Background: Pulmonary vascular resistance (PVR) is used as a surrogate of pulmonary vascular remodeling and risk-predictor of post-transplant outcomes when selecting heart transplant (HT) candidate...

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

BackgroundPrior studies have found that smokers undergoing thrombolytic therapy for ST‐segment elevation myocardial infarction have lower in‐hospital mortality than nonsmokers, a phenomenon called the “smoker's paradox.” Evidence, however, has been conflicting regarding whether this paradoxical association persists in the era of primary percutaneous coronary intervention. Methods and ResultsWe used the 2003–2012 National Inpatient Sample databases to identify all patients aged ≥18 years who underwent primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction. Multivariable logistic regression was used to compare in‐hospital mortality between smokers (current and former) and nonsmokers. Of the 985 174 patients with ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, 438 954 (44.6%) were smokers. Smokers were younger, were more often men, and were less likely to have traditional vascular risk factors than nonsmokers. Smokers had lower observed in‐hospital mortality compared with nonsmokers (2.0% versus 5.9%; unadjusted odds ratio 0.32, 95% CI 0.31–0.33, P<0.001). Although the association between smoking and lower in‐hospital mortality was partly attenuated after baseline risk adjustment, a significant residual association remained (adjusted odds ratio 0.60, 95% CI 0.58–0.62, P<0.001). This association largely persisted in age‐stratified analyses. Smoking status was also associated with shorter average length of stay (3.5 versus 4.5 days, P<0.001) and lower incidence of postprocedure hemorrhage (4.2% versus 6.1%; adjusted odds ratio 0.81, 95% CI 0.80–0.83, P<0.001) and in‐hospital cardiac arrest (1.3% versus 2.1%; adjusted OR 0.78, 95% CI 0.76–0.81, P<0.001). ConclusionsIn this nationwide cohort of patients undergoing primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction, we observed significantly lower risk‐adjusted in‐hospital mortality in smokers, suggesting that the smoker's paradox also applies to ST‐segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Sex-based differences in in-hospital clinical outcomes after left ventricular assist device (LVAD) implantation have not been well studied in real-world advanced heart failure patients. - Of the 14,273 LVAD recipients in the Nationwide Inpatient Sample databases 2002-2012 (weighted sample), 3,256 (

Opioid use is associated with unintentional and intentional overdose and is one of the leading causes of emergency room visits and accidental deaths. However, the association between opioid abuse/dependence and outcomes in hospitalized patients has not been well studied. Congestive heart failure (HF) is the fourth most common cause of hospitalization in the United States. The purpose of this study was to examine the effect of opioid abuse/dependence on outcomes in patients hospitalized with HF. We queried the 2002-2010 Nationwide Inpatient Sample databases to identify all patients aged 18 years and older admitted with the primary diagnosis of HF. Multivariate logistic regression analysis was used to compare the frequency of hospital-acquired conditions (HACs) and in-hospital mortality between patients with and without a history of opioid abuse/dependence. Of 9,993,240 patients with HF, 29,014 had a history of opioid abuse or dependence. Opioid abusers/dependents were likely to be younger men of poor socioeconomic background with self pay or Medicaid as their primary payer. They had a lower prevalence of dyslipidemia, diabetes mellitus, coronary artery disease, prior myocardial infarction, and peripheral vascular disease (P < 0.001 for all). They were more likely to be smokers and have chronic pulmonary disease, depression, liver disease, and obesity (P < 0.001 for all). Patients with a history of opioid abuse/dependence had lower incidence of HACs (14.8% vs. 16.5%, adjusted odds ratio: 0.71, P < 0.001) and lower in-hospital mortality (1.3% vs. 3.6%, adjusted odds ratio: 0.64, P < 0.001) as compared with patients without prior opioid abuse/dependence. In conclusion, among adult patients aged 18 years and older hospitalized with HF, opioid abuse/dependence was associated with lower frequency of HACs and lower in-hospital mortality.

