Publications by authors named "Paulino Alvarez"

94 Publications

Outcomes after heart transplantation in patients with cardiac sarcoidosis.

ESC Heart Fail 2022 Jan 15. Epub 2022 Jan 15.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.

Background: The number of patients with sarcoidosis requiring heart transplantation (HT) is increasing. The aim of this study was to evaluate outcomes of isolated HT in patients with sarcoid cardiomyopathy and compare them to recipients with non-ischaemic restrictive or dilated cardiomyopathy.

Methods And Results: Adult HT recipients were identified in the UNOS Registry between 1990 and 2020. Patients were grouped according to diagnosis. The cumulative incidences for the all-cause mortality and rejection were compared using Fine and Gray model analysis, accounting for re-transplantation as a competing risk. Rejection was evaluated using logistic regression analysis. We also reviewed characteristics and outcomes of all HT recipients with previous diagnosis of sarcoid cardiomyopathy from a single centre. A total of 30 160 HT recipients were included in the present study (n = 239 sarcoidosis, n = 1411 non-ischaemic restrictive cardiomyopathy, and n = 28 510 non-ischaemic dilated cardiomyopathy). During a total of 194 733 patient-years, all-cause mortality at the latest follow-up was not significantly different when comparing sarcoidosis to non-ischaemic dilated cardiomyopathy [adjusted subhazard ratio (aSHR) 1.46, 95% confidence intervals (CIs): 0.9-2.4, P = 0.12] or restrictive cardiomyopathy (aSHR 1.12, 95% CI: 0.65-1.95, P = 0.67). Accordingly, multivariable analysis suggested that 1 year mortality was not significantly different between sarcoidosis and non-ischaemic dilated cardiomyopathy (aSHR 1.56, 95% CI: 0.9-2.7, P = 0.12) or restrictive cardiomyopathy (aSHR 1.15, 95% CI: 0.61-2.18, P = 0.66). No differences were observed regarding 30 day mortality, treated and hospitalized acute rejection, and 30 day death from graft failure after HT. Thirty-day mortality did not improve significantly in more recent HT eras whereas there was a trend towards improved 1 year mortality in the latest HT era (P = 0.06). Data from the single-centre case review showed excellent long-term outcomes with sirolimus-based immunosuppression.

Conclusions: Short-term and long-term post HT outcomes among patients with sarcoid cardiomyopathy are similar to those with common types of non-ischaemic cardiomyopathy.
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http://dx.doi.org/10.1002/ehf2.13789DOI Listing
January 2022

Outcomes of diabetic patients with end-stage heart failure listed for heart transplantation: A propensity-matched analysis.

Clin Transplant 2022 Jan 12:e14590. Epub 2022 Jan 12.

Division of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa, IA, United States.

Background: We investigated the current trends and outcomes of diabetic patients listed for heart transplants in the U.S. and provided a method for risk-stratification.

Methods: Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity-matched with non-diabetics, and waitlist mortality as well as post-transplant graft survival were compared between the two groups. Further risk-stratification of diabetic patients was done based on the risk factors that independently predict graft failure.

Results: 28,928 adult patients (30% diabetic) with end-stage heart failure were added to the waitlist over the study period. In the propensity-matched cohort, waitlist mortality was higher in diabetic patients compared to non-diabetics (HR = 1.13 (95% CI = 1.04-1.22, p = 0.002). Over the study period, 5739 patients with diabetes were transplanted. In the propensity-matched cohorts of transplant recipients, the rate of graft failure was significantly higher for diabetic patients (23.3%) compared to non-diabetics (20.4%); HR = 1.17, 95% CI = 1.08-1.26, p<0.001. We identified 12 risk factors of graft failure among diabetic patients and developed a risk score that further risk-stratify these patients. Diabetic patients at low risk (score≤4) had similar graft survival as patients without diabetes (HR = 0.91, 95% CI = 0.82-1.01, p = 0.06). On the other hand, high-risk diabetic patients had worse graft survival compared to non-diabetics (HR = 1.52, 95% CI = 1.38-1.67, P<0.001).

Conclusion: Among patients with end-stage heart failure, pre-existing diabetes was associated with higher waitlist mortality and worse graft survival. However, with careful patient selection, graft survival is similar to those without diabetes. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/ctr.14590DOI Listing
January 2022

Incidence and long-term outcome of heart transplantation patients who develop postoperative renal failure requiring dialysis.

J Heart Lung Transplant 2021 Nov 29. Epub 2021 Nov 29.

Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa City, Iowa; National and Kapodistrian University of Athens, Athens, Greece. Electronic address:

Background: Acute renal failure requiring dialysis after heart transplantation remains a significant clinical issue because of its increasing incidence. We aimed to investigate its time trends, clinical predictors, and long-term outcomes.

Methods: Adult heart transplantation recipients registered in the United Network for Organ Sharing registry between 2009 and 2020 were identified. The patients were grouped according to the requirement for dialysis in the postoperative heart transplantation period. The independent risk predictors were identified, and the association between post-heart transplantation renal failure requiring dialysis and long-term mortality accounting for re-transplantation was investigated.

Results: A total of 28,170 patients were included in the study, of which 3,371 (12%) required dialysis immediately post-heart transplantation. The incidence increased from 7.9% to 13.9% during the study period. Longer ischemic time, serum creatinine at transplantation >1.2 mg/dL, prior cardiac surgery, higher recipient body mass index, support of mechanical ventilation or extracorporeal membrane oxygenation, and history of congenital heart disease or restrictive/hypertrophic cardiomyopathy were its predictors (all p < 0.05). Patients on posttransplant dialysis had a higher risk of all-cause mortality (adjusted hazard ratio [aHR]: 5.2, 95% CI: 4.7-5.7, p < 0.001), 30 day mortality (aHR: 7.7, 95% CI: 6.3-9.6, p < 0.001) and 1 year mortality (aHR: 7.5, 95% CI: 6.6-8.6, p < 0.001). Post-transplant dialysis was associated with a risk of treated rejection at 1 year.

