Yeo, Ilhwan

Background: Pulmonary embolism (PE) is a major cause of morbidity and mortality accounting for 100,000 deaths per year in the United States and 5–10% of in-hospital deaths. There is sparse comparative data on readmission patterns in patients who undergo early versus late catheter directed thrombolysis (CDT) for acute PE. Research Question: Is the procedure day for acute PE associated with a difference in 30-day readmission rates? Study Design and Method: This study was performed by using the Nationwide Readmissions Database between 2016 and 2019. Patients with acute PE who underwent CDT were identified using codes from the International Classification of Diseases, 10th Edition (ICD 10). Results: The 30-day readmission rates were higher for patients who underwent CDT on Day 2 or afterwards compared to Day 1 and Day 0 (7.1% vs. 5.7% vs. 5.2%). Patients who had CDT on Day 2 or later had a higher rate of 30-day readmission mortality compared to those who had CDT on Day 1 or 0 (0.6% vs. 0.3% vs. 0.2%. The 30-day readmission rates for heart failure were higher among patients who had CDT on Day 2 compared to those who had CDT on Day 0 of admission (2% vs. 1.0% vs. 0.9%). Interpretation: Delayed CDT for acute PE was associated with increased rates of 30-day readmission, readmission mortality, and readmission for heart failure. These findings emphasize the need for earlier CDT for the treatment of acute PE.

Background Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra‐aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA‐ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA‐ECMO. Methods and Results Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA‐ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA‐ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P ‐trend<0.001). In‐hospital mortality was higher with ECMO with Impella (54.8%) compared with ECMO only (50.4%) and ECMO with IABP (48.4%). After adjustment, ECMO with IABP versus ECMO only was associated with lower in‐hospital mortality (adjusted odds ratio [aOR], 0.83; P =0.02). ECMO with Impella versus ECMO only had similar in‐hospital mortality (aOR, 1.09; P =0.695) but was associated with more bleeding (aOR, 1.21; P =0.007) and more acute kidney injury requiring hemodialysis (aOR, 1.42; P <0.001). ECMO with Impella versus ECMO with IABP was associated with greater risk of acute kidney injury requiring hemodialysis (aOR, 1.49; P =0.002), higher in‐hospital mortality (aOR, 1.32; P =0.001), and higher 40‐day mortality (hazard ratio, 1.25; P <0.001). Conclusions In patients with cardiogenic shock on VA‐ECMO, LVU with Impella, particularly with 2.5/CP, was not associated with improved survival at 40 days but was associated with increased adverse events compared with IABP. More data are needed to assess Impella platform‐specific comparative outcomes of LVU.

Introduction: Testing for coronary artery disease (CAD) is recommended for patients with new-onset heart failure (HF). There are limited data on the association between testing for CAD during index hospitalization for patients with the new-onset HF and early readmission rates and readmission mortality. Hypothesis: CAD testing for new-onset HF during index hospitalization may reduce 30-day readmission rates and readmission-related mortality. Methods: Patients hospitalized for new-onset HF were identified from the Nationwide Readmission Database of the United States. Clinical characteristics, 30-day readmission rates, readmission-related mortality were compared in patients with or without testing for CAD during index hospitalization. CAD testing includes coronary angiography, coronary CT angiography, cardiac MRI, nuclear imaging or cardiac stress test. Results: Between January 2016 and November 2019, of 151,172 patients hospitalized for new-onset HF, 30,444 (20.1%) patients underwent testing for CAD during index hospitalization. Younger patients, males, and patients with HF with reduced ejection fraction (HFrEF) had more frequent testing for CAD. Only 9.5% of CAD-tested patients received percutaneous coronary intervention during the index hospitalization. Patients with CAD testing had lower 30-day readmission rates than those without testing (11.4% vs 14.3%, P<0.001; adjusted odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76 to 0.87). Patients with CAD testing had lower 30-day readmission-related mortality rates than those without testing (0.5% vs 0.9%, P<0.001; adjusted OR 0.82, 95% CI 0.65 to 1.04). Readmission rate for HF at 30 days was 2.3% for patients with CAD testing vs 3.5% for those without testing (P<0.001; adjusted OR 0.67, 95% CI 0.59 to 0.76). There was a significant interaction between HF type (HFrEF vs HF with preserved EF) and CAD testing on 30-day readmission rates (P for interaction <0.001). Conclusions: Testing for CAD during index hospitalization for patients with new-onset HF was associated with reduced 30-day readmission rates. There was substantial decrease in readmission for HF and readmission-related mortality in patients who underwent CAD testing during index hospitalization.