Publications by authors named "Umesh Gidwani"

36 Publications

Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project.

Am Heart J 2022 Jun 30;253:30-38. Epub 2022 Jun 30.

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Background: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer.

Approach: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care.

Conclusions: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
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http://dx.doi.org/10.1016/j.ahj.2022.06.008DOI Listing
June 2022

Critical Care Simulation Education Program During the COVID-19 Pandemic.

J Patient Saf 2022 06 27;18(4):e810-e815. Epub 2021 Sep 27.

From the Institute for Critical Care Medicine.

Background: Coronaviruses are important emerging human and animal pathogens. SARS-CoV-2, the virus that causes COVID-19, is responsible for the current global pandemic. Early in the course of the pandemic, New York City became one of the world's "hot spots" with more than 250,000 cases and more than 15,000 deaths. Although medical providers in New York were fortunate to have the knowledge gained in China and Italy before it came under siege, the magnitude and severity of the disease were unprecedented and arguably under appreciated. The surge of patients with significant COVID-19 threatened to overwhelm health care systems, as New York City health systems realized that the number of specialized critical care providers would be inadequate. A large academic medical system recognized that rapid redeployment of noncritical providers into such roles would be needed. An educational gap was therefore identified: numerous providers with minimal critical care knowledge or experience would now be required to provide critical-level patient care under supervision of intensivists. Safe provision of such high level of patient care mandated the development of "educational crash courses."

Methods: The purpose of this special article is to summarize the approach adopted by the Institute for Critical Care Medicine and Department of Anesthesiology, Perioperative and Pain Medicine's Human Emulation, Education, and Evaluation Lab for Patient Safety and Professional Study Simulation Center in developing a training program for noncritical care providers in this novel disease.

Results: Using this joint approach, we were able to swiftly educate a wide range of nonintensive care unit providers (such as surgical, internal medicine, nursing, and advanced practice providers) by focusing on refreshing critical care knowledge and developing essential skillsets to assist in the care of these patients.

Conclusions: We believe that the practical methods reviewed here could be adopted by any health care system that is preparing for an unprecedented surge of critically ill patients.
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http://dx.doi.org/10.1097/PTS.0000000000000928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9161751PMC
June 2022

The Mount Sinai Hospital Institute for critical care medicine response to the COVID-19 pandemic.

Acute Crit Care 2021 Aug 10;36(3):201-207. Epub 2021 Aug 10.

Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of critically ill patients. This was especially true in New York City. We present a roadmap for hospitals and healthcare systems to prepare for a Pandemic.

Methods: This was a retrospective review of how Mount Sinai Hospital (MSH) was able to rapidly prepare to handle the pandemic. MSH, the largest academic hospital within the Mount Sinai Health System, rapidly expanded the intensive care unit (ICU) bed capacity, including creating new ICU beds, expanded the workforce, and created guidelines.

Results: MSH a 1,139-bed quaternary care academic referral hospital with 104 ICU beds expanded to 1,453 beds (27.5% increase) with 235 ICU beds (126% increase) during the pandemic peak in the first week of April 2020. From March to June 2020, with follow-up through October 2020, MSH admitted 2,591 COVID-19-positive patients, 614 to ICUs. Most admitted patients received noninvasive support including a non-rebreather mask, high flow nasal cannula, and noninvasive positive pressure ventilation. Among ICU patients, 68.4% (n=420) received mechanical ventilation; among the admitted ICU patients, 42.8% (n=263) died, and 47.8% (n=294) were discharged alive.

Conclusions: Flexible bed management initiatives; teamwork across multiple disciplines; and development and implementation of guidelines were critical accommodating the surge of critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units. This approach to rapidly expand bed availability and staffing across the system helped provide the best care for the patients and saved lives.
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http://dx.doi.org/10.4266/acc.2021.00402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435441PMC
August 2021

Clinical Characteristics and In-Hospital Mortality for COVID-19 Across The Globe.

Cardiol Ther 2020 Dec 18;9(2):553-559. Epub 2020 Jul 18.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.

Introduction: Numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with COVID-19, however, these studies included patients localized in a specific geographic region. The purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of COVID-19 internationally.

Methods: A comprehensive search of all published literature on adult patients with laboratory-confirmed diagnosis of COVID-19 that reported on the clinical characteristics and in-hospital mortality was performed. Groups were compared using a Chi-square test with Yates correction of continuity. A two-tailed p value of less than 0.05 was considered as statistically significant.

Results: After screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. Patients with COVID-19 in America and Europe were older compared to their Asian counterparts. Europe had the highest percentage of male patients. American and European patients had a higher incidence of co-morbid conditions (p < 0.05 for all variables). In-hospital mortality was significantly higher in America (22.23%) and Europe (22.9%) compared to Asia (12.65%) (p < 0.0001), but no difference was seen when compared with each other (p = 0.49).

Conclusions: There is a significant variation in the clinical characteristics in patients diagnosed with COVID-19 across the globe. In-hospital mortality is similar between America and Europe, but considerably higher than Asia.
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http://dx.doi.org/10.1007/s40119-020-00189-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368614PMC
December 2020

Non-invasive cerebral perfusion monitoring in cardiac arrest patients: a prospective cohort study.

Clin Neurol Neurosurg 2020 09 30;196:105970. Epub 2020 May 30.

Department of Neurology, Henry Ford Health System, 2799 W. Grand Blvd, Clara Ford Pavillion, Room 462, Detroit, MI 48202, United States; Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States.

