervention in Cardiac Transplant Patients: A Binational Analysis Derived From the United Kingdom and United States.

J Invasive Cardiol 2020 Sep;32(9):321-329

Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom.

Aims: To compare and contrast the indications, clinical and procedural characteristics, and periprocedural outcomes of patients with cardiac transplant undergoing percutaneous coronary intervention (PCI) in the United States and United Kingdom.

Methods And Results: The British Cardiovascular Intervention Society Registry (BCIS) (2007-2014) and the United States National Inpatient Sample (NIS) (2004-2014) data were utilized for this analysis. There were 466 PCIs (0.09%) and 1122 PCIs (0.02%) performed in cardiac transplant patients in the BCIS and NIS registries, respectively. The cardiac transplant PCI cohort was younger and mostly men, with an increased prevalence of chronic kidney disease, left main PCI, and multivessel disease, and with lower use of newer antiplatelets agents, antithrombotics, and radial artery access vs the non-cardiac transplant PCI cohort. In the BCIS registry, the cardiac transplant PCI cohort had similar in-hospital mortality (odds ratio [OR], 1.05; P=.91), 30-day mortality (OR, 1.38; P=.31), vascular complications (OR, 0.69; P=.46), and major adverse cardiovascular event (OR, 1.41; P=.26) vs the non-cardiac transplant PCI cohort. However, the cardiac transplant group had higher 1-year mortality (OR, 2.30; P<.001). The NIS data analysis revealed similar rates of in-hospital mortality (OR, 2.40; P=.14), cardiac complications (OR, 0.26; P=.17), major bleeding (OR, 0.36; P=.16), vascular complications (OR, 0.46; P=.45), and stroke (OR, 0.50; P=.40) in the cardiac transplant PCI cohort vs the non-cardiac transplant PCI cohort.

Conclusions: PCI in cardiac transplant recipients was associated with similar short-term mortality and vascular complications compared with PCI in the general populace. However, a higher 1-year morality was observed in the BCIS cohort.
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September 2020

The predictive value of CHADS-VASc score on in-hospital death and adverse periprocedural events among patients with the acute coronary syndrome and atrial fibrillation who undergo percutaneous coronary intervention: a 10-year National Inpatient Sample (NIS) analysis.

Cardiovasc Revasc Med 2020 Aug 7. Epub 2020 Aug 7.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America. Electronic address:

Background: The predictive value of CHADS-VASc score regarding the in-hospital death and periprocedural adverse events following percutaneous coronary intervention (PCI) among patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is not established.

Methods: We retrospectively analyzed data of patients with the in-hospital and primary diagnosis of ACS, with concomitant AF, who underwent PCI during the 2004-2014 period from the US National Inpatient Sample database. A CHADS-VASc score was incorporated into multiple covariate-adjusted logistic regression analyses to determine its independent impact on designated outcomes.

Results: A total of 283,890 patients hospitalized with the primary diagnosis of ACS who underwent PCI and had an AF on record were included in the analysis. The average reported prevalence of AF in the whole cohort of ACS patients was 10.0% with a significant increasing trend during the observed 10-year period (p < .001). The average age of the cohort was 72.1 ± 11 years, 63.4% were male while the median CHADS-VASc score was 3 (IQR 2-4). Following adjustment for baseline covariates, incremental increase in CHADS-VASc score was independently associated with an increased odds of in-hospital death (OR 1.20, CI 95% 1.18-1.22), periprocedural vascular injury (OR 1.18, 95% CI 1.17-1.20), bleeding (OR 1.17, 95% CI 1.16-1.18), stroke/transient ischemic attack (OR 1.17, 95% CI 1.15-1.19), and acute kidney injury (OR 1.05, 95% CI 1.04-1.06).

Conclusions: The CHADS-VASc score provides important prognostic information in ACS patients undergoing PCI. It is independently associated with in-hospital death and adverse periprocedural events following PCI in patients presenting with ACS and concomitant AF.
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http://dx.doi.org/10.1016/j.carrev.2020.08.003DOI Listing
August 2020

Trends in sex-based differences in outcomes following coronary artery bypass grafting in the United States between 2004 and 2015.