Conclusion: Acute renal failure requiring dialysis after heart transplantation is associated with significantly worse 30 day and long-term mortalities, and thus, early identification of high-risk patients is crucial to prevent severe renal complications.
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http://dx.doi.org/10.1016/j.healun.2021.11.017DOI Listing
November 2021

Direct Oral Anticoagulants in Cardiac Amyloidosis-Associated Heart Failure and Atrial Fibrillation.

Am J Cardiol 2022 Feb 27;164:141-143. Epub 2021 Nov 27.

Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.amjcard.2021.10.018DOI Listing
February 2022

Changing Demographics, Temporal Trends in Waitlist, and Posttransplant Outcomes After Heart Transplantation in the United States: Analysis of the UNOS Database 1991-2019.

Circ Heart Fail 2021 11 25;14(11):e008764. Epub 2021 Oct 25.

Division of Heart Failure and Transplant (A.B.), University of Iowa Hospitals and Clinics, Iowa City.

Background: We sought to investigate temporal trends in patient characteristics, waitlist, and posttransplant outcomes after heart transplantation in the United States.

Methods: Using data from the United Network of Organ Sharing, we identified adults listed for heart transplantation between 1991 and 2019. Patients were divided into 4 eras based on the 3 time points in which changes were made to the patient selection/allocation policy (Era 1=January 1991-January 1999; Era 2=January 1999-July 2006; Era 3=July 2006-October 2018; and Era 4=October 2018-March 2020), and patient characteristics, waitlist, and posttransplant outcomes were evaluated for each era.

Results: Between 1991 and 2019, 95 179 patients were added to the heart transplantation waitlist. Compared with Era 1, patients listed in Era 4 were older (mean age: 50 versus 52 years) and with higher risk comorbidities (eg, 10% versus 28.8% diabetes, 23.3% versus 35.6% obese). Over the study period, 22 738 patients died or were permanently delisted for deterioration on the waitlist while 61 687 were transplanted. Compared with the preceding era, there was significant decrease in death or deterioration in the last 2 eras (sub-hazard ratio, 0.67 [95% CI, 0.65-0.70] for Era 3 versus Era 2 and sub-hazard ratio, 0.65 [95% CI, 0.58-0.73] for Era 4 versus 3). Across the years, 27.1% to 40.5% of those on the waitlist were transplanted. Among those transplanted, there was increase in the rates of in-hospital stroke (2.8% in Era 1 to 3.7% in Era 4), renal failure requiring dialysis (7.2%-17.1%), and length-of-stay (14-17days), <0.001. However, this did not negatively impact short-term survival when compared with the preceding era (1-year graft survival from Era 1 to Era 4=84.1%, 86.4%, 90.4%, and 89.7%, respectively).

Conclusions: There have been significant changes in the characteristics of patients listed for heart transplantation. Although transplant volume has increased, the wide supply-demand gap persisted. The last two changes in the allocation policy achieved their primary objective of reducing waitlist mortality.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.008764DOI Listing
November 2021

Trends, risk factors, and outcomes of post-operative stroke after heart transplantation: an analysis of the UNOS database.

ESC Heart Fail 2021 10 25;8(5):4211-4217. Epub 2021 Aug 25.

National Kapodistrian University of Athens Medical School, Athens, Greece.

Background: Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HTx) are limited.

Methods And Results: We conducted a retrospective analysis of the United Network for Organ Sharing (UNOS) database from 2009 to 2020 to identify adults who developed stroke after orthotropic HTx. Heart transplant recipients were divided according to the presence or absence of post-operative stroke. The primary endpoint was all-cause mortality. A total of 25 015 HT recipients were analysed, including 719 (2.9%) patients who suffered a post-operative stroke. The stroke rates increased from 2.1% in 2009 to 3.7% in 2019, and the risk of stroke was higher after the implantation of the new allocation system [odds ratio 1.29, 95% confidence intervals (CI) 1.06-1.56, P = 0.01]. HTx recipients with post-operative stroke were older (P = 0.008), with higher rates of prior cerebrovascular accident (CVA) (P = 0.004), prior cardiac surgery (P < 0.001), longer waitlist time (P = 0.04), higher rates of extracorporeal membrane oxygenation (ECMO) support (P < 0.001), left ventricular assist devices (LVADs) (P < 0.001), mechanical ventilation (P = 0.003), and longer ischaemic time (P < 0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischaemic time, and mechanical ventilation at the time of HTx were independent predictors of post-operative stroke. Stroke was associated with increased risk of 30 day and all-cause mortality (hazard ratio 1.49, 95% CI 1.12-1.99, P = 0.007).

Conclusions: Post-operative stroke after HTx is infrequent but associated with higher mortality. Redo sternotomy, LVAD, and ECMO support at HTx are among the risk factors identified.
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http://dx.doi.org/10.1002/ehf2.13562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497374PMC
October 2021

Prognostic Implications of Ambulatory N-Terminal Pro-B-Type Natriuretic Peptide Changes in Patients with Continuous-Flow Left Ventricular Assist Devices.

ASAIO J 2021 Aug 3. Epub 2021 Aug 3.

From the Department of Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa, Iowa Department of Medicine, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York Department of Surgery, University of Iowa Health Care, Carver College of Medicine, Iowa, Iowa.

