Arora, Shilpkumar

Introduction: Heart Disease and Stroke Statistics_2014 Update suggests more than 424,000 people suffer out of hospital cardiac arrest (OHCA) in the United States. Hypothesis: We assessed seasonal variation in OHCA from a large national hospitalisation database in the past decade. Methods: The Nationwide Inpatient Sample database was used to estimate the annual number of hospitalisations with from 2000-2011. Identification of out of hospital cardiac arrest related hospitalisations was based on the designation of the International Classification of Diseases (9th Edition) Clinical Modification (ICD-9-CM) diagnosis code 427.5 (OHCA) as the principal discharge diagnosis. The frequency of hospitalisation for each month cumulative over 11 years was calculated and divided by number of days in that month to obtain the mean hospitalisations per day for each month. All calculations were carried out using the weighted estimates approximating nationwide population estimates. Results: An estimated 93,209 hospitalisations with primary diagnosis of OHCA occurred in the United States from the beginning of the calendar year 2000 to the end of the calendar year 2011. The number of hospitalisations per day in each month is shown in Figure 1.The number of hospitalisation was maximum in the winter months and minimum in summer months. Specifically, the mean number of hospitalisation each day (averaged over 11 years) was least in August (242). There was a rising trend from August to January. The average number of hospitalisation was highest in January (310); thereafter, the hospitalisation rate dropped to a nadir in August. There was however no seasonal pattern in inhospital mortality. Conclusions: We identified for the first time in United States an impressive pattern of seasonal variation in hospitalisations for OHCA. Further efforts must be made to identify triggers and methods to prevent OHCA and reduce its burden on health care system.

Objective: To identify possible racial and/or health insurance disparities with respect to ablation procedures for atrial fibrillation (AF). Method: Using the Nationwide Inpatient Sample (2000-2011), we identified adult patients (pts) admitted with principle diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code - 37.34). We stratified patients by race (White, Black, Hispanic, and other minority racial groups), insurance status, age, gender, type of hospital, and type of hospital admission. A hierarchical mixed effect multivariate model was created to identify independent predictors of AF ablation. Results: Among 4,547,144 patients hospitalized with AF during the study period, 201,447(4.43%) underwent ablation procedures. In absolute numbers, the majority of the ablations were performed in Whites (65.7%) and patients with Medicare (66.7%) or private insurance (24.7%). After adjusting for confounding factors, the proportions of Black pts (compare to White), and Medicare, Medicaid, and Uninsured pts (compare to private insurance), receiving ablation therapy were lower (see table). Odds of having ablation were lower in older and female patients and higher in teaching hospitals and after elective admissions (p<0.001 for all comparisions). Similar racial and insurance disparities were observed over the time course of the study. Conclusion: We identified lower rates of AF ablation among black pts even after correction of other factors such as insurance. Ablation rates were also lower among patients without private insurance. These trends persisted during the study period of 2000-2011.

Objective: To identify racial and/or health insurance disparities in the population undergoing ablation for paroxysmal supraventricular tachycardia(PSVT). Method: We identified adult patients (pts) admitted with principle diagnosis of PSVT by ICD 9 code 427.0 who had catheter ablation (ICD 9 code - 37.34), using the Nationwide Inpatient Sample (2000-2011). We stratified patients by race (White, Black, Hispanic, and other minority racial groups)and insurance status, and a hierarchical mixed effect multivariate model was created to identify independent predictors of PSVT ablation. Results: 64,564(20.2%) patients underwent ablation out of 319,579 patients admitted for PSVT during the period of 2000-2011. In absolute numbers, the majority of ablations were performed in Whites (58.7%) and patients with Medicare (56.3%) or private insurance (30.1%). After adjusting for confounding factors, the odds of having ablation were lower in Black pts (compare to White), and Medicare, Medicaid, and Uninsured pts (compare to private insurance) (see table). Other predictors of lower rate of ablations were: older age and female patients while odds of receiving ablation were higher for elective admissions and in teaching hospitals (p<0.001 for all comparisons). Conclusion: In a population of pts admitted for PSVT, those without private insurance and Black pts were less like to be treated with catheter ablation; and, this disparity persisted from 2000-2011. Since catheter ablation for PSVT is generally considered a curative procedure, future studies are needed to identify the factors that lead to these disparities of care.