Background: Limited data are available on the impact of chronic kidney disease (CKD) and end stage renal disease (ESRD) on outcomes after percutaneous coronary intervention (PCI). Objectives: To determine the association between baseline renal insufficiency with in-hospital outcomes after PCI. Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥ 18 years undergoing PCI. Patients who underwent coronary artery bypass grafting during the same admission were excluded. Patients with concomitant diagnosis of CKD (ICD-9 codes 585.1-585.5 and 585.9) and ESRD (ICD-9 diagnosis code 585.6 or procedure code for hemodialysis [39.95, excluding patients with concurrent diagnosis of acute renal failure] or peritoneal dialysis [54.98]) were then identified. Multivariable logistic regression was used to compare outcomes between patients with CKD and patients with ESRD to those without CKD or ESRD. Results: Of 6,417,970 patients who underwent PCI, 93.3% (mean age 64.2±12.3 years, 33.7% females) had no CKD/ESRD; 4.9% (mean age 71.5±11.3 years, 35% females) had CKD; and 1.8% (mean age 64.2±11.8 years, 42.2% females) had ESRD. The prevalence of smoking was highest in patients with no CKD/ESRD; that of dyslipidemia, coronary artery disease, prior myocardial infarction, atrial fibrillation, and obesity was highest in CKD patients; diabetes mellitus, hypertension, and congestive heart failure were most prevalent in ESRD patients (p<0.001 for all). Of patients undergoing PCI, 61.2% patients in no CKD/ESRD group had an acute coronary syndrome, as compared to 65.4% in CKD group, and 58.2% in ESRD group (p<0.001). Compared to patients with no CKD/ESRD, those with CKD and those with ESRD had higher in-hospital mortality and higher incidence of post-procedure hemorrhage. Baseline renal insufficiency was also associated with longer average length of stay and higher average total hospital charges (Table). Conclusions: In patients undergoing PCI, baseline renal insufficiency is associated with worse outcomes. Patients with CKD and patients with ESRD had increased in-hospital mortality, higher hemorrhagic complications, longer average length of hospital stay, and higher average hospital charges than those without CKD or ESRD.

Arrhythmias are a well-known complication of alcoholic cardiomyopathy (ACMP); however, there are limited data on the burden of arrhythmias and their association with outcomes in ACMP patients. We used the 2003-2011 Nationwide Inpatient Sample Databases to identify all patients aged ≥ 18 years

BACKGROUND: Acute myocardial infarction is a recognized complication in patients with hypertrophic cardiomyopathy. However, limited data are available on outcomes of patients with hypertrophic cardiomyopathy and acute myocardial infarction.METHODS: We analyzed the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged >= 18 years with a principal diagnosis of acute myocardial infarction. Patients with a concomitant diagnosis of hypertrophic cardiomyopathy were then identified and analyzed as a separate cohort. Multivariate logistic regression was used to compare outcomes in patients with acute myocardial infarction with and without hypertrophic cardiomyopathy.RESULTS: Of 5,901,827 patients with acute myocardial infarction, 5688 (0.1%) had a diagnosis of hypertrophic cardiomyopathy. Patients with hypertrophic cardiomyopathy were older, more likely to be female, and less likely to have traditional cardiovascular risk factors. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy were less likely to present with ST-elevation myocardial infarction and more likely to present with non-ST-elevation myocardial infarction. Patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction were less likely to receive revascularization. In the overall population with acute myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.84-1.11; P = .59). In the population with ST-elevation myocardial infarction, patients with hypertrophic cardiomyopathy had lower risk-adjusted in-hospital mortality than those without hypertrophic cardiomyopathy (OR, 0.75; 95% CI, 0.63-0.91; P = .003), whereas in the population with noneST-elevation myocardial infarction, there was no difference in risk-adjusted in-hospital mortality between patients with and without hypertrophic cardiomyopathy (OR, 0.97; 95% CI, 0.84-1.11; P = .63).CONCLUSIONS: Patients with hypertrophic cardiomyopathy represent a small proportion of patients with acute myocardial infarction and are less likely to receive revascularization. Compared with patients without hypertrophic cardiomyopathy, patients with hypertrophic cardiomyopathy with ST-elevation myocardial infarction have lower risk-adjusted in-hospital mortality. (C) 2015 Elsevier Inc. All rights reserved.