Objectives: To determine if non-invasive cerebral perfusion estimation provided by a new acousto-optic technology can be used as a reliable predictor of neurological outcome.

Patients And Methods: We performed a prospective, observational cohort study of consecutive comatose patients successfully resuscitated from out-of-hospital cardiac arrest. Patients were monitored using c-FLOW (Ornim Medical) from critical care unit admission up to 72 h, full awakening, or death. Primary outcome was favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2.

Results: A total of 21 patients were enrolled, without any loss to follow-up. Mean perfusion index over the monitoring period was not associated with functional outcome at hospital discharge (OR 1.03 [0.93, 1.17]). Adjustment for initial rhythm, time to return of spontaneous circulation and Glasgow coma scale motor score did not significantly alter the results (OR 1.06 [0.99, 1.12]). Mean perfusion index showed a poor discriminative value with an area under the curve of 0.60 for functional outcome (0.64 for survival). Correlation between the probes was weak (Pearson coefficient 0.35).

Conclusion: Cerebral perfusion monitoring using a c-FLOW device in survivors of cardiac arrest is feasible, but reliability of the information provided has yet to be demonstrated. In our cohort, we were unable to identify any association between the perfusion index and clinical outcomes at discharge. As such, clinical management of cardiac arrest patients based on non-invasive perfusion index is not supported and should be limited to research protocols. The trial was registered with ClinicalTrials.gov, number NCT02575196.
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http://dx.doi.org/10.1016/j.clineuro.2020.105970DOI Listing
September 2020

The emergence of methemoglobinemia amidst the COVID-19 pandemic.

Am J Hematol 2020 08 3;95(8):E196-E197. Epub 2020 Jun 3.

Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute, New York, USA.

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http://dx.doi.org/10.1002/ajh.25868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276830PMC
August 2020

The Imperfect Cytokine Storm: Severe COVID-19 With ARDS in a Patient on Durable LVAD Support.

JACC Case Rep 2020 Jul 8;2(9):1315-1320. Epub 2020 Apr 8.

Division of Cardiology, Department of Medicine, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

As health systems worldwide grapple with the coronavirus disease-2019 (COVID-19) pandemic, patients with durable LVAD support represent a unique population at risk for the disease. This paper outlines the case of such a patient who developed COVID-19 complicated by a "cytokine storm" with severe acute respiratory distress syndrome and myocardial injury and describes the challenges that arose during management.
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http://dx.doi.org/10.1016/j.jaccas.2020.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142699PMC
July 2020

Orbital atherectomy versus rotational atherectomy: A systematic review and meta-analysis.

Int J Cardiol 2020 03 17;303:16-21. Epub 2019 Dec 17.

Department of Cardiology, Montefiore Medical Center, New York NY10467, USA.

Background: Coronary artery calcification is associated with poor outcomes in patients undergoing percutaneous coronary intervention (PCI). Atheroablative techniques such as orbital atherectomy (OA) and rotational atherectomy (RA) are routinely utilized to treat these calcified lesions in order to optimize lesion preparation and facilitate stent delivery.

Objectives: The purpose of this systematic review and meta-analysis is to compare the performance of OA versus RA in patients with calcified coronary artery disease (CAD) undergoing PCI.

Methods: We conducted an electronic database search of all published data for studies that compared OA versus RA in patients with calcified coronary artery disease undergoing PCI and reported on outcomes of interest. Event rates were compared using a forest plot of odds ratios using a random-effects model assuming interstudy heterogeneity.

Results: A total of five observational studies (total number of patients = 1872; OA = 535, RA = 1337) were included in the final analysis. On pooled analysis, OA compared to RA was associated with a significant reduction in fluoroscopy times (OR = -6.33; 95% CI = -9.90 to -2.76; p < .0005; I = 82). There was no difference between the two techniques in terms of contrast volume, coronary artery dissection, device induced arterial perforation, cardiac tamponade, slow flow/no reflow, periprocedural myocardial infarction (MI), in-hospital mortality, 30-day mortality, 30-day MI, 30-day target vessel revascularization (TVR), and 30-day major adverse cardiovascular events (MACE).

Conclusion: Except for lower fluoroscopy time with OA, there are no significant differences between OA and RA in relation to procedural, periprocedural, and thirty day outcomes among patients with calcified CAD undergoing PCI.
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http://dx.doi.org/10.1016/j.ijcard.2019.12.037DOI Listing
March 2020

Mitraclip Plus Medical Therapy Versus Medical Therapy Alone for Functional Mitral Regurgitation: A Meta-Analysis.

Cardiol Ther 2020 Jun 9;9(1):5-17. Epub 2019 Dec 9.

Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Introduction: The purpose of this meta-analysis is to compare the efficacy of MitraClip plus medical therapy versus medical therapy alone in patients with functional mitral regurgitation (FMR). FMR caused by left ventricular dysfunction is associated with poor prognosis. Whether MitraClip improves clinical outcomes in this patient population remains controversial.

Methods: We conducted an electronic database search of PubMed, CINAHL, Cochrane Central, Scopus, Google Scholar, and Web of Science databases for randomized control trials (RCTs) and observational studies with propensity score matching (PSM) that compared MitraClip plus medical therapy with medical therapy alone for patients with FMR and reported on subsequent mortality, heart failure re-hospitalization, and other outcomes of interest. Event rates were compared using a random-effects model with odds ratio as the effect size.