Introduction: Short-term use of Mechanical Circulatory Support (MCS) has the potential to benefit the patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who may be high-risk or suffer complications. The present study was conducted to address the contemporary use of MCS in TAVR procedures. Methods: The study included a total of 1794 TAVR procedures in the years 2011-2012 from Nationwide Inpatient Sample (NIS) database. Use of MCS was identified using ICD-9-CM codes. The patients were divided based on use of MCS devices. The primary outcome of the study was in-hospital mortality and the secondary outcomes were complications, length of stay (LOS) and cost. Multi-variate simple logistic regression models were used to identify independent predictors of the outcomes. Results: Out of total 1794 TAVR procedures, 190 (10.6 %) utilized a MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVR was associated with increase in the in-hospital mortality (14.9% vs. 3.5%, p<0.01) with same results obtained in multi-variate models. The rates of complications were significantly higher in MCS group so as the mean length of stay (11.8±0.8 vs. 8.1±0.2 days, p<0.01) and cost ($68,997±3,656 vs. $55,878±653, p=0.03). Conclusion: Use of MCS in TAVR predicts increase in-hospital mortality, complications, LOS and cost of care.

Background: Contemporary outcome data regarding effects of atherectomy in lower extremity arterial revascularization is lacking. Methods: We queried HCUP’s Nationwide Inpatient Sample (NIS) for 2012 using the appropriate primary ICD 9-CM diagnostic code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral artherectomy) and 39.50 for angioplasty. Only procedures performed in patients >= 18 years were included. Hierarchical mixed effects logistic regression models were generated to evaluate multivariate predictors of outcomes. Results: In total 13,206 (weighted: 66,030) lower extremity arterial revascularization were analyzed (65.5% white, 56.2% Male & 97.4% angioplasty). Atherectomy utilization (23.2%) was associated with significant reduction in amputation (11.5% vs 13.4%), any complications (13.2% vs 16.3%) and in hospital morality (0.8% vs 1.4%) compared to no atherectomy group (p < 0.001). Multivariate analysis showed similar results with decrease amputation (OR, 95% CI; p - value) (0.83, 0.71 - 0.97, p = 0.02) and in hospital mortality/any complication (0.79, 0.69 - 0.90, p = 0.001) with atherectomy (similar results were observed with propensity score matching). “Atherectomy only” was utilized only in 2.3%. post-hoc analysis also shows better outcomes when atherectomy was used with either angioplasty or stenting (figure a & b). subgroup multivariate analysis shows significant reduction in amputation when atherectomy was utilized in chronic limb ischemia (0.74, 0.59 - 0.93, p = 0.01) and with angioplasty (0.72, 0.60 - 0.87, p = 0.001) and trend towards advantage while used along with stents but not reaching statistical significant. Conclusion: Lower extremity atherectomy utilization was associated with significant reduction in amputation and overall complication. We observed better outcomes when atherectomy was used in conjunction with angioplasty.