Arrhythmias are relatively common in patients with hypertrophic cardiomyopathy (HCM); however, there are limited data on the association of various arrhythmias with outcomes in these patients. Patients hospitalized with a primary diagnosis of HCM were identified from the 2003-2011 Nationwide

Background: Arrhythmias are relatively common in patients with non-ischemic cardiomyopathies. There are limited data on the association of atrial and ventricular arrhythmias with outcomes in patients with peripartum cardiomyopathy (PPCM). Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnostic codes 674.50 to 674.55, to identify all women aged between 15-55 years admitted with a diagnosis of PPCM. The various arrhythmias were identified using appropriate ICD-9 diagnostic codes - atrial fibrillation (AF) (427.31), atrial flutter (427.32), supraventricular tachycardia (SVT) (427.0), ventricular tachycardia (VT) (427.1), ventricular fibrillation (VF) (427.41 and 427.42). Multivariable adjusted logistic regression was used to study the association of arrhythmias with in-hospital mortality and multivariable adjusted linear regression was used to study the association of arrhythmias with length of stay and hospital charges. Results: From 2003 to 2011, 34,944 patients were hospitalized with PPCM. The mean age was 30±7 years. Among these patients with PPCM, ventricular tachycardia (VT) (4.8%) was the most common arrhythmia followed by atrial fibrillation (AF) (2.2%), ventricular fibrillation (VF) (1.3%), atrial flutter (0.8%) and supraventricular tachycardia (SVT) (0.6%). The risk adjusted in-hospital mortality was higher in PPCM patients with AF (3.6% vs 1.2%, adjusted OR 2.38, 95% CI 1.50-3.78), VT (3.7% vs 1.1%, adjusted OR 1.8, 95% CI 1.30-2.48) and VF (14.2% vs 1.1%, adjusted OR 5.39, 95% CI 3.75-7.74) compared to those without arrhythmias. Among the study population, the average length of stay was longer in patients with AF (8 vs 5 days, p<0.001), atrial flutter (10 vs 5 days, p<0.001), SVT (10 vs 5 days, p<0.001), VT (9 vs 5 days, p<0.001) and VF (10 vs 5 days, p<0.001). The average hospital charges was also higher in patients with AF ($74,799 vs $40,974; p=0.004), atrial flutter ($129,692 vs $41,042; p<0.001), SVT ($133,223 vs $41,165; p<0.001), VT ($97,525 vs $38,929; p<0.001) and VF ($158,381 vs $40,194; p<0.001). Conclusions: In patients hospitalized with PPCM AF, VT and VF were independently associated with significantly higher in-hospital mortality. Also in these patients AF, atrial flutter, SVT, VT and VF were independently associated with higher hospital charges and longer length of stay.

Donor-recipient race mismatch (DRRM) has been shown to increase graft failure and mortality among pediatric heart transplant (HT) recipients. However, similar association has not been examined among adult HT recipients. Of 40,705 adult HT recipients in the United Network of Organ Sharing (UNOS)

Acute myocardial infarction in patients with end-stage renal disease (ESRD) is associated with increased risk of morbidity and mortality. Limited data are available on the contemporary trends in management and outcomes of ST-elevation myocardial infarction (STEMI) in patients with ESRD. We analyzed the 2003 to 2011 Nationwide Inpatient Sample databases to examine the temporal trends in STEMI, use of mechanical revascularization for STEMI, and in-hospital outcomes in patients with ESRD aged years in the United States. From 2003 to 2011, whereas the number of patients with ESRD admitted with the primary diagnosis of acute myocardial infarction increased from 13,322 to 20,552, there was a decrease in the number of STEMI hospitalizations from 3;169 to 2,558 (p(trend) <0.001). The overall incidence rate of cardiogenic shock in patients with ESRD and STEMI increased from 6.6% to 18.3% (P-trend <0.001). The use of percutaneous coronary intervention for STEMI increased from 18.6% to 37.8% (p(trend) <0.001), whereas there was no significant change in the use of coronary artery bypass grafting (p(trend) = 0.32). During the study period, in-hospital mortality increased from 22.3% to 25.3% (adjusted odds ratio [per year] 1.09; 95% confidence interval 1.08 to 1.11; p(trend) <0.001). The average hospital charges increased from $60,410 to $97,794 (P-trend <0.001), whereas the average length of stay decreased from 8.2 to 6.5 days (p(trend) <0.001). In conclusion, although there have been favorable trends in the utilization of percutaneous coronary intervention and length of stay in patients with ESRD and STEMI, the incidence of cardiogenic shock has increased threefold, with an increase in risk-adjusted in-hospital mortality, likely because of the presence of greater co-morbidities. (C) 2015 Elsevier Inc. All rights