Results: Five studies (n = 1513; MitraClip = 796, medical therapy = 717) were included in the final analysis. MitraClip plus medical therapy compared to medical therapy alone was associated with a significant reduction in overall mortality (OR = 0.66, 95% CI = 0.44-0.99, P = 0.04) and heart failure (HF) re-hospitalization rates (OR = 0.57, 95% CI = 0.36-0.91, P = 0.02). There was reduced need for heart transplantation or mechanical support requirement (OR = 0.48, 95% CI = 0.25-0.91, P = 0.02) and unplanned mitral valve surgery (OR = 0.21, 95% CI = 0.07-0.61, P = 0.004) in the MitraClip group. No effect was observed on cardiac mortality (P = 0.42) between the two groups.

Conclusions: MitraClip plus medical therapy improves overall mortality and reduces HF re-hospitalization rates compared to medical therapy alone in patients with FMR.
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http://dx.doi.org/10.1007/s40119-019-00157-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237594PMC
June 2020

Dual Versus Triple Antithrombotic Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: An Updated Meta-Analysis.

Cardiovasc Revasc Med 2020 02 20;21(2):239-241. Epub 2019 Aug 20.

Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, 10029, NY, USA.

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http://dx.doi.org/10.1016/j.carrev.2019.08.015DOI Listing
February 2020

Transcatheter aortic valve replacement versus surgical aortic valve replacement in low-surgical-risk patients: An updated meta-analysis.

Catheter Cardiovasc Interv 2020 07 21;96(1):169-178. Epub 2019 Oct 21.

Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: The purpose of this meta-analysis is to compare the safety and efficacy of transcatheter aortic-valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in low-surgical-risk patients.

Background: TAVR is proven to be safe and effective in patients with high- and intermediate-risk aortic stenosis. However, there is limited data on the safety and efficacy of TAVR in patients with low surgical risk.

Methods: We conducted an electronic database search of all published data for studies that compared TAVR to SAVR in low-surgical-risk patients (mean society for thoracic surgery [STS] score <4% and/or logistic EuroScore <10%) and reported on subsequent all-cause mortality, cardiac mortality, stroke rates, and other outcomes of interest. Event rates were compared with a forest plot of odds ratio using a random-effects model assuming interstudy heterogeneity.

Results: A total of seven studies (n = 6,293 patients; TAVR = 2,912; and SAVR = 3,381) were included in the final analysis. There was no significant difference between TAVR and SAVR in terms of all-cause mortality (OR 0.82; 95% CI 0.50-1.36, I = 51%), cardiac mortality (OR 0.57; 95% CI 0.32-1.02, I = 0%), new pacemaker implantation (OR = 3.11; 95% CI 0.58-16.60, I = 89%), moderate/severe paravalvular leak (PVL; OR 3.50; 95% CI 0.64-19.10, I = 54%) and rate of stroke (OR 0.63; 95% CI 0.34-1.15, I = 39%) at 1-year follow-up. TAVR was found to have a significantly lower incidence of atrial fibrillation (AF; OR 0.15, 95% CI 0.10-0.24, I = 38%) as compared to SAVR.

Conclusion: The results of our meta-analysis demonstrate similar rates of all-cause mortality, cardiac mortality, and stroke at 1-year follow-up in patients undergoing TAVR and SAVR. TAVR is associated with a lower incidence of AF relative to SAVR. However, there was a significantly higher incidence of PVL with TAVR compared to SAVR.
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http://dx.doi.org/10.1002/ccd.28520DOI Listing
July 2020

Left main percutaneous coronary intervention-Radial versus femoral access: A systematic analysis.

Catheter Cardiovasc Interv 2020 06 20;95(7):E201-E213. Epub 2019 Aug 20.

Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Debate still occurs of the benefits of transradial access (TRA) versus transfemoral access (TFA), especially for complex percutaneous coronary interventions. Recent data has shown equivalent efficacy and improved safety outcomes with TRA.

Objectives: To systematically review and perform a meta-analysis comparing procedural characteristics and clinical outcomes of TRA versus TFA in patients who underwent percutaneous coronary intervention (PCI) for left main (LM) disease.

Methods: We conducted an electronic database search of all published data for studies that compared TRA with TFA in patients undergoing PCI of LM disease. Event rates were compared using the odds ratio (OR) as a measure of effect size. Random-effects models were used to account for interstudy heterogeneity.

Results: A total of 12 observational studies including 17,258 patients (TRA n = 7,971; TFA n = 9,287) were included. Compared to TFA, TRA was associated with a significant reduction in access site bleeding (OR = 0.11; 95% confidence interval [CI] = 0.04-0.26; I = 0%; p < .0001), major bleeding (OR = 0.44; 95% CI = 0.27-0.69; I = 0%; p = .0005) or any bleeding episode (OR = 0.43; 95% CI = 0.27-0.69; I = 12%; p = .0004). Rates of access site or vascular complications (OR = 0.26; 95% CI = 0.17-0.40; I = 0%; p < .00001) and in-hospital mortality (OR = 0.49; 95% CI = 0.31-0.79: I = 11%; p = .004) were also lower in the TRA group. There were no significant differences in procedural outcomes between TRA and TFA except for a significant reduction in the rate of long-term target vessel revascularization (TVR) in the TRA group (OR = 0.62; 95% CI = 0.41-0.94: I = 0%: p = .02). We further performed a subgroup analysis for unprotected left main PCI only, which showed a significant reduction in rates of any bleeding episode, lower access site or vascular complications, and in-hospital mortality with TRA as compared to TFA.