Data regarding the role of N-terminal Pro-B-type natriuretic peptide (NT-pro BNP) in patients with a continuous-flow left ventricular assist device (CFLVAD) is scarce. To evaluate the prognostic implications of measuring both absolute values and changes in NT-pro BNP concentrations in ambulatory patients with a CFLVAD, we performed a retrospective study of 168 consecutive patients who had an LVAD implantation at our institution and survived beyond their index hospitalization. Of these, 127 patients (56.2 ± 12.5 years, 21.2% female) had NT-pro BNP measured at 1 and 3 months postdischarge in ambulatory settings. Compared to the NT-pro BNP concentration at 1 month, 94 patients (74%) had a decline, and 33 patients (26%) had an increase in concentrations, from their 1 month baseline. After a median follow-up of 17 months, a total of 53 (41.7%) adverse events occurred. Of these, 37 (69.8%) were heart failure (HF) hospitalizations, and 16 (30.2%) were deaths. For each 1,000 unit increase in NT-pro BNP concentration at 3 months, there was a 17% increase in the risk of HF hospitalization or death (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.04-1.32, p = 0.007). Conversely, each 1000 unit decline during the same time, was associated with an 11% decrease in the risk of HF hospitalization or death (HR = 0.89, 95% CI = 0.77-0.98, p = 0.04). In conclusion, in patients with a CFLAD, an increase in NT-pro BNP concentration from 1 to 3 months is associated with an increased risk of HF hospitalization and death. In contrast, a decline is associated with a reduction in the risk of HF hospitalization and death.
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http://dx.doi.org/10.1097/MAT.0000000000001524DOI Listing
August 2021

Impact of induction therapy on outcomes after heart transplantation.

Clin Transplant 2021 Oct 29;35(10):e14440. Epub 2021 Jul 29.

Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa, Iowa, USA.

Background: Approximately 50% of heart transplant (HT) programs utilize induction therapy (IT) with interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG).

Methods: Adult HT recipients were identified in the UNOS Registry between 2010 and 2020. We compared mortality between IT strategies with competing risk analysis.

Results: A total of 28 634 HT recipients were included in the study (50.1% no IT, 21.3% ATG, 27.9% IL2RA, .7% alemtuzumab, .01% OKT3). Adjusted all-cause, 30 day and 1 year mortality were lower among those treated with IT than no IT (sub-hazard ratio [SHR] .87, 95% CI .79-.96, SHR .86, .76-.97, SHR .76, .63-.93, P = .007, respectively). In propensity score matching analysis IT was associated with lower 30-day and 1-year mortality. IL2RA had higher all-cause and 1-year mortality than ATG (SHR 1.41, 95% CI 1.23-1.69 and 1.55, 95% CI 1.29-1.88, respectively). Utilization of IT was associated with significantly lower risk of treated rejection at 1 year after HT compared with no IT (relative risk ratio [RRR] .79) and similarly ATG compared with IL2RA (RRR .51).

Conclusion: IT was associated with lower mortality and treated rejection episodes than no IT. IL2RA is the most used IT approach but ATG has lower risk of treated rejection and mortality.
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http://dx.doi.org/10.1111/ctr.14440DOI Listing
October 2021

Trends, Risk Factors, and Mortality of Unplanned 30-day Readmission After Heart Transplantation.

Am J Cardiol 2021 09 18;154:130-133. Epub 2021 Jul 18.

Department of Cardiology, Westchester Medical Center, New York, New York.

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http://dx.doi.org/10.1016/j.amjcard.2021.06.002DOI Listing
September 2021

Chronic disease management in heart failure: focus on telemedicine and remote monitoring.

Rev Cardiovasc Med 2021 06;22(2):403-413

Department of Clinical Therapeutics, National Kapodistrian University of Athens, 15771 Attica, Greece.

In the context of the COVID-19 pandemic, many barriers to telemedicine disappeared. Virtual visits and telemonitoring strategies became routine. Evidence is accumulating regarding the safety and efficacy of virtual visits to replace in-person visits. A structured approach to virtual encounters is recommended. Telemonitoring includes patient reported remote vital sign monitoring, information from wearable devices, cardiac implantable electronic devices and invasive remote hemodynamic monitoring. The intensity of the monitoring should match the risk profile of the patient. Attention to cultural and educational barriers is important to prevent disparities in telehealth implementation.
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http://dx.doi.org/10.31083/j.rcm2202046DOI Listing
June 2021

Outflow graft foreign body reaction and thrombosis in HeartMate 3 left ventricular assist device.

Asian Cardiovasc Thorac Ann 2021 Jul 5:2184923211031343. Epub 2021 Jul 5.

Section of Heart Failure and Transplantation, Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Outflow cannula occlusion is an infrequent complication occurring among recipients of continuous flow left ventricular assist devices. Hereby, we present a case of a 66-year-old man with a HeartMate 3 left ventricular assist device that presented 18 months after implantation and during his admission, evidence of poor left ventricular unloading and forward flow uncovered intrinsic and extrinsic outflow cannula obstruction. The patient's course was complicated by cardiogenic shock, diffuse alveolar hemorrhage and multiorgan failure. Post-mortem examination suggested foreign body reaction as a potential contributor of outflow graft obstruction at the level of the bend relief.
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http://dx.doi.org/10.1177/02184923211031343DOI Listing
July 2021

Enoxaparin Use and Adverse Events in Outpatients With a Continuous Flow Left Ventricular Assist Device at a Single Institution.

J Pharm Pract 2021 Mar 2:897190021993382. Epub 2021 Mar 2.

Department of Pharmaceutical Care, The University of Iowa Hospitals and Clinics, University of Iowa Health Care, Iowa City, IA, USA.

Background: Patients with left ventricular assist devices (LVADs) are anticoagulated with warfarin and may receive enoxaparin bridging for a subtherapeutic international normalized ratio (INR). There is no guideline regarding enoxaparin bridging in LVAD patients and a dosing strategy to ensure efficacy and safety is uncertain.

Objective: The objective was to characterize the use of enoxaparin bridging for subtherapeutic INRs and its impact on thrombotic or major bleeding events (MBE) in patients with an LVAD.

Methods: A retrospective review from 6/1/17 to 6/30/18 was performed. Patients with an LVAD were excluded if they had less than 60 days of outpatient anticoagulation or age <18 years old. Patients were divided into 2 cohorts based on enoxaparin exposure. MBE and thrombotic events were classified as related to enoxaparin if events occurred while receiving enoxaparin and up to 7 days or 30 days, respectively, after discontinuation.