Int J Cardiol 2020 Dec 29;320:42-48. Epub 2020 Jul 29.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK. Electronic address:

Background: The present study sought to examine the trends of sex-based differences in clinical outcomes after coronary artery bypass grafting (CABG), an area in which the current evidence remains limited.

Methods: All US adults hospitalized for first-time isolated CABG in the National Inpatient Sample database between 2004 and 2015 were included, stratified by sex. Multivariable regression analysis examined the adjusted odds ratios (OR) of postoperative in-hospital complications in females versus males. Trend analyses of sex-based differences in in-hospital post-operative complications over the study period were performed.

Results: Overall, 2,537,767 CABG procedures were analyzed, including 27.9% (n = 708,459) females. Female sex was associated with an increase in adjusted odds of all-cause mortality (OR 1.43 95% CI 1.40, 1.45), stroke (OR 1.34 95% CI 1.32, 1.37) and thoracic complications (OR 1.28 95% CI 1.27, 1.29) and lower odds of all-cause bleeding (OR 0.87 95% CI 0.86, 0.89) compared to males. Trend analysis revealed these sex differences to be persistent for mortality, stroke and thoracic complications (p = non-significant) but eliminated for bleeding over the study period (p < 0.001).

Conclusion: Despite technical advances over the 12-year period, worse post-operative outcomes including death, stroke, and thoracic complications have persisted in female patients after CABG. These findings are concerning and underscore the need for risk reduction strategies to address this disparity gap.
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http://dx.doi.org/10.1016/j.ijcard.2020.07.039DOI Listing
December 2020

Impact of Charlson Co-Morbidity Index Score on Management and Outcomes After Acute Coronary Syndrome.

Am J Cardiol 2020 09 17;130:15-23. Epub 2020 Jun 17.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; School of Primary, Community, and Social Care, Keele University, United Kingdom. Electronic address:

Patients presenting with acute coronary syndrome (ACS) are frequently co-morbid. However, there is limited data on how co-morbidity burden impacts their receipt of invasive management and subsequent outcomes. We analyzed all patients with a discharge diagnosis of ACS from the National Inpatient Sample (2004 to 2014), stratified by Charlson Co-morbidity Index (CCI) into 4 classes (CCI 0, 1, 2, and ≥3). Regression analyses were performed to examine associations between co-morbidity burden and receipt of invasive intervention and in-hospital clinical outcomes. Of all 6,613,623 ACS patients analyzed, the prevalence of patients with severe co-morbidity (CCI ≥3) increased from 10.8% (2004) to 18.1% (2014). CCI class negatively correlated with receipt of invasive management, with CCI ≥3 group being the least likely to receive coronary angiography and percutaneous coronary intervention (odds ratio (OR) 0.42 95% confidence interval [CI] 0.41 to 0.43 and OR 0.47, 95% CI 0.46 to 0.48, respectively). CCI class was independently associated with an increased risk of mortality and complications, especially CCI ≥3 that was associated with significantly increased odds of Major Acute Cardiovascular & Cerebrovascular Events (OR 1.70, 95% CI 1.66 to 1.75), mortality (OR 1.74, 95% CI 1.68 to 1.79), acute ischemic stroke (OR 2.35, 95% CI 2.23 to 2.46), and major bleeding (OR 1.64, 95% CI 1.59 to 1.69). Co-morbidity burden has significantly increased amongst those presenting with ACS over an 11-year period and correlates with reduced likelihood of receipt of invasive management and increased odds of mortality and adverse outcomes. In conclusion, objective assessment of co-morbidities using CCI score identifies high-risk ACS patients in whom targeted risk reduction strategies may reduce their inherent risk of mortality and complications.
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http://dx.doi.org/10.1016/j.amjcard.2020.06.022DOI Listing
September 2020

Outcomes of Percutaneous Coronary Intervention in Patients With Crohn's Disease and Ulcerative Colitis (from a Nationwide Cohort).