Background-The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized.Methods and Results-We queried the 2007-2011 Nationwide Inpatient Sample databases to identify all patients aged >= 18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% versus 6.0%, respectively; adjusted odds ratio for CKD 1.21, 95% CI 1.18 to 1.23, P<0.001; adjusted odds ratio for ESRD 1.27, 95% CI 1.23 to 1.32, P<0.001), longer average length of stay (2.9 days versus 5.0 days versus 6.4 days, respectively; P<0.001), and higher average total hospital charges ($60 526 versus $77 324 versus $97 102, respectively; P<0.001). Similar results were seen in subgroups of patients undergoing PCI for acute coronary syndrome or stable ischemic heart disease.Conclusions-In patients undergoing PCI, chronic renal insufficiency is associated with higher in-hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.

BackgroundThe prevalence and contemporary trends of pre-heart transplantation (HT) coagulopathy and associated clinical outcomes have not been studied from a national database.HypothesisPre-HT coagulopathy is associated with increased in-hospital mortality.MethodsAmong 2454 adult HT recipients from the 2003 to 2010 Nationwide Inpatient Sample databases, 707 (29%) had pre-HT coagulopathy (defined as a comorbidity variable, based on International Classification of Diseases, Ninthe Revision, Clinical Modification and Diagnosis Related Group codes). We used propensity scores for coagulopathy to assemble a matched cohort of 664 pairs of patients with and without coagulopathy balanced in 54 baseline characteristics.ResultsThe prevalence of pre-HT coagulopathy increased from 17% in 2003 to 44% in 2010 (P for trend <0.001). In-hospital mortality occurred in 8.6% and 4.7% of matched HT recipients with and without coagulopathy, respectively (hazard ratio: 1.81; 95% confidence interval [CI]: 1.17-2.80; P = 0.008). Coagulopathy was not significantly associated with post-HT graft complications (odds ratio [OR]: 1.20; 95% CI: 0.95-1.52; P = 0.131) but was associated with increased blood transfusions (OR: 1.92; 95% CI, 1.54-2.41; P < 0.001). Coagulopathy and no-coagulopathy groups had no difference in median length of stay (22 days in each group, P = 0.746), but median total hospital charges were higher among patients with coagulopathy compared to those without (US$425 643 vs US$389 656; P = 0.008).ConclusionsIn this national study of HT recipients, pretransplant coagulopathy was common, increased over time, and was not significantly associated with post-HT graft complications or increased hospital stay. However, it was associated with increased bleeding risk, in-hospital mortality, and total hospital charges. These findings may have implications for the selection of patients for HT.

Background: Atrial fibrillation is a relatively common comorbid condition in patients with coronary artery disease. However, there are limited data on the association of atrial fibrillation (AF) with outcomes in ST-elevation myocardial infarction (STEMI). Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnosis codes, to identify all patients > 18 years admitted with a primary diagnosis of STEMI. We studied the association of AF with in-hospital outcomes in these patients both by regression analysis and propensity match to adjust for demographics, hospital characteristics and co-morbidities. Results: Of the total 452,772 (64.5% men) STEMI hospitalizations, AF was documented in 58,273 (12.9%) cases. Patients with AF were older (mean age 75±12 vs 64±14 years; p<0.001) and had a higher proportion of women (42.5% vs 34.5%; p<0.001) than patients without AF. STEMI patients with AF had a higher risk-adjusted in-hospital mortality (OR 1.15, 95% CI 1.12-1.19, p<0.001), longer average length of stay (7 days vs 4 days, P<0.001) and higher average total hospital charges ($74,082 vs $57,331, P<0.001) than those without AF. Using propensity matching, 57,388 STEMI patients with AF were compared with the same number of patients without AF. Within these matched cohorts, STEMI patients with AF had higher in-hospital mortality (16.7% vs 15.1%, OR 1.13, 95% CI 1.09-1.16; p<0.001), longer average length of stay (7 days vs 6 days, P<0.001), and higher average total hospital charges ($73,832 vs $65,201, P<0.001) than patients without AF. Conclusions: In patients hospitalized with STEMI, AF was independently associated with modestly higher in-hospital mortality, higher hospital charges, and longer length of stay.

