Thakkar, Badal

ABSTRACTFibrinolytic therapy is still used in patients with ST‐segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic‐treated STEMI patients have not been well assessed in real‐world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in‐hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in‐hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.

Purpose: To examine the impact of intravascular ultrasound (IVUS) utilization during lower limb endovascular interventions as regards postprocedural complications and amputation. Methods: The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database between the years 2006 and 2011. Peripheral endovascular interventions were identified using appropriate ICD-9 procedure codes. Two-level hierarchical multivariate mixed models were created. The co-primary outcomes were in-hospital mortality and amputation; the secondary outcome was postprocedural complications. Model results are given as the odds ratio (OR) and 95% confidence interval (CI). Hospitalization costs were also assessed. Results: Overall, among the 92,714 patients extracted from the database during the observation period, IVUS was used in 1299 (1.4%) patients. IVUS utilization during lower extremity peripheral vascular procedures was independently predictive of a lower rate of postprocedural complications (OR 0.80, 95% CI 0.66 to 0.99, p=0.037) as well as lower amputation rates (OR 0.59, 95% CI 0.45 to 0.77, p<0.001) without any significant impact on in-hospital mortality. Multivariate analysis also revealed IVUS utilization to be predictive of a nonsignificant increase in hospitalization costs ($1333, 95% CI −$167 to +$2833, p=0.082). Conclusion: IVUS use during lower limb endovascular interventions is predictive of lower postprocedural complication and amputation rates with a nonsignificant increase in hospitalization costs.

ObjectivesTo compare the in‐hospital outcomes in cirrhosis patients undergoing transcatheter aortic valve replacement (TAVR) versus those undergoing surgical aortic valve replacement (SAVR).BackgroundOver the last 10 years, TAVR has emerged as a therapeutic option for treating severe aortic stenosis in high‐risk patients. Cirrhosis patients have a high risk of operative morbidity and mortality while undergoing cardiac surgery. This study's hypothesis was that TAVR is a safer alternative compared to SAVR in cirrhosis patients.MethodsThe study population was derived from the National Inpatient Sample (NIS) for the years 2011–2012 using ICD‐9‐CM procedure codes 35.21 and 35.22 for SAVR, and 35.05 and 35.06 for TAVR. Patients <50 years of age and those who concomitantly underwent other valvular procedures were excluded. ICD‐9‐CM diagnosis codes were used to identify patients with liver cirrhosis, portal hypertension, and esophageal varices. Using propensity score matching, two matched cohorts were derived in which the outcomes were compared using appropriate statistical tests.ResultsThere were 30 patients in the SAVR and TAVR group each. Compared to the TAVR group, the patients in SAVR group had significantly higher rate of transfusion of whole blood or blood products (p = 0.037), longer mean postprocedural length of stay (p = 0.006), and nonsignificantly higher mean cost of hospitalization (p = 0.2), any complications rate (p = 0.09), and liver complications rate (p = 0.4). In‐hospital mortality rate was same in the both the groups. No patients in the TAVR group required open‐heart surgery or cardiopulmonary bypass.ConclusionTAVR could be a viable option for aortic valve replacement in cirrhosis patients. © 2015 Wiley Periodicals, Inc.

ObjectiveThe aim of the study was to assess the utilization of catheter‐directed thrombolysis (CDT) and its comparative effectiveness against systemic thrombolysis in acute pulmonary embolism (PE).BackgroundContemporary real world data regarding utilization and outcomes comparing systemic thrombolysis with CDT for PE is sparse.MethodsWe queried the Nationwide Inpatient Sample from 2010 to 2012 using the ICD‐9‐CM diagnosis code 415.11, 415.13, and 415.19 for acute PE. We used propensity score analysis to compare outcomes between systemic thrombolysis and CDT. Primary outcome was in‐hospital mortality. Secondary outcome was combined in‐hospital mortality and intracranial hemorrhage (ICH).ResultsOut of 110,731 patients hospitalized with PE, we identified 1,521 patients treated with thrombolysis, of which 1,169 patients received systemic thrombolysis and 352 patients received CDT. After propensity‐matched comparison, primary and secondary outcomes were significantly lower in the CDT group compared to systemic thrombolysis (21.81% vs. 13.36%, OR 0.55, 95% CI 0.36–0.85, P value = 0.007) and (22.89% vs. 13.36%, OR 0.52, 95% CI 0.34–0.80, P value = 0.003), respectively. The median length of stay [7 days, interquartile range (IQR) (5–9 days) vs. 7 days, IQR (5–10 days), P = 0.17] was not significant between the two groups. The CDT group had higher cost of hospitalization [$17,218, IQR ($12,272–$23,906) vs. $23,799, IQR ($17,892–$35,338), P < 0.001]. Multivariate analysis identified increasing age, saddle PE, cardiopulmonary arrest, and Medicaid insurance as independent predictors of in‐hospital mortality.ConclusionsCDT was associated with lower in‐hospital mortality and combined in‐hospital mortality and ICH. © 2015 Wiley Periodicals, Inc.

Background: Multivessel coronary artery disease carries significant mortality risk. Comprehensive data on inhospital outcomes following multivessel percutaneous coronary intervention (MVPCI) are sparse. Methods: We queried the Healthcare Cost and Utilization Project’s nationwide inpatient sample (NIS) between 2006 and 2011 using different International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. The primary outcome was inhospital all-cause mortality, and the secondary outcome was a composite of inhospital mortality and periprocedural complications. Results: The overall mortality was low at 0.73% following MVPCI. Multivariate analysis revealed that (odds ratio, 95% confidence interval, P value) age (1.63, 1.48-1.79; <.001), female sex (1.19, 1.00-1.42; P = .05), acute myocardial infarction (AMI; 2.97, 2.35-3.74; <.001), shock (17.24, 13.61-21.85; <.001), a higher burden of comorbidities (2.09, 1.32-3.29; .002), and emergent/urgent procedure status (1.67, 1.30-2.16; <.001) are important predictors of primary and secondary outcomes. MVPCI was associated with higher mortality, length of stay (LOS), and cost of care as compared to single vessel single stent PCI. Conclusion: MVPCI is associated with higher inhospital mortality, LOS, and hospitalization costs compared to single vessel, single stent PCI. Higher volume hospitals had lower overall postprocedural mortality rate along with shorter LOS and lower hospitalization costs following MVPCI.

ObjectivesWe studied