Introduction: Risk stratification of the pregnant population is critical to improving outcomes associated with pregnancy-related Acute myocardial infarction (AMI). Methods: Pregnancy-related hospitalizations (antepartum as well as postpartum) and AMI were identified using appropriate International classification of disease-Ninth revision (ICD-9) codes from nationwide inpatient sample database (2005-2014). Simple logistic regression was used to calculate predictors of AMI during pregnancy. Results: We identified 3,786 cases of AMI from a total of 43,437,621 pregnancy related hospitalization during study period. Compared to pregnant women <20-year, we noted more than 10-fold risk of AMI among patients ≥ 40 years (OR 10.1, 95% CI 5.3-19.0, p<0.001). Other significant predictors of AMI during pregnancy were black race compared to white ( OR 1.6, 95% CI 1.3-1.9, p<0.001), co-existing comorbidities such as hypertension (OR 1.9, 95% CI 1.5-2.5, p<0.001),, thrombophilia (OR 4.8, 95% CI 2.7-8.5, p<0.001), diabetes milletus (OR 1.4, 95% CI 1.0-1.9, p<0.027),hyperlipidemia (OR 13.2, 95% CI 9.9-17.6, p<0.001),smoking (OR 3.3, 95% CI 2.3-4.6, p<0.001), substance abuse (OR 1.7, 95% CI 1.2-2.6, p=0.007), congestive heart failure (OR 26.0, 95% CI 20.3-33.2 p<0.001), deep venous thrombosis (OR 2.8, 95% CI 1.3-6.2, p=0.010) as well as obstetric condition including postpartum hemorrhage (OR 1.8, 95% CI 1.3-2.4, p<0.001),, transfusion during pregnancy (OR 3.2, 95% CI 2.4-4.2, p<0.001), postpartum infection (OR 2,7, 95% CI 1.9-3.9, p<0.001),, fluid and electrolyte imbalance (OR 5.2, 95% CI 4.2- 6.6, p<0.001), and postpartum depression (OR 1.4, 95% CI 1.1-1.9 p=0.013). Conclusions: We identified certain patient-level characteristics which correlated to high risk of AMI. This information can be utilized to decide resource allocation and the introduction of early multidisciplinary intervention among high-risk population

Introduction: Acute myocardial infarction (AMI) during pregnancy is a rare but fatal complication. Recent trends in incidence of pregnancy-related AMI and associated outcomes are unclear. Methods: Nationwide inpatient sample (NIS) database was utilized for years 2005-2014. International classification of disease-Ninth revision (ICD-9) was used to identify pregnancy-related (antepartum as well as postpartum) admissions and acute myocardial infarction (AMI). The primary outcome was incidence and trend of AMI related to pregnancy during the study period. Secondary outcomes were trends in mortality and resource utilization. P-values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. Results: We identified a total of 43,437,621 pregnancy-related hospitalization and 3,786 cases of AMI (86% antepartum and 14% post-partum) were noted during the study period. The incidence of AMI during the study period was 8.7 per 100,000 pregnancies with an overall increase in incidence during study period (relative increase of 18.9%, p <0.001) and concomitant decrease in mortality (relative decrease of 40.05%, p <0.001), cost of care (relative decrease of 8.70%, p<0.001) and length of stay (relative decrease of 13.53%, p<0.001). Conclusions: Incidence of AMI during the period is on the rise in recent years with concomitant improvement in mortality and resource utilization. This reflects improved diagnostic capability and a better understanding of non-atherosclerotic mechanisms of AMI during pregnancy such as spontaneous coronary artery dissection, coronary spasm, and coronary thrombus.

Introduction: Recent trials have suggested potential benefits of performing multivessel percutaneous coronary intervention (MVPCI) on non-infarct related artery (non-IRA) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease. Methods: National Readmissions Database (NRD) 2010-14 was utilized to select study cohort. Appropriate International Classification of Diseases, 9th Revision (ICD-9-CM) diagnostic and procedural codes were utilized to identify STEMI patients undergoing multivessel PCI and infarct-related artery only PCI (IRA-PCI). Propensity score matched cohorts using greedy matching algorithm were generated for comparison of outcomes. Results: We identified 116592 IRA-PCI (83.97%) and 22257 MVPCI (16.03%) cases. With 1:3 propensity matched cohorts accounting for confounders such as age, gender, race and comorbidities, in comparison to IRA-PCI, MVPCI patients have higher 30-day readmission rate (10.40% vs 9.40%, p=0.001), in-hospital mortality (1.96% vs 1.57%,p<0.001), mechanical circulatory support utilization (4.27 vs 2.44%,p<0.001) as well as higher complication including vascular (0.51% vs 0.28%, p<0.001), cardiac (5.97% vs 3.97%, p<0.001), respiratory (4.89% vs 4.02%,p<0.001), neurologic complications (0.77% vs 0.58%,p=0.003), major bleeding (1.01% vs 0.79%, p=0.002) and cardiac arrest(3.48% vs 3.17%, p=0.027). We also noted higher cost of care ($27100 vs $20900, p<0.001) and length of stay (3.8 days vs 3.4 days, p<0.001) in MVPCI group compared to IRA-PCI group. Conclusions: We noted higher 30- day readmission rate, in-hospital mortality, complications and resource utilization with MVPCI compared to IRA-PCI approach among STEMI patients which further demands large-scale randomized control trials to determine the utility of MVPCI in the “real world”.