Background: Percutaneous ventricular assist devices (pVAD) can be rapidly deployed in cardiac catheterization laboratory and have emerged as an effective modality for short-term hemodynamic support in patients with cardiogenic shock. There are limited data on contemporary trends in utilization and outcomes of pVAD in patients with cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). Objectives: To determine the temporal trends in utilization and outcomes of pVAD in patients with cardiogenic shock complicating STEMI. Methods: We queried the 2007-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥ 18 years with STEMI and cardiogenic shock. Patients who underwent pVAD implantation were then identified using ICD-9 procedure code 37.68. Temporal trends in utilization of pVAD in STEMI patients with cardiogenic shock and in-hospital outcomes in these patients were analyzed. Results: From 2007-2011, of 1,053,161 patients with STEMI, 100,881 (9.6%) had cardiogenic shock. The in-hospital mortality in patients with cardiogenic shock decreased from 39.2% in 2007 to 33.9% in 2011 (P trend <0.001, adjusted OR [per year] 0.98, 95% CI 0.97-0.99). Of the STEMI patients with cardiogenic shock, a total of 1,068 (1.1%) patients underwent pVAD implantation. The use of pVAD in STEMI patients with cardiogenic shock increased from 0.1% in 2007 to 2.6% in 2011 (P trend <0.001). The incidence of acute cerebrovascular accident in patients with pVAD was 6.7% with no significant temporal change in incidence (P trend =0.99). The incidence of acute gastrointestinal bleeding in these patients was 14.3% with no significant temporal change in incidence (P trend =0.52). The overall in-hospital mortality in patients who received pVAD was 49.6% with an increase in in-hospital mortality during the study period (P trend =0.03, adjusted OR [per year] 1.22, 95% CI 1.02-1.47). The average length of stay in these patients increased from 12 days to 15 days (P trend <0.001), whereas the average total hospital charges increased from $180,849 to $361,050 (P trend <0.001). Conclusion: In recent years, there has been an increase in utilization of pVAD in patients with cardiogenic shock complicating STEMI. However, this trend was not accompanied with a decrease in overall in-hospital mortality among patients who underwent pVAD implantation. There were also adverse temporal trends in the average length of stay and average hospital cost in STEMI patients with cardiogenic shock undergoing pVAD implantation.

BACKGROUND Older women presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to receive revascularization and have worse outcomes relative to their male counterparts.OBJECTIVES This study sought to determine temporal trends and sex differences in revascularization and in-hospital outcomes of younger patients with STEMI.METHODS We used the 2004 to 2011 Nationwide Inpatient Sample databases to identify all patients age 18 to 59 years hospitalized with STEMI. Temporal trends and sex differences in revascularization strategies, in-hospital mortality, and length of stay were analyzed.RESULTS From 2004 to 2011, of 1,363,492 younger adults (age <60 years) with acute myocardial infarction, 632,930 (46.4%) had STEMI. Younger women with acute myocardial infarction were less likely than men to present with STEMI (adjusted odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.73 to 0.75). Younger women with STEMI were less likely to receive reperfusion as compared with younger men (percutaneous coronary intervention adjusted OR: 0.74; 95% CI: 0.73 to 0.75) (coronary artery bypass grafting adjusted OR: 0.61; 95% CI: 0.60 to 0.62) (thrombolysis adjusted OR: 0.80; 95% CI: 0.78 to 0.82). From 2004 to 2011, use of percutaneous coronary intervention for STEMI increased in both younger men (63.9% to 84.8%; p(trend) < 0.001) and women (53.6% to 77.7%; p(trend) < 0.001). In-hospital mortality was significantly higher in younger women compared with men (4.5% vs. 3.0%; adjusted OR: 1.11; 95% CI: 1.07 to 1.15). There was an increasing trend in risk-adjusted in-hospital mortality in both younger men and women during the study period. Length of stay decreased in both younger men and women (p(trend) < 0.001).CONCLUSIONS Younger women are less likely to receive revascularization for STEMI and have higher in-hospital mortality as compared with younger men. Use of percutaneous coronary intervention for STEMI and in-hospital mortality have increased, whereas length of stay has decreased in both sexes over the past several years. (C) 2015 by the American College of Cardiology Foundation.