Aggarwal, Saurabh

Introduction: There are limited contemporary data on prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods: Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, and use of tracheostomy and percutaneous endoscopic gastrostomy (PEG). The discharge destination was used to classify AIS survivors into good and poor functional outcomes with poor (moderate to severe disability) defined as discharge to extended care facility including short-term hospital/rehabilitation facility, intermediate care or long-term care facilities. Results: Of a total 11,622,528 AMI admissions, 183,896 (1.6%) had concomitant AIS. Over the 18-year period, AIS rates were stable in STEMI admissions and decreased in NSTEMI (p<0.001). Compared to those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% vs. 63.8%) and percutaneous coronary angiography (22.7% vs 41.8%) (p<0.001). Female sex, non-White race, higher comorbidity, ST-segment-elevation AMI presentation, atrial fibrillation/flutter, use of mechanical circulatory support and invasive mechanical ventilation were identified as individual predictors of AIS after AMI. The AIS cohort had higher in-hospital mortality (16.4% vs. 6.0%; adjusted OR 1.75 [95% CI 1.72-1.78]; p<0.001) with a steady decrease in the adjusted in-hospital mortality in over the 18-year period (21% in 2000 vs 17% in 2017). The AIS cohort had longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and PEG, and less frequent discharges to home (all p<0.001). In AMI-AIS survivors (N=153,318), 57.3% had a poor functional outcome with temporal trends showing a slight increase in recent years (57% in 2000 vs 62% in 2017). Conclusions: AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions. Despite improvement in in-hospital mortality, poor functional outcomes remain high.

Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000–2017) were evaluated for in‐hospital AIS. Outcomes of interest included in‐hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST‐segment–elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04–1.15]) and decreased in non–ST‐segment–elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46–0.49]) admissions ( P <0.001). Compared with those without, the AIS cohort was on average older, female, of non‐White race, with greater comorbidities, and higher rates of arrhythmias. The AMI‐AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) ( P <0.001). The AIS cohort had higher in‐hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72–1.78]; P <0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P <0.001). Among AMI‐AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in‐hospital mortality and poor functional outcomes in AMI admissions.

Introduction Moderate mitral regurgitation (MR) of ischemic etiology has been associated with worse outcomes after coronary artery bypass grafting (CABG). Studies comparing concomitant mitral valve replacement/repair (MVR/Re) with CABG and standalone CABG have reported conflicting results. We performed a systematic review and meta-analysis of the published literature. Patients and Methods We searched using PubMed, Cochrane, EMBASE, CINAHL, and Google scholar databases from January 1960 to June 2016 for clinical trials comparing CABG to CABG + MVR/Re for moderate MR. Pooled risk ratio or mean difference (MD) with 95% confidence intervals (CI) for individual outcomes were calculated using random effects model and heterogeneity was assessed using Cochrane's Q-statistic. Results A total of 11 studies were included. Mean follow-up was 35.3 months. All-cause mortality (Mantel–Haenszel [MH] risk ratio [RR]: 0.96, 95% CI: 0.75–1.24, p = 0.775), early mortality (MH RR: 0.65, 95% CI: 0.39–1.07, p = 0.092), and stroke rates (MH RR 0.65, 95% CI: 0.21–2.03, p = 0.464) were similar between CABG and CABG + MVR/Re groups. Adverse event at follow-up was lower with CABG (MH RR: 0.90, 95% CI: 0.61–1.32, p = 0.584). MD of change from baseline in left ventricular (LV) end-systolic dimension (MD: − 2.50, 95% CI: − 5.21 to − 0.21, p = 0.071) and LV ejection fraction (MD: 0.48, 95% CI: − 2.48 to 3.44, p = 0.750) were not significantly different between the groups. Incidence of moderate MR (MH RR: 3.24, 95% CI: 1.79–5.89, p < 0.001) was higher in the CABG only group. Conclusion Addition of MVR/Re to CABG in patients with moderate ischemic MR did not result in improvement in early or overall mortality, stroke risk, or intermediate markers of LV function when compared with CABG alone.