Results: Seventy-one LVAD patients met inclusion criteria and 50 patients received enoxaparin bridging. Therapeutic-dose enoxaparin was initiated at a mean INR of 1.8 for a mean duration of 2.8 days. In the enoxaparin exposure group, one MBE occurred 6 days after enoxaparin discontinuation, coinciding with an INR increase from 1.8 to 4.7. One thrombotic event occurred 2 days after enoxaparin discontinuation at an INR of 5.0.

Conclusion: This institution's bridging strategy of therapeutic-dose enoxaparin with a short duration has a low rate of bleeding and thrombotic events. Additional prospective studies of anticoagulation bridging based on characteristics such as type of LVAD device are warranted.
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http://dx.doi.org/10.1177/0897190021993382DOI Listing
March 2021

Is Ambulatory Hemodynamic Monitoring Beneficial to Patients With Advanced Heart Failure?

J Am Heart Assoc 2021 02 25;10(5):e020817. Epub 2021 Feb 25.

Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH.

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http://dx.doi.org/10.1161/JAHA.121.020817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174288PMC
February 2021

Characteristics, trends, outcomes, and costs of stimulant-related acute heart failure hospitalizations in the United States.

Int J Cardiol 2021 05 31;331:158-163. Epub 2021 Jan 31.

Department of Cardiology, Cleveland Clinic, Cleveland, OH, USA.

Background: Heart failure (HF) hospitalizations remains a significant burden on the health care system. Stimulants including cocaine, amphetamine and its derivatives are amongst the most used illegal substances in the United States. The information regarding stimulant-related HF hospitalizations is scarce. We sought to evaluate the characteristics and trends of stimulant-related HF hospitalizations in the United States and their associated outcomes and resource utilization.

Methods: Using the National Inpatient Sample (NIS), we identified patients with a primary diagnosis of HF hospitalization. These hospitalizations were further divided into those with and without a concomitant diagnosis of stimulant (cocaine or amphetamine) dependence or abuse. Survey specific techniques were employed to compare trends in baseline characteristics, complications, procedures, outcomes and resource utilization between the two cohorts.

Results: We identified 9,932,753 hospitalizations (weighted) with a primary diagnosis of heart failure, of those 138,438 (1.39%) had a diagnosis of active stimulant use. The proportion of stimulant-related HF hospitalization is on the rise (1.1% to 1.9%). Stimulant-related HF hospitalization was highest amongst age group 30-39 years and 7.9% of HF hospitalizations in this age group were due to stimulant use. The proportion of stimulant-related HF hospitalization for the White and Hispanic race has doubled from 2008 to 2017. Stimulant-related HF hospitalization is associated with increased incidence of in-hospital complications like cardiogenic shock, acute kidney injury and ventricular tachycardia. These patients have more than 7-fold higher discharge against medical advice.

Conclusions: Stimulant-related HF hospitalizations have been increasing. It is associate with significant morbidity burden and health care utilization.
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http://dx.doi.org/10.1016/j.ijcard.2021.01.060DOI Listing
May 2021

Longitudinal trends and outcomes of adult heart transplantation in the U.S.

Eur J Intern Med 2021 04 22;86:115-117. Epub 2021 Jan 22.

Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ejim.2021.01.001DOI Listing
April 2021

Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients with Atrial Fibrillation.

Cardiovasc Drugs Ther 2021 04 6;35(2):261-272. Epub 2021 Jan 6.

Division of General Medicine, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA, USA.

Background: Unlike warfarin direct oral anticoagulants (DOACs) are administered in fixed doses, which raises concerns of its effectiveness on larger patients. Data from randomized trials are limited on the safety and efficacy of DOACs in morbidly obese individuals with atrial fibrillation (AF).

Methods: We analyzed a cohort of obese (≥ 120 kg) and morbidly obese (BMI > 40 kg/m) patients from the Veterans Health Administration system with AF who initiated apixaban, rivaroxaban, dabigatran, or warfarin between years 2012 and 2018. We used inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression models to evaluate the relative hazard of death, myocardial infarction (MI), ischemic stroke, heart failure (HF), and bleeding events between oral anticoagulant (OAC) groups while censoring for medication cessation.

Results: We identified 6052 obese patients on apixaban, 4233 on dabigatran, 4309 on rivaroxaban, and 13,417 on warfarin (mean age 66.7 years, 91% males, 80.4% whites). At baseline patients on apixaban had the lowest glomerular filtration rate and highest rates of previous stroke and MI compared to other OACs. Among patients with weight ≥ 120 kg and those with BMI > 40 kg/m, all DOACs were associated with lower risk of any hemorrhage, hemorrhagic stroke, and gastrointestinal (GI) bleeding. Patients with BMI > 40 kg/m treated with DOACs had similar ischemic stroke risk with those on warfarin.

Conclusions: In this large cohort of obese Veterans Health Administration system patients, the use of DOACs resulted in lower hemorrhagic complications than warfarin while maintaining efficacy on ischemic stroke prevention.
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http://dx.doi.org/10.1007/s10557-020-07126-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382577PMC
April 2021

State-Level Variation in Waitlist Mortality and Transplant Outcomes Among Patients Listed for Heart Transplantation in the US From 2011 to 2016.

JAMA Netw Open 2020 12 1;3(12):e2028459. Epub 2020 Dec 1.

Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City.

Importance: Little is known about geographic variation in the outcomes of adult patients listed for heart transplantation in the US. Identifying the patterns and extent of variation is important to minimize disparity in outcomes.

Objective: To evaluate the geographic patterns, extent, and factors associated with state-level variation in outcomes of adult patients listed for heart transplantation in the US.

Design, Setting, And Participants: This nationwide retrospective cohort study used data from the United Network for Organ Sharing database to identify adult patients listed for heart transplantation at status 1A between January 1, 2011, and December 31, 2016. Patients were followed up until March 31, 2018. Data were analyzed from November 1, 2019, to September 19, 2020.