Conclusion: Patients undergoing PCI for LM disease via TRA have with less bleeding, reduced access site or vascular complications, reduced in-hospital mortality, comparable procedural success, and possibly better long-term clinical efficacy when compared to those undergoing the procedure via TFA.
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http://dx.doi.org/10.1002/ccd.28451DOI Listing
June 2020

Three to four years outcomes of the absorb bioresorbable vascular scaffold versus second-generation drug-eluting stent: A meta-analysis.

Catheter Cardiovasc Interv 2020 02 19;95(2):216-223. Epub 2019 Apr 19.

Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: This meta-analysis sought to evaluate the outcomes of absorb bioresorbable vascular scaffolds (BVS) compared with second-generation drug-eluting stents (DES) after 3 years, the approximate time of complete polymer bioresorption.

Background: BVS were found to be inferior to second-generation DES in early and mid-term outcomes with a higher rate of target vessel myocardial infarction (TV-MI) and device thrombosis (DT). Improper implantation techniques and incomplete bioresorption of the poly-l-lactide (PLLA) polymer were sighted as possible reasons.

Methods: We conducted an electronic database search for all randomized control trials that compared absorb BVS to second-generation DES and reported outcomes of interest after 3 years of absorb BVS implantation. Assuming interstudy heterogeneity, a random-effects analysis was conducted with odds ratio as the effect size of choice to compare the event rates between the two groups.

Results: A total of four studies (n = 3,245, BVS = 2075, DES = 1,170) were included in the final analysis. Pooled analysis revealed that there was no difference between absorb BVS and second-generation DES with respect to target lesion failure (TLF) (OR = 1.23, 95% CI = 0.73-2.07, p = 0.44), TV-MI (OR = 1.03, 95% CI = 0.42-2.53, p = 0.95), target lesion revascularization (TLR) (OR = 1.61, 95% CI = 0.77-3.33, p = 0.20) and definite/probable DT (OR = 0.71, 95% CI = 0.10-5.07, p = 0.74). Also, there was no difference in cardiac mortality (OR = 0.66, 95% CI = 0.22-1.94, p = 0.45).

Conclusions: Between 3 and 4 years of follow-up, patients receiving absorb BVS did not have significantly different outcomes, in terms of TLF, TV-MI, TLR, DT, and cardiac mortality, compared to DES.
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http://dx.doi.org/10.1002/ccd.28290DOI Listing
February 2020

Heart failure: Same-hospital vs. different-hospital readmission outcomes.

Int J Cardiol 2019 Mar 15;278:186-191. Epub 2018 Dec 15.

Department of Interventional Cardiology/Structural Heart Disease, University of Iowa, United States of America.

Background: Heart Failure (HF) is a major driver of the readmissions/penalties in the US. Although extensive literature on rehospitalization attributed to HF, studies to compare outcomes for same-hospital vs. different-hospital readmissions are sparse.

Methods: Nationwide Readmission Database from 2010 to 14 utilized for HF-related hospitalization using appropriate ICD-9-CM diagnostic codes. 30-day readmissions were classified into two groups: same-hospital and different-hospital. A comparative analysis was conducted focusing on: in-hospital mortality, length of stay (LOS) and hospitalization cost. Hierarchical two-level modeling and propensity score matching utilized to adjust confounders.

Results: 715,993 HF readmissions were identified, of which 21.3% were readmitted to different-hospital. Elderly, females, patients with higher co-morbidities and higher median household income were less likely to be readmitted to different-hospital. Index hospitalizations in a teaching hospital and/or larger hospital were associated with reduced different-hospital readmissions. Readmissions to the different hospital were associated with higher in-hospital mortality (7.7% vs. 6.6%, p < 0.001), higher resource utilization (LOS:7.5 days vs. 6.1 days, p < 0.001 and Cost: $22,602 vs. $13,740, p < 0.001) after adjusting for propensity score match. Similar results were observed with propensity score matching of multiple high-risk subgroups.

Conclusion: Resources should be directed towards minimizing different-hospital HF readmissions to improve patient outcomes by identifying the vulnerable subgroup and further tailoring in-hospital and post-discharge care.
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http://dx.doi.org/10.1016/j.ijcard.2018.12.043DOI Listing
March 2019

Nationwide Trends in Hospital Outcomes and Utilization After Lower Limb Revascularization in Patients on Hemodialysis.

JACC Cardiovasc Interv 2017 10;10(20):2101-2110

Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objectives: This study aimed to describe the temporal trends and outcomes of endovascular and surgical revascularization in a large, nationally representative sample of patients with end-stage renal disease on hemodialysis hospitalized for peripheral artery disease (PAD).

Background: PAD is prevalent among patients with end-stage renal disease on hemodialysis and is associated with significant morbidity and mortality. There is a paucity of information on trends in endovascular and surgical revascularization and post-procedure outcomes in this population.

Methods: We used the Nationwide Inpatient Sample (2002 to 2012) to identify hemodialysis patients undergoing endovascular or surgical procedures for PAD using diagnostic and procedural codes. We compared trends in amputation, post-procedure complications, mortality, length of stay, and costs between the 2 groups using trend tests and logistic regression.