Am J Cardiol 2020 09 17;130:30-36. Epub 2020 Jun 17.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; Department of Cardiology, Jefferson University, Philadelphia, Pennsylvania. Electronic address:

Patients with inflammatory bowel disease (IBD) are at an increased risk of ischemic heart disease. However, there is limited evidence on how their outcomes after percutaneous coronary intervention (PCI) compare with those without IBD. All PCI-related hospitalizations from the National Inpatient Sample from 2004 to 2015 were included, stratified into 3 groups: no-IBD, Crohn's disease (CD), and ulcerative colitis (UC). We assessed the association between IBD subtypes and in-hospital outcomes. A total of 6,689,292 PCI procedures were analyzed, of which 0.3% (n = 18,910) had an IBD diagnosis. The prevalence of IBD increased from 0.2% (2004) to 0.4% (2015). Patients with IBD were less likely to have conventional cardiovascular risk factors and more likely to undergo PCI for an acute indication, and to receive bare metal stents. In comparison to patients without IBD, those with IBD had reduced or similar adjusted odds ratios (OR) of major adverse cardiovascular and cerebrovascular events (CD OR 0.69, 95% confidence interval (CI) 0.62 to 0.78; UC OR 0.75, 95% CI 0.66 to 0.85), mortality (CD: OR 0.94, 95% CI 0.79 to 1.11; UC OR 0.35, 95% CI 0.27 to 0.45) or acute cerebrovascular accident (CD: OR 0.73, 95% CI 0.60 to 0.89; UC: OR 0.94, 95% CI 0.77 to 1.15). However, IBD patients had an increased odds for major bleeding (CD: OR 1.42 95% CI 1.23 to 1.63, and UC: OR 1.35 95% CI 1.16 to 1.58). In summary, IBD is associated with a decreased risk of in-hospital post-PCI complications other than major bleeding that was significantly higher in this group. Long term follow-up is required to evaluate the safety of PCI in IBD patients from both bleeding and ischemic perspectives.
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http://dx.doi.org/10.1016/j.amjcard.2020.06.013DOI Listing
September 2020

Impact of coronary lesion complexity in percutaneous coronary intervention: one-year outcomes from the large, multicentre e-Ultimaster registry.

EuroIntervention 2020 Sep;16(7):603-612

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, Newcastle, United Kingdom.

Aims: The present study sought to examine the prevalence, clinical characteristics and one-year outcomes of patients undergoing percutaneous coronary intervention (PCI) to complex lesions (multivessel PCI, ≥3 stents, ≥3 lesions, bifurcation with ≥2 stents, total stent length >60 mm or chronic total occlusion [CTO]) in a prospective multicentre registry.

Methods And Results: Using the e-Ultimaster multicentre registry, a post hoc subgroup analysis was performed on 35,839 patients undergoing PCI, stratified by procedure complexity, and further by number and type of complex features. Overall, complex PCI patients (n=9,793, 27.3%) were older, more comorbid and were associated with an increased hazard ratio (HR) of the composite endpoint at one year (target lesion failure [TLF]: 1.41 [1.25; 1.59]), driven by an increased hazard of cardiac death (1.28 [1.05; 1.55]), target vessel myocardial infarction (1.48 [1.18; 1.86]) and clinically driven target lesion revascularisation. The hazard of complications increased with the rising number of complex features (3-6 vs 1-2 vs none) for all outcomes. All individual complex features were associated with an increased hazard of composite complications (except CTO) and definite/probable stent thrombosis.

Conclusions: Overall, complex PCI is associated with an increased risk of mortality and complications at one year. The number and types of complex features have differing impacts on long-term outcomes.
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http://dx.doi.org/10.4244/EIJ-D-20-00361DOI Listing
September 2020

Socioeconomic Status and Differences in the Management and Outcomes of 6.6 Million US Patients With Acute Myocardial Infarction.

Am J Cardiol 2020 08 26;129:10-18. Epub 2020 May 26.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK; Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Electronic address:

Little is known about the impact of socioeconomic status (SES) on management strategies and in-hospital clinical outcomes in patients with acute myocardial infarction (AMI) and its subtypes, and whether these trends have changed over time. All AMI hospitalizations from the National Inpatient Sample (2004 to 2014) were analyzed and stratified by zip code-based median household income (MHI) into 4 quartiles (poorest to wealthiest): 0th to 25th, 26th to 50th, 51st to 75, and 76th to 100th. Logistic regression was performed to examine the association between MHI and AMI management strategy and in-hospital clinical outcomes. A total of 6,603,709 AMI hospitalizations were analyzed. Patients in the lowest MHI group had more co-morbidities, a worse cardiovascular risk factor profile and were more likely to be female. Differences in receipt of invasive management were observed between the lowest and highest MHI quartiles, with the lowest MHI group less likely to undergo coronary angiography (63.4% vs 64.3%, p <0.001) and percutaneous coronary intervention (40.4% vs 44.3%, p <0.001) compared with the highest MHI group, especially in the STEMI subgroup. In multivariable analysis, the highest MHI group experienced better outcomes including lower risk (adjusted odds ratio; 95% confidence intervals) of mortality (0.88; 0.88 to 0.89), MACCE (0.91; 0.91 to 0.92) and acute ischemic stroke (0.90; 0.88 to 0.91), but higher all-cause bleeding (1.08; 1.06 to 1.09) in comparison to the lowest MHI group. In conclusion, the provision of invasive management for AMI in patients with lower SES is less than patients with higher SES and is associated with worse in-hospital clinical outcomes. This work highlights the importance of ensuring equity of access and care across all strata SES.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.025DOI Listing
August 2020

Prevalence and in-hospital outcomes of patients with malignancies undergoing de novo cardiac electronic device implantation in the USA.

Europace 2020 07;22(7):1083-1096

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK.

Aims: To study the outcomes of cancer patients undergoing cardiac implantable electronic device (CIED) implantation.

Methods And Results: De novo CIED implantations (2004-15; n = 2 670 590) from the National Inpatient Sample were analysed for characteristics and in-hospital outcomes, stratified by presence of cancer (no cancer, historical and current cancers) and further by current cancer type (haematological, lung, breast, colon, and prostate). Current and historical cancer prevalence has increased from 3.3% to 7.8%, and 5.8% to 7.8%, respectively, between 2004 and 2015. Current cancer was associated with increased adjusted odds ratio (OR) of major adverse cardiovascular events (MACE) [composite of all-cause mortality, thoracic and cardiac complications, and device-related infection; OR 1.26, 95% confidence interval (CI) 1.23-1.30], all-cause mortality (OR 1.43, 95% CI 1.35-1.50), major bleeding (OR 1.38, 95% CI 1.32-1.44), and thoracic complications (OR 1.39, 95% CI 1.35-1.43). Differences in outcomes were observed according to cancer type, with significantly worse MACE, mortality and thoracic complications with lung and haematological malignancies, and increased major bleeding in colon and prostate malignancies. The risk of complications was also different according to CIED subtype.

Conclusion: The prevalence of cancer patients amongst those undergoing CIED implantation has significantly increased over 12 years. Overall, current cancers are associated with increased mortality and worse outcomes, especially in patients with lung, haematological, and colon malignancies whereas there was no evidence that historical cancer had a negative impact on outcomes.
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http://dx.doi.org/10.1093/europace/euaa087DOI Listing
July 2020

Temporal Trends in Comorbidity Burden and Impact on Prognosis in Patients With Acute Coronary Syndrome Using the Elixhauser Comorbidity Index Score.

Am J Cardiol 2020 06 17;125(11):1603-1611. Epub 2020 Mar 17.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. Electronic address:

Despite current evidence, little is known about the impact of comorbidity burden on invasive management strategies and clinical outcomes in the context of acute coronary syndrome (ACS). All ACS hospitalizations between 2004 and 2014 from the National Inpatient Sample were included, stratified by Elixhauser Comorbidity Score (ECS) and number of Elixhauser Comorbidities (NEC) to compare the receipt of invasive management and clinical outcomes between different ECS and NEC classes to the lowest class of either measure. A total of 6,613,623 records with ACS were included in the analysis. Overall comorbidity burden increased over the 11-year period, with higher comorbidity classes (ECS ≥ 14 and NEC ≥ 5) increasing from 2.1% to 4.6% and 4% to 16%, respectively. Higher ECS and NEC classes negatively correlated with the rates of utilization of coronary angiography (CA) and percutaneous coronary intervention (PCI) (ECS ≥14 vs <0: CA: 38.2% vs 69.3%, PCI: 18.6% vs 45.3%; NEC ≥5 vs 0: CA: 49.3% vs 73.4%, PCI: 24.4% vs 57.4%). Overall, higher ECS and NEC classes were independently associated with significantly increased odds of all complications, including major acute cardiovascular and cerebrovascular events, mortality, stroke and bleeding. In conclusion, among patients hospitalized for ACS, a higher comorbidity number or severity is associated with lower rates of receipt of CA and PCI, but not coronary artery bypass grafting, and worse clinical outcomes. Comorbidity burden assessment using ECS can help stratify patient groups at greatest risk of adverse outcomes in which invasive management is currently underutilized.
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http://dx.doi.org/10.1016/j.amjcard.2020.02.044DOI Listing
June 2020

Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI.