Main Outcomes And Measures: The study evaluated state-level variation in the 3 main organ transplant measures: waitlist mortality, transplant rate, and risk-adjusted 1-year graft survival. The rate of death while on the waitlist and the rate of transplant were calculated for each state per 1000 waitlist person-days listed at status 1A over the study period. Risk-adjusted 1-year graft survival was calculated based on the Scientific Registry of Transplant Recipients risk-adjustment model. State-level variation in each outcome measure was evaluated via multivariable-adjusted models.

Results: Across 50 states and the District of Columbia, a total of 15 036 patients (mean [SD] age, 52 [13] years; 3531 women [24%]; 9626 White [64%]) were listed at status 1A for adult heart transplantation between 2011 and 2016. Of those, 2146 patients (14.3%) died while on the waitlist, and 10 982 patients (73.0%) received transplants. Among those who received transplants, the median time on the waitlist was 31 days (interquartile range, 13-61 days). State-level outcomes ranged from 1.0 to 7.8 deaths per 1000 waitlist person-days for waitlist mortality, 5.6 to 34.5 transplants per 1000 waitlist person-days for transplant rate, and 87% to 92% for risk-adjusted 1-year graft survival. In a comparison of the highest and lowest quartiles, significant state-level variation was found in waitlist mortality (hazard ratio [HR], 1.53; 95% CI, 1.27-1.86), transplant rate (HR, 1.57; 95% CI, 1.31-1.87), and 1-year graft survival (odds ratio, 2.07; 95% CI, 1.64-2.62).

Conclusions And Relevance: The study's findings indicate that significant state-level variation exists in the outcomes of patients listed for heart transplantation in the US. Identifying and addressing the factors associated with these geographic variations in outcomes is important to ensure a fair allocation system.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.28459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726636PMC
December 2020

Trends, Perioperative Adverse Events, and Survival of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery.

JAMA Netw Open 2020 11 2;3(11):e2025118. Epub 2020 Nov 2.

Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City.

Importance: Information regarding the performance and outcomes of noncardiac surgery (NCS) in patients with left ventricular assist devices (LVADs) is scarce, with limited longitudinal follow-up data that are mostly limited to single-center reports.

Objective: To examine the trends, patient characteristics, and outcomes associated with NCS among patients with LVAD.

Design, Setting, And Participants: This cohort study examined patients enrolled in Medicare undergoing durable LVAD implantation from January 2012 to November 2017 with follow-up through December 2017. The study included all Medicare Provider and Analysis Review Part A files for the years 2012 to 2017. Patients identified by International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision (ICD-10) procedure codes for new LVAD implantation were included. Data analysis was performed from November 2019 to February 2020.

Exposures: NCS procedures were identified using the ICD-9-CM and ICD-10 procedural codes and divided into elective and urgent or emergent.

Main Outcomes And Measures: The primary outcome was major adverse cardiovascular events (MACEs), defined as in-hospital or 30-day all-cause mortality, ischemic stroke, or intracerebral hemorrhage after NCS. Early (<60 days after NCS) and late (≥60 days after NCS) mortality after NCS were analyzed in both subgroups using time-varying covariate and landmark analysis using patients who did not undergo NCS as reference.

Results: Of the 8118 patients with LVAD (mean [SD] age, 63.4 [10.8] years; 6484 men [79.9%]), 1326 (16.3%, or approximately 1 in 6) underwent NCS, of which 1000 procedures (75.4%) were emergent or urgent and 326 (24.6%) were elective. There was no difference in age between patients who underwent NCS and patients who did not (mean [SD] age, 63.6 [10.6] vs 63.4 [10.9] years). The number of NCS procedures among patients with LVAD increased from 64 in 2012 to 304 in 2017. The median (interquartile range) time from LVAD implantation to NCS was 309 (133-606) days. The most frequent type of NCS was general (613 abdominal, pelvic, and gastrointestinal procedures [46.2%]). Perioperative MACEs occurred in 169 patients (16.9%) undergoing emergent or urgent NCS and 23 patients (7.1%) undergoing elective NCS. Urgent or emergent NCS was associated with higher mortality early (adjusted hazard ratio [aHR], 8.78; 95% CI, 7.20-10.72; P < .001) and late (aHR, 1.71; 95% CI, 1.53-1.90; P < .001) after NCS compared with patients with LVAD who did not undergo NCS. Elective NCS was also associated with higher mortality early (aHR, 2.65; 95% CI, 1.74-4.03; P < .001) and late (aHR, 1.29; 95% CI, 1.07-1.56; P = .008) after NCS.

Conclusions And Relevance: One of 6 patients with LVAD underwent NCS. Perioperative MACEs were frequent. Higher mortality risk transcended the early postoperative period in urgent or emergent and elective surgical procedures.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662145PMC
November 2020

The role of renin-angiotensin system in patients with left ventricular assist devices.

J Renin Angiotensin Aldosterone Syst 2020 Oct-Dec;21(4):1470320320966445

Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

End-stage heart failure is a condition in which the up-regulation of the systemic and local renin-angiotensin-aldosterone system (RAAS) leads to end-organ damage and is largely irreversible despite optimal medication. Left ventricular assist devices (LVADs) can downregulate RAAS activation by unloading the left ventricle and increasing the cardiac output translating into a better end-organ perfusion improving survival. However, the absence of pulsatility brought about by continuous-flow devices may variably trigger RAAS activation depending on left ventricular (LV) intrinsic contractility, the design and speed of the pump device. Moreover, the concept of myocardial recovery is being tested in clinical trials and in this setting LVAD support combined with intense RAAS inhibition can promote recovery and ensure maintenance of LV function after explantation. Blood pressure control on LVAD recipients is key to avoiding complications as gastrointestinal bleeding, pump thrombosis and stroke. Furthermore, emerging data highlight the role of RAAS antagonists as prevention of arteriovenous malformations that lead to gastrointestinal bleeds. Future studies should focus on the role of angiotensin receptor inhibitors in preventing myocardial fibrosis in patients with LVADs and examine in greater details the target blood pressure for these patients.
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http://dx.doi.org/10.1177/1470320320966445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871286PMC
September 2021

Trends and outcomes of device-related 30-day readmissions after left ventricular assist device implantation.