Results: There were 77,049 endovascular and 29,556 surgical procedures for PAD in hemodialysis patients. Trend analysis showed that endovascular procedures increased by nearly 3-fold, whereas there was a reciprocal decrease in surgical revascularization. Post-procedure complication rates were relatively stable in persons undergoing endovascular procedures but nearly doubled in those undergoing surgery. Surgery was associated with 1.8 times adjusted odds (95% confidence interval: 1.60 to 2.02) for complications and 1.6 times the adjusted odds for amputations (95% confidence interval: 1.40 to 1.75) but had similar mortality (adjusted odds ratio: 1.05; 95% confidence interval: 0.85 to 1.29) compared with endovascular procedures. Length of stay for endovascular procedures remained stable, whereas a decrease was seen for surgical procedures. Overall costs increased marginally for both procedures.

Conclusions: Rates of endovascular procedures have increased, whereas those of surgeries have decreased. Surgical revascularization is associated with higher odds of overall complications. Further prospective studies and clinical trials are required to analyze the relationship between the severity of PAD and the revascularization strategy chosen.
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http://dx.doi.org/10.1016/j.jcin.2017.05.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685672PMC
October 2017

Atrial fibrillation: Utility of CHADS and CHADS-VASc scores as predictors of readmission, mortality and resource utilization.

Int J Cardiol 2017 Oct;245:162-167

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States.

Background: CHADS and CHADS-VASc scores are widely used for thromboembolic risk assessment in Atrial Fibrillation(AF) cohort, however further utilization to predict outcomes is understudied.

Method: HCUP's National Readmission Data(NRD) 2013 was queried for AF admissions using ICD-9-CM code 427.31 in principal diagnosis field. Patients with mitral valve disease or repair/or replacement were excluded to estimate population with non-valvular AF only. CHADS and CHADS-VASc were calculated for each patient. Hierarchical two-level logistic and linear models were used to evaluate study outcomes in terms of mortality, 30 or 90-day readmissions, length of stay(LOS) and cost.

Result: Of 116,450 principal non-valvular AF admissions(50.2% female and 43.1% age≥75years) 29,179 patients were readmitted, with total 40,959 readmissions. Higher CHADS and CHADS-VASc score were associated with increased mortality from 0.4% for CHADS of 0 to 3.2% for score of 6 and from 0.2% for CHADS-VASc of 0 to 3.2% for score≥8. LOS increased from 2.20days for CHADS of 0 to 5.08days for score of 6, while cost increased from $7888 to $11,151. 30-day readmission rate increased from 8.9% for CHADS of 0 to 26.0% for score of 6, and 90-day readmission rate increased from 15.2% to 39%. CHADS-VASc scoring similarly demonstrated a trend towards increasing readmission rate, LOS and cost for higher scores. Also, similar results were seen in hierarchical modeling with increment of CHADS and CHADS-VASc scores.

Conclusion: CHADS and CHADS-VASc scores can be used as quick surrogate markers for predicting outcomes beyond thromboembolic risk. Physician familiarity with these systems makes them easy to use bedside clinical tools to improve outcomes and resource allocation.
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http://dx.doi.org/10.1016/j.ijcard.2017.06.090DOI Listing
October 2017

Etiologies, Trends, and Predictors of 30-Day Readmissions in Patients With Diastolic Heart Failure.

Am J Cardiol 2017 Aug 1;120(4):616-624. Epub 2017 Jun 1.

Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.

An estimated half of all heart failure (HF) populations has been categorized to have diastolic HF (DHF), but sparse data are available describing etiologies and predictors of 30-day readmission in DHF population. The study cohort was derived from the National Readmission Database 2013 to 2014, a subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. DHF was identified using International Classification of Diseases, 9th Revision code 428.3x in primary diagnosis field. Readmission etiologies were identified by International Classification of Diseases, 9th Revision code in primary diagnosis field. The primary outcome was 30-day readmission. Hierarchical multivariable logistic regression was used to adjust for confounders. In total, 192,394 patients with DHF were included, of which 40,927 (21.27%) patients were readmitted with total readmissions of 47,056 within 30 days. Predictors of increased readmissions were age (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.001 to 1.0003, p <0.001), diabetes (OR 1.08, 95% CI 1.05 to 1.11, p <0.001), chronic pulmonary disease (OR 1.18, 95% CI 1.15 to 1.21, p <0.001), renal failure (OR 1.21, 95% CI 1.17 to 1.25, p <0.001), peripheral vascular disease (OR 1.05, 95% CI 1.02 to 1.09, p = 0.002), anemia (OR 1.12, 95% CI 1.10 to 1.15, p <0.001), transfusion during index admission (OR 1.18, 95% CI 1.13 to 1.23, p <0.001), discharge to the facility (OR 1.13, 95% CI 1.10 to 1.16, p <0.001), length of stay >2 days, and Charlson comorbidity index ≥3, whereas obesity (OR 0.82, 95% CI 0.80 to 0.85, p <0.001), elective admissions (OR 0.88, 95% CI 0.83 to 0.94, p <0.001), and non-Medicare/Medicaid primary payer were predictors of lower readmission rate. Most common etiologies of readmission were acute HF (28.01%), infections (9.54%), acute kidney injury (5.35%), acute respiratory failure (4.86%), and pneumonia (3.92%). In conclusion, DHF population with higher comorbidity burden, longer length of stay, and discharge to facility were prone to increased readmissions, with most common etiologies of readmission being HF, infections, and acute kidney injury.
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http://dx.doi.org/10.1016/j.amjcard.2017.05.028DOI Listing
August 2017

Do Not Resuscitate, with No Surrogate and No Advance Directive: An Ethics Case Study.