AbstractBackgroundThe improved life expectancy observed in patients living with human immunodeficiency virus (HIV) infection has made age‐related cardiovascular complications, including arrhythmias, a growing health concern.HypothesisWe describe the temporal trends in frequency of various arrhythmias and assess impact of arrhythmias on hospitalized HIV patients using the Nationwide Inpatient Sample (NIS).MethodsData on HIV‐related hospitalizations from 2005 to 2014 were obtained from the NIS database using International Classification of Diseases, 9th Revision (ICD‐9) codes. Data was further subclassified into hospitalizations with associated arrhythmias and those without. Baseline demographics and comorbidities were determined. Outcomes including in‐hospital mortality, cost of care, and length of stay were extracted. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for analysis. A multivariable analysis was performed to identify predictors of arrhythmias among hospitalized HIV patients.ResultsAmong 2 370 751 HIV‐related hospitalizations identified, the overall frequency of any arrhythmia was 3.01%. Atrial fibrillation (AF) was the most frequent arrhythmia (2110 per 100 000). The overall frequency of arrhythmias increased over time by 108%, primarily due to a 132% increase in AF. Arrhythmias are more frequent among older males, lowest income quartile, and nonelective admissions. Patients with arrhythmias had a higher in‐hospital mortality rate (9.6%). In‐hospital mortality among patients with arrhythmias decreased over time by 43.8%. The cost of care and length of stay associated with arrhythmia‐related hospitalizations were mostly unchanged.ConclusionsArrhythmias are associated with significant morbidity and mortality in hospitalized HIV patients. AF is the most frequent arrhythmia in hospitalized HIV patients.

Abstract Background The effectiveness of catheter ablation as a management modality amongst patients with coexisting atrial flutter (AFL) and heart failure with reduced ejection fraction (HFrEF) is scarcely studied. Methods Appropriate ICD 10 codes were applied to the 2016 and 2017 National Readmission Database (NRD) to isolate patients having coexistent AFL and HFrEF including who had undergone an ablation. All-cause mortality at the end of 1 year was used as a primary outcome. Readmission due to AFL, heart failure (HF) and other causes were secondary outcomes. The hazard ratios were generated using Cox regression analysis while the time to event analysis was demonstrated with the Kaplan Meier curves. Results Out of a total of 9966 patients with AFL and HFrEF, 1980 (24.79%) patients underwent catheter ablation. The primary outcome, all-cause mortality (2.8% vs. 4.6%, HR: 0.610, 95% CI: 0.460–0.808, p=0.001) at the end of 1 year was significantly lower. Significant difference was also noted amongst two groups when it came to secondary outcomes such as readmissions due to AFL (1.6% vs. 6.3%, HR: 0.247, 95% CI: 0.173–0.354, p&lt;0.001), HF (8.2% vs. 11.4%, HR: 0.693, 95% CI: 0.587–0.819, p&lt;0.001) and other causes (29.4% vs. 37.1%, HR: 0.735, 95% CI: 0.673–0.804, p&lt;0.001) Conclusion Ablative intervention amongst AFL patients with concomitant HFrEF showed a significant reduction in all-cause mortality. It also leads to significant reductions in readmissions due to AFL, HF and other causes at the end of one year. Outcomes of AFL and HFrEF Funding Acknowledgement Type of funding source: None