Eur J Intern Med 2021 Feb 7;84:56-62. Epub 2020 Oct 7.

Department of Cardiology, Westchester Medical Center & New York Medical College, NY, USA.

Background: Left ventricular assist devices (LVAD) improve morbidity and mortality in end-stage heart failure patients, but high rates of readmissions remain a problem after implantation. We aimed to assess the incidence, trends, outcomes, and predictors of device-related 30-day readmissions after LVAD implantation.

Methods: The National Readmission Database was used to identify patients who underwent LVAD implantation between 2012 and 2017 and those with 30-day readmissions.

Results: The analysis included a total of 16499 adults who survived the index hospitalization for LVAD implantation. Among those, 28.1% were readmitted at 30 days, and the readmission rate has been grossly stable during the study period. Most of the readmissions occurred in the first 15 days after discharge from the index admission. The most frequent cause of readmissions was gastrointestinal bleeding (14.9% of readmissions), followed by heart failure, arrhythmias, device infection, and device thrombosis. Among reasons for readmission, intracranial bleeding was associated with highest mortality (37.6%), followed by device thrombosis (13.1%), and ischemic stroke (7.6%). Intracranial bleeding and device thrombosis were associated with lengthier stay (20.4 and 15.5 days, respectively). Readmission rates for gastrointestinal bleeding decreased, whereas device infection increased. Multivariate logistic regression model revealed the length of stay, oxygen dependence, gastrointestinal bleeding at index admission, depression and ECMO, private insurance as independent predictors of 30-day readmission.

Conclusion: Over one-fourth of LVAD recipients have 30-day readmissions, with most of them occurring within 15 days. Most frequent cause of readmission was gastrointestinal bleeding, which was associated with the lowest in-hospital mortality among other complications.
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http://dx.doi.org/10.1016/j.ejim.2020.10.004DOI Listing
February 2021

Incidence and clinical outcomes of nosocomial infections in patients presenting with STEMI complicated by cardiogenic shock in the United States.

Heart Lung 2020 Nov - Dec;49(6):716-723. Epub 2020 Aug 28.

Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. Electronic address:

Objectives: This study addresses the incidence, trends, and impact of nosocomial infections (NI) on the outcomes of patients admitted with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (STEMI-CS) using the United States National Inpatient Sample (NIS) database.

Methods: We analyzed data from 105,184 STEMI-CS patients using the NIS database from the years 2005-2014. NI was defined as infections of more than or equal to three days, comprising of central line-associated bloodstream infection (CLABSI), urinary tract infection (UTI), hospital-acquired pneumonia (HAP), Clostridium difficile infection (CDI), bacteremia, and skin related infections. Outcomes of the impact of NI on STEMI-CS included in-hospital mortality, length of hospital stay (LOS) and costs. Significant associations of NI in patients admitted with STEMI-CS were also identified.

Results: Overall, 19.1% (20,137) of patients admitted with STEMI-CS developed NI. Trends of NI have decreased from 2005-2014. The most common NI were UTI (9.2%), followed by HAP (6.8%), CLABSI (1.5%), bacteremia (1.5%), skin related infections (1.5%), and CDI (1.3%). The strongest association of developing a NI was increasing LOS (7-9 days; OR: 1.99; 95% CI: 1.75-2.26; >9 days; OR: 4.51; 95% CI: 4.04-5.04 compared to 4-6 days as reference). Increased mortality risk among patients with NI was significant, especially those with sepsis-associated NI compared to those without sepsis (OR: 2.95; 95% CI: 2.72-3.20). Patients with NI were found to be associated with significantly longer LOS and higher costs, irrespective of percutaneous mechanical circulatory support placement.

Conclusions: NI were common among patients with STEMI-CS. Those who developed NI were at a greater risk of in-hospital mortality, increased LOS and costs.
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http://dx.doi.org/10.1016/j.hrtlng.2020.08.008DOI Listing
March 2021

In-Hospital Outcomes of Left Ventricular Assist Device Implantation and Concomitant Valvular Surgery.

Am J Cardiol 2020 10 13;132:87-92. Epub 2020 Jul 13.

Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York.

Valvular heart disease is common among left ventricular assist device (LVAD) recipients. However, its management at the time of LVAD implantation remains controversial. Patients who underwent LVAD implantation and concomitant aortic (AVR), mitral (MVR), or tricuspid valve (TVR) repair or replacement from 2010 to 2017 were identified using the national inpatient sample. End points were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via ICD-9 and ICD-10 coding and analysis was performed via mixed effect models. A total of 25,171 weighted adults underwent LVAD implantation without valvular surgery, 1,329 had isolated TVR, 1,021 AVR, 377 MVR, and 615 had combined valvular surgery (411 had TVR + AVR, 115 TVR + MVR, 62 AVR + MVR, 25 AVR + MVR + TVR). During the study period, rates of AVR decreased and combined valvular surgeries increased. Patients who underwent TVR or combined valvular surgery had overall higher burden of co-morbidities than LVAD recipients with or without other valvular procedures. Postoperative bleeding was higher with AVR whereas acute kidney injury requiring dialysis was higher with TVR or combined valvular surgery. In-hospital mortality was higher with AVR, MVR, or combined surgery without differences in the rates of stroke. Length of stay did not differ significantly among groups but cost of hospitalization and nonroutine discharge rates were higher for cases of TVR and combined surgery. Approximately 1 in 9 LVAD recipients underwent concomitant valvular surgery and TVR was the most frequently performed procedure. In-hospital mortality and cost were lower among those who did not undergo valvular surgery.
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http://dx.doi.org/10.1016/j.amjcard.2020.06.067DOI Listing
October 2020

Noninvasive measurement of arterial blood pressure in patients with continuous-flow left ventricular assist devices: a systematic review.