J Clin Ethics 2017 ;28(2):159-162

Icahn School of Medicine, 1 Gustave Levy Place, Box 1076, New York, New York 10029 USA.

Do-not-resuscitate (DNR) orders are typically signed by physicians in conjunction with patients or their surrogate decision makers in order to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR). Both the medical literature and CPR guidelines fail to address when it is appropriate for physicians to sign DNR orders without any knowledge of a patient's wishes. We explore the ethical issues surrounding instituting a two-physician DNR for a dying patient with multiple comorbidities and no medical record on file, no advance directives, and no surrogate decision maker. Through this case we also highlight the issues of poor prognostication and the reversal of a DNR in such circumstances.
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March 2018

Renal cell carcinoma with inferior vena cava thrombus extending to the right atrium diagnosed during pregnancy.

Ther Adv Urol 2017 Dec 16;9(6):155-159. Epub 2017 Apr 16.

Assistant Professor, Department of Urology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1272, New York, NY 10029, USA.

Only one case of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus diagnosed and treated during pregnancy has been reported in the literature. In that report, the tumor thrombus extended to the infrahepatic IVC (level II tumor thrombus). In the present case, a 37-year-old woman with lupus anticoagulant antibodies was diagnosed with RCC and IVC tumor thrombus extending to the right atrium (level IV tumor thrombus) at 24 weeks of pregnancy. The fetus was safely delivered by cesarean section at 30 weeks of gestation. At 4 days later, an open right radical nephrectomy and IVC and right atrial thrombectomy were performed on cardiopulmonary bypass (CPB) once the patient's hemodynamic status had been optimized. Fetal and maternal concerns included the risk of a thromboembolic event (due to increased hypercoagulability from pregnancy, active malignancy, and lupus anticoagulant), intraoperative hemorrhage risk (due to extensive venous collaterals and anticoagulation), and fetal morbidity and mortality (due to fetal lung immaturity). Standardized guidelines for treatment of RCC with or without IVC tumor thrombus during pregnancy are unavailable due to the infrequency of such cases. Treatment decisions are therefore individualized and this case report may inform the management of future patients diagnosed with RCC with level IV tumor thrombus during pregnancy.
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http://dx.doi.org/10.1177/1756287217701378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444575PMC
December 2017

Coronary Artery PET/MR Imaging: Feasibility, Limitations, and Solutions.

JACC Cardiovasc Imaging 2017 10 18;10(10 Pt A):1103-1112. Epub 2017 Jan 18.

Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

Objectives: The aims of this study were to describe the authors' initial experience with combined coronary artery positron emission tomographic (PET) and magnetic resonance (MR) imaging using F-fluorodeoxyglucose (F-FDG) and F-sodium fluoride (F-NaF) radiotracers, describe common problems and their solutions, and demonstrate the feasibility of coronary PET/MR imaging in appropriate patients.

Background: Recently, PET imaging has been applied to the aortic valve and regions of atherosclerosis. F-FDG PET imaging has become established for imaging inflammation in atherosclerosis in the aorta and carotid arteries. Moreover, F-NaF has emerged as a novel tracer of active microcalcification in the aortic valve and coronary arteries. Coronary PET imaging remains challenging because of the small caliber of the vessels and their complex motion. Currently, most coronary imaging uses combined PET and computed tomographic imaging, but there is increasing enthusiasm for PET/MR imaging because of its reduced radiation, potential to correct for motion, and the complementary information available from cardiac MR in a single scan.

Methods: Twenty-three patients with diagnosed or documented risk factors for coronary artery disease underwent either F-FDG or F-NaF PET/MR imaging. Standard breath-held MR-based attenuation correction was compared with a novel free-breathing approach. The impact on PET image artifacts and the interpretation of vascular uptake were evaluated semiquantitatively by expert readers. Moreover, PET reconstructions with more algorithm iterations were compared visually and by target-to-background ratio.

Results: Image quality was significantly improved by novel free-breathing attenuation correction. Moreover, conspicuity of coronary uptake was improved by increasing the number of algorithm iterations from 3 to 6. Elevated radiotracer uptake could be localized to individual coronary lesions using both F-FDG (n = 1, maximal target-to-background ratio = 1.61) and F-NaF (n = 7, maximal target-to-background ratio = 1.55 ± 0.37), including in 1 culprit plaque post-myocardial infarction confirmed by myocardial late gadolinium enhancement.

Conclusions: The authors provide the first demonstration of successful, low-radiation (7.2 mSv) PET/MR imaging of inflammation and microcalcification activity in the coronary arteries. However, this requires specialized approaches tailored to coronary imaging for both attenuation correction and PET reconstruction.
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http://dx.doi.org/10.1016/j.jcmg.2016.09.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509532PMC
October 2017

Etiologies, Trends, and Predictors of 30-Day Readmission in Patients With Heart Failure.

Am J Cardiol 2017 03 14;119(5):760-769. Epub 2016 Dec 14.

Cardiology Department, Icahn School of Medicine at Mount Sinai, New York, New York.