Can J Cardiol 2020 06 16;36(6):868-877. Epub 2019 Oct 16.

Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke on Trent, United Kingdom; Department of Cardiology, University Hospital of North Midlands, Stoke on Trent, United Kingdom; Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.

Background: Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown.

Methods: We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes.

Results: A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.

Conclusions: This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.
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http://dx.doi.org/10.1016/j.cjca.2019.10.010DOI Listing
June 2020

Unplanned hospital readmissions after acute myocardial infarction: a nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014.

Coron Artery Dis 2020 Jun;31(4):354-364

Keele Cardiovascular Research Group, Keele University.

Background: Unplanned hospital readmissions are an important quality metric for benchmarking, but there are limited data following an acute myocardial infarction (AMI). This study aims to examine the 30-day unplanned readmission rate, predictors, causes and outcomes after hospitalization for AMI.

Methods: The USA Nationwide Readmission Database was utilized to analyze patients with a primary diagnosis of AMI between 2010 and 2014. Rates of readmissions, causes and costs were determined and multiple logistic regressions were used to identify predictors of readmissions.

Results: Of 2 204 104 patients with AMI, the 30-day unplanned readmission rate was 12.3% (n = 270 510), which changed from 13.0 to 11.5% between 2010 and 2014. The estimated impact of readmissions in AMI was ~718 million USD and ~281000 additional bed days per year. Comorbidities such as diabetes [odds ratio (OR) 1.27, 95% confidence interval (CI) 1.25-1.29], chronic lung disease (OR 1.29, 95% CI 1.26-1.31), renal failure (OR 1.38, 95% CI 1.35-1.40) and cancer (OR 1.35, 95% CI 1.30-1.41) were independently associated with unplanned readmission. Discharge against medical advice was the variable most strongly associated with unplanned readmission (OR 2.40, 95% CI 2.27-2.54). Noncardiac causes for readmissions accounted for 52.9% of all readmissions. The most common cause of cardiac readmission was heart failure (14.3%) and for noncardiac readmissions was infections (8.8%).

Conclusion: Readmissions during the first month after AMI occur in more than one in 10 patients resulting in a healthcare cost of ~718 million USD per year and ~281000 additional bed days per year. These findings have important public health implications. Strategies to identify and reduce readmissions in AMI will dramatically reduce healthcare costs for society.
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http://dx.doi.org/10.1097/MCA.0000000000000844DOI Listing
June 2020

Management strategies and clinical outcomes of acute myocardial infarction in leukaemia patients: Nationwide insights from United States hospitalisations.

Int J Clin Pract 2020 May 20;74(5):e13476. Epub 2020 Jan 20.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK.

Background: Patients with leukaemia are at increased risk of cardiovascular events. There are limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI).

Methods: We queried the Nationwide Inpatient Sample (2004-2014) for patients with a primary discharge diagnosis of AMI, and a concomitant diagnosis of leukaemia, and further stratified according to the subtype of leukaemia. Multivariable logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding.

Results: Out of 6 750 878 AMI admissions, a total of 21 694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs 7.8%), mortality (10.3% vs 5.8%) and bleeding (5.6% vs 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20, 1.31]) and mortality (OR 1.43 [1.37, 1.50]) without an increased risk of bleeding (OR 0.86 [0.81, 0.92]). Acute myeloid leukaemia (AML) was associated with approximately threefold risk of MACCE (OR 2.81 [2.51, 3.13]) and a fourfold risk of mortality (OR 3.75 [3.34, 4.22]). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs 42.9%) compared with those without leukaemia.

Conclusion: Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared with those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.
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http://dx.doi.org/10.1111/ijcp.13476DOI Listing
May 2020