Heart Fail Rev 2021 01;26(1):47-55

Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.

Accurate mean blood pressure determination is essential to prevent adverse events in patients with continuous-flow left ventricular assist devices (CFLVAD). We sought to evaluate the accuracy of noninvasive methods of blood pressure measurement compared with invasive intra-arterial recordings in patients with CFLVAD. Systematic electronic search was performed on four online databases (PubMed, Scopus, Embase, and Web of Knowledge) for the terms "Blood Pressure" AND ("Heart-Assist Devices" OR "Left ventricular Assist Devices"). Only studies that compared an intra-arterial and noninvasive blood pressure measurement were included. Electronic search of scientific literature identified 5968 articles. After deduplication, screening of titles and abstracts, full-text review, and excluding incorrect populations and comparator, a total of 12 studies with 502 participants were included, of those 402 participants who had intra-arterial blood pressure measurement. Doppler mean arterial blood pressure showed a very high correlation with mean intra-arterial blood pressure (r = 0.97, r = 0.87) in low pulsatility situations. When the pulsatility was not evaluated, the correlation was high moderate (r = 0.63, r = 0.741). In low pulsatility situations, the correlation was moderate to high moderate (r = 0.42 to r = 0.65). Oscillometer automatic blood pressure cuff showed a moderate to very high correlation with intra-arterial mean arterial blood pressure (r = 0.42, r = 0.86) but also could be low in the context of low pulsatility associated with inconsistent success in noninvasive measurement (r = 0.25). Studies correlating intra-arterial with noninvasive techniques were performed in the context of routine clinical care using fluid-filled catheters. The degree of correlation between both methods is at least moderate.
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http://dx.doi.org/10.1007/s10741-020-10006-4DOI Listing
January 2021

Characteristics and Outcomes of Patients Undergoing Combined Organ Transplantation (from the United Network for Organ Sharing).

Am J Cardiol 2020 08 24;129:42-45. Epub 2020 May 24.

Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Studies have shown that highly selected patients who underwent combined heart-kidney (HK) and heart-liver transplants (HLv) have short- and long-term outcomes comparable to those observed in primary heart transplantation (HT). Adults patients with stage D heart failure that underwent combined HK, HLv, and heart-lung (HL) were identified in the United Network for Organ Sharing registry from 1991 to 2016, with follow-up through March 2018. We conducted inverse probability of treatment weighting survival analysis of long-term survival stratified by type of combined organ transplant, accounting for donor, recipient, and operative characteristics. We identified 2,300 patients who underwent combined organ transplant (HK 1,257, HLv 212, HL 831). HL recipients were more likely white (77%), women (58%), with congenital heart disease (44.5%), and longer waiting list time (median 195 days). HK transplant increased significantly during the study period where as HL decreased significantly. Median survival was 12.2 years for HK (95% confidence intervals [CI] 10.8 to 12.8), 12 for HLv (95% CI 8.6 to 17.6) but significantly lower at 4.5 years for HL (95% CI 3.6 to 5.8). Combined HK and HLv transplantation rates are increasing and long-term survival is comparable to primary HT, unlike HL which is associated with decreasing trends and significantly lower survival.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.034DOI Listing
August 2020

In-hospital Outcomes of Left Ventricular Assist Devices (LVAD) Patients Undergoing Noncardiac Surgery.

ASAIO J 2021 02;67(2):144-148

From the Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

An increasing number of stage D heart failure patients are supported with left ventricular assist devices (LVADs), and the management of LVAD patients who require noncardiac surgery (NCS) presents unique challenges. Using the 2010-2014 National Inpatient Sample, we identified all adult cases of LVAD patients undergoing noncardiac surgeries using ICD-9-CM codes. We estimated inpatient mortality, bleeding complications, stroke, length of stay (LOS), and cost of hospitalization of the admissions related to NCS using mixed effects logistic and linear mixed regressions, respectively. A total of 30,323 patients with LVADs underwent 3,216 noncardiac surgeries (73.5% urgent) during the study period. LVAD recipients undergoing NCS had higher burden of certain comorbidities such as history of end-stage renal disease, pulmonary circulation disorders, peripheral vascular disease, and obesity. The most frequent NCS were general surgery, which included breast, endocrine, skin/burn, noncardiac transplantation, and abdominal surgeries (47.9%). In-hospital mortality was 7.7% with the highest rates observed among cases of neurologic surgeries. Vascular surgeries had the highest rates of ischemic stroke and gastrointestinal bleeding. Patients who underwent NCS had higher LOS and cost of hospitalization compared with LVAD recipients admitted to reasons other than NCS. Although bleeding complication trends have decreased, ischemic stroke and in-hospital mortality rates have increased overall during the study period. Urgent or emergency surgery was an independent predictor of mortality (OR 3.1, 95% CI 1.9-5). A significant burden of complications occurs after noncardiac surgeries in LVAD recipients.
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http://dx.doi.org/10.1097/MAT.0000000000001205DOI Listing
February 2021

Maintenance immunosuppression in heart transplantation: insights from network meta-analysis of various immunosuppression regimens.

Heart Fail Rev 2020 May 18. Epub 2020 May 18.

Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA.