Heart failure (HF) is the most common discharge diagnosis across the United States, and these patients are particularly vulnerable to readmissions, increasing attention to potential ways to address the problem. The study cohort was derived from the Healthcare Cost and Utilization Project's National Readmission Data 2013, sponsored by the Agency for Healthcare Research and Quality. HF was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Readmission was defined as a subsequent hospital admission within 30 days after discharge day of index admission. Readmission causes were identified using International Classification of Diseases, Ninth Revision, codes in primary diagnosis filed. The primary outcome was 30-day readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. From a total 301,892 principal admissions (73.4% age ≥65 years and 50.6% men), 55,857 (18.5%) patients were readmitted with a total of 64,264 readmissions during the study year. Among the etiologies of readmission, cardiac causes (49.8%) were most common (HF being most common followed by coronary artery disease and arrhythmias), whereas pulmonary causes were responsible for 13.1% and renal causes for 8.9% of the readmissions. Significant predictors of increased 30-day readmission included diabetes (odds ratio, 95% confidence interval, p value: 1.06, 1.03 to 1.08, p <0.001), chronic lung disease (1.13, 1.11 to 1.16, p <0.001), renal failure/electrolyte imbalance (1.12, 1.10 to 1.15, p <0.001), discharge to facilities (1.07, 1.04 to 1.09, p <0.001), lengthier hospital stay, and transfusion during index admission. In conclusion, readmission after a hospitalization for HF is common. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome.
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http://dx.doi.org/10.1016/j.amjcard.2016.11.022DOI Listing
March 2017

National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation.

J Am Heart Assoc 2016 12 20;5(12). Epub 2016 Dec 20.

Icahn School of Medicine at Mount Sinai, New York, NY

Background: Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI-D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI-D utilizing a nationally representative database.

Methods And Results: Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI-D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI-D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI-D included mechanical ventilation (aOR 13.12; 95% CI 9.88-17.43); sepsis (aOR 8.20; 95% CI 6.00-11.20); and liver failure (aOR 3.72; 95% CI 2.92-4.75). AKI-D was associated with higher risk of in-hospital mortality (aOR 3.54; 95% CI 2.81-4.47) and adverse discharge (aOR 4.01; 95% CI 3.12-5.17). Although percentage mortality within AKI-D decreased over the decade, attributable risk percentage mortality remained stable.

Conclusions: AF hospitalizations complicated by AKI-D have quintupled over the last decade with differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. Without effective AKI-D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.
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http://dx.doi.org/10.1161/JAHA.116.004509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5210405PMC
December 2016

Imaging Modalities to Identity Inflammation in an Atherosclerotic Plaque.

Radiol Res Pract 2015 20;2015:410967. Epub 2015 Dec 20.

Department of Cardiology, Maimonides Medical Center, Brooklyn, NY 11219, USA.

Atherosclerosis is a chronic, progressive, multifocal arterial wall disease caused by local and systemic inflammation responsible for major cardiovascular complications such as myocardial infarction and stroke. With the recent understanding that vulnerable plaque erosion and rupture, with subsequent thrombosis, rather than luminal stenosis, is the underlying cause of acute ischemic events, there has been a shift of focus to understand the mechanisms that make an atherosclerotic plaque unstable or vulnerable to rupture. The presence of inflammation in the atherosclerotic plaque has been considered as one of the initial events which convert a stable plaque into an unstable and vulnerable plaque. This paper systemically reviews the noninvasive and invasive imaging modalities that are currently available to detect this inflammatory process, at least in the intermediate stages, and discusses the ongoing studies that will help us to better understand and identify it at the molecular level.
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http://dx.doi.org/10.1155/2015/410967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699110PMC
January 2016

Variation in utilization of multivessel percutaneous coronary intervention: influence of hospital volume.

Coron Artery Dis 2015 Dec;26(8):657-64

aDepartment of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey bDivision of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky cDivision of Cardiovascular Diseases, Detroit Medical Center, Detroit, Michigan dCardiology Division, University of Miami Miller School of Medicine, Miami, Florida eDepartment of Internal Medicine, Mount Sinai St Luke's Roosevelt Hospital fDivision of Cardiology, The Mount Sinai Hospital, New York, New York gInterventional Cardiology, The Everett Clinic, Everett, Washington, USA.

Background: The purpose of this study was to investigate the contemporary trends in the utilization of multivessel percutaneous coronary interventions (MVPCIs) in the USA.

Methods: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2006 and 2011 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes 00.40 (single stent), 00.46, 00.47, and 00.48 (single vessel and multiple stents) and 00.41, 00.42 and 00.43 (MVPCI). We built a hierarchical three-level model adjusted for multiple confounding factors.

Results: A total of 543 434 (weighted: 2 683 206) procedures were identified. Independent predictors of increased MVPCI utilization (odds ratio, 95% confidence interval, P-value) were found to be age (1.05, 1.04-1.07, P<0.001) and comorbid conditions on using Deyo's modification of Charlson's comorbidity index of at least 2 (1.13, 1.09-1.16, P<0.001). Female sex (0.88, 0.87-0.90, P<0.001), myocardial infarction (0.86, 0.83-0.89, P<0.001), weekend admissions (0.94, 0.91-0.96, P<0.001), and urgent admissions (0.88, 0.83-0.93, P<0.001) predicted decreased utilization. Highest quartile of hospital (1.34, 1.16-1.54, P<0.001) predicted higher utilization. Between-hospital variation of 7.7% (interclass correlation coefficient) was observed, which was minimally affected by patient or hospital mix. A randomly selected patient was ∼1.6 (median odds ratio) times more likely to receive an MVPCI from a given hospital compared with another identical patient being treated at a different random hospital.

Conclusion: The utilization rate of MVPCI varied considerably among hospitals. Higher annual hospital volume was associated with a higher utilization rate of MVPCI.
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http://dx.doi.org/10.1097/MCA.0000000000000298DOI Listing
December 2015

The Pulmonary Artery Catheter in 2015: The Swan and the Phoenix.

Cardiol Rev 2016 Jan-Feb;24(1):1-13

*Department of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY; and †Department of Medicine, Maimonides Medical Center, Brooklyn, NY.

The pulmonary artery catheter (PAC) has revolutionized the care of critically ill patients by allowing physicians to directly measure important cardiovascular variables at the bedside. The relative ease of placement and the important physiological data obtained by PAC led to its incorporation as a central tool in the management of critically ill patients in intensive care units. Given the lack of demonstrable benefit in randomized clinical trials, persistent questions about safety, and recent advancements in noninvasive imaging modalities that purport to more accurately estimate cardiovascular hemodynamics, the use of the PAC has declined rapidly over recent years. Devised by cardiologists to measure hemodynamic parameters in patients with acute myocardial infarction, the PAC was quickly and enthusiastically adopted by intensivists, anesthesiologists, surgeons, and other specialists. This unbridled proliferation may have resulted in negative publicity surrounding the PAC. This article systematically reviews the evolution of PACs, the results of nonrandomized and randomized studies in various clinical conditions, the reasons for its decline, and current indications of PAC.
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http://dx.doi.org/10.1097/CRD.0000000000000082DOI Listing
September 2016

Comparison of inhospital mortality, length of hospitalization, costs, and vascular complications of percutaneous coronary interventions guided by ultrasound versus angiography.

Am J Cardiol 2015 May 18;115(10):1357-66. Epub 2015 Feb 18.

Cardiovascular Division, Detroit Medical Center, Detroit, Michigan.

Despite the valuable role of intravascular ultrasound (IVUS) guidance in percutaneous coronary interventions (PCIs), its impact on clinical outcomes remains debatable. The aim of the present study was to compare the outcomes of PCIs guided by IVUS versus angiography in the contemporary era on inhospital outcomes in an unrestricted large, nationwide patient population. Data were obtained from the Nationwide Inpatient Sample from 2008 to 2011. Hierarchical mixed-effects logistic regression models were used for categorical dependent variables like inhospital mortality, and hierarchical mixed-effects linear regression models were used for continuous dependent variables like length of hospital stay and cost of hospitalization. A total of 401,571 PCIs were identified, of which 377,096 were angiography guided and 24,475 (weighted n = 119,102) used IVUS. In a multivariate model, significant predictors of higher mortality were increasing age, female gender, higher baseline co-morbidity burden, presence of acute myocardial infarction, shock, weekend and emergent admission, or occurrence of any complication during hospitalization. Significant predictors of reduced mortality were the use of IVUS guidance (odds ratio 0.65, 95% confidence interval 0.52 to 0.83; p <0.001) for PCI and higher hospital volumes (third and fourth quartiles). The use of IVUS was also associated with reduced inhospital mortality in subgroup of patients with acute myocardial infarction and/or shock and those with a higher co-morbidity burden (Charlson's co-morbidity index ≥2). In one of the largest studies on IVUS-guided PCIs in the drug-eluting stent era, we demonstrate that IVUS guidance is associated with reduced inhospital mortality, similar length of hospital stay, and increased cost of care and vascular complications compared with conventional angiography-guided PCIs.
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http://dx.doi.org/10.1016/j.amjcard.2015.02.037DOI Listing
May 2015

Palliative care in the cardiac intensive care unit.

Am J Cardiol 2015 Mar 18;115(5):687-90. Epub 2014 Dec 18.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

Patients admitted to today's cardiac intensive care units (CICUs) have increasingly complex medical conditions; consequently, palliative care is becoming an integral component of their care. Although there is a robust body of literature emanating from other intensive care unit settings, there has been less discussion about the role of palliative care in the CICU. This study examined all admissions to the Mount Sinai Hospital CICU from January 1 through December 31, 2012. Of the 1,368 patients admitted, there were 117 CICU patient deaths. End-of-life discussions were carried out in 85 patients (72.6%) who died during that hospital admission; the primary CICU team led these discussions and helped with decision making in >1/2 of them. For the 85 patients who had goals of care (GOC) discussions, there was a higher rate of redirected GOC toward comfort care or no escalation of care (38.8% vs 3.1%, p <0.001) and withdrawal of life-sustaining treatments, such as mechanical ventilation and vasopressors (23.5% vs 6.3%, p = 0.02) compared with patients for whom no GOC discussions were held. Among patients who had GOC discussions, there was no statistically significant difference for patients who had their mechanical circulatory support, defibrillator, or pacing therapies turned off compared with patients who were not involved in GOC discussions. With the exception of discontinuation of mechanical circulatory support which took place for 6 of the 7 patients in the CICU, end-of-life interventions were split evenly between the palliative care unit and the CICU. There was no difference in CICU length of stay or days to mortality from the time of CICU admission between the 2 groups. In conclusion, our study demonstrates the effect of palliative care and end-of-life decision making in the CICU. As such, we advocate for increased palliative care education and training among clinicians who are involved in cardiac critical care.
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http://dx.doi.org/10.1016/j.amjcard.2014.12.023DOI Listing
March 2015

Cardiovascular intensive care. Preface.

Cardiol Clin 2013 Nov;31(4):xiii-xiv

The Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Box 1030, One Gustave L. Levy Place, New York, NY 10029-6754, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ccl.2013.09.001DOI Listing
November 2013
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