Previous studies have reported superiority of mechanistic target-of-rapamycin (mTOR) antagonists (mTA) over calcineurin inhibitors (CNI) as part of maintenance immunosuppression (IS) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). MEDLINE and EMBASE were searched through October 2019 for studies comparing maintenance IS with mTA + antimetabolites (AM), CNI + mTA or CNI + AM post HT. The main outcomes were all-cause mortality, CAV, acute rejection, CMV infections, and change in eGFR. To compare different IS antagonists, a random-effects network meta-analysis was performed. We used p-scores to rank best treatments per outcome. Our search identified fifteen eligible studies (5 studies comparing mTA + AM vs. CNI + AM, 9 comparing CNI + mTA vs. CNI + AM, 1 comparing mTA + AM vs. CNI + mTA, 8 using everolimus and 7 sirolimus as mTA) reporting the selected outcomes. We did not identify any statistical difference in all-cause mortality among the three IS regimens without heterogeneity among studies. CAV rates were significantly lower with CNI + mTA (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.3-0.92). Acute rejection rates were significantly lower with CNI + AM (OR 0.26, 95% CI 0.12-0.56) and with CNI + mTA (OR 0.16, 95% CI 0.07-0.33) compared with mTA + AM without significant heterogeneity (I = 43%, p = 0.9). CMV infections were significantly lower with mTA + AM (OR 0.13, 95% CI 0.03-0.46) and with CNI + mTA (OR 0.27, 95% CI 0.2-0.38) compared with CNI + AM without heterogeneity. mTA + AM led to higher eGFR compared with CNI + AM (9.06 ml/min/1.73 m2, 95% CI 3.15-14.97) and CNI + Mta (9.64 ml/min/1.73 m2, 95% CI 0.91-18.36), but the heterogeneity among studies was significant. CNI + mTA ranked better for CAV (p = 0.78), and acute rejection (p = 0.99) while mTA + AM for CMV infection (p = 0.94) and improvement in renal function (p = 0.93) than other regimens. Different IS regimens have similar effects on survival post HT, but CNI + mTA was associated with lower CAV rates, and acute rejection, while mTA + AM with less CMV infection post HT.
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http://dx.doi.org/10.1007/s10741-020-09967-3DOI Listing
May 2020

Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction.

ESC Heart Fail 2020 08 17;7(4):1862-1871. Epub 2020 May 17.

Institute for Clinical and Translational Sciences, University of Iowa, 200 Hawkins Drive, C44-GH, Iowa City, IA, 52242, USA.

Aims: This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes.

Methods And Results: We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014-2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time-dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non-steroidal anti-inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05-1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085-1.382, P = 0.0011).

Conclusions: In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline-directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.
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http://dx.doi.org/10.1002/ehf2.12752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373931PMC
August 2020

Outcomes of Thoracentesis for Acute Heart Failure in Hospitals.

Am J Cardiol 2020 06 3;125(12):1863-1869. Epub 2020 Apr 3.

Department of Internal Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa, Iowa.

Data on in-hospital outcomes for hospitalizations undergoing thoracentesis (THR) for any cause has been conflicting. For hospitalizations with acute heart failure (HF), however, to date, no study has evaluated the outcomes of THR. Accordingly, our current study addresses this knowledge gap. We analyzed data from the Nationwide Inpatient Sample (2005-14). The study population included all adults (>18 years) with the principal discharge diagnosis of HF and the presence of procedure code for THR. Hospitalizations with pneumonia, acute kidney injury, and co-morbidities such as malignancy, lymphoma, liver disease, end-stage renal disease, metastatic disease, and tuberculosis were excluded. Propensity matching was performed to identify a similar cohort of admissions that did not undergo THR. Primary outcome of interest was in-hospital mortality and length of hospitalization. During the study period, 2,251,927 hospitalizations for HF were found from the database; of which, 70,823 (3.14%) had THR. After propensity matching, a matched cohort of 70,785 hospitalizations for HF was identified. In-hospital mortality was higher for those who underwent THR (2.5% vs 1.6%; p <0.001). In-hospital complications and procedures including cardiac arrest, sepsis, pneumothorax and hemothorax were more frequent in the THR group. Those who underwent THR had a longer mean length of stay (6.9 vs 4.5 days; p <0.01) and higher cost of hospitalization ($13,448 vs $ 8940; p <0.01). The trend analysis demonstrated a steady increase in the performance of THR in hospitalized HF between 2005 and 2014. In conclusion, THR performed during HF hospitalizations were associated with higher rates of in-hospital mortality, complications and increased healthcare utilization in the form of longer length of stay and higher costs.
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http://dx.doi.org/10.1016/j.amjcard.2020.03.032DOI Listing
June 2020

Central Nervous System Depressants and Risk of Hospitalization due to Community-Acquired Pneumonia in very Old Patients.

Curr Drug Saf 2020 ;15(2):131-136

Department of Medicine, Centro de Educación Médica e Investigacion Clínica (CEMIC) "Norberto Quirno", Buenos Aires, Argentina.

Background: Central Nervous System (CNS) depressants like antipsychotics, opioids, benzodiazepines and zolpidem are frequently used by patients of a wide range of ages. Uncertainty remains about their effect in very old adults (>80 years old) and their potential for pharmacodynamic and pharmacokinetic drug-drug interactions in this population.

Objective: To assess if the use of CNS depressants is associated with a higher risk of hospitalization due to community-acquired pneumonia (CAP) in very old patients.

Methods: In this prospective study, 362 patients over 80 years of age who had been consequently admitted to the general ward of a teaching hospital were examined. Each patient was assessed, by our pharmacovigilance team within 24 hours of admission, to identify outpatient medication use and potential drug-drug interactions.

Results: The overall use of CNS depressants as a group was not associated with a higher risk of admission due to CAP in very old patients (55% vs. 49%; OR=1.28 [0.76-2.16], p=0.34). However, the use of antipsychotics was associated with a higher rate of admissions due to CAP in this population (OR=1.98 [1.10-3.57], p=0.02). No association was seen between opioids (p=0.27), zolpidem (p=0.83), or benzodiazepines (p=0.15) and the rate of admissions due to CAP in these patients. Moreover, pharmacodynamic or pharmacokinetic interactions leading to CNS depression were equally found in patients admitted for CAP and those admitted for other reasons.

Conclusion: The use of antipsychotics in very old adults was associated with an increased risk of hospital admission due to CAP. This suggests that the use of these medications in this population should be done with caution. No association was observed with opioids, benzodiazepines and zolpidem with the latter outcome.
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http://dx.doi.org/10.2174/1574886315666200319110114DOI Listing
May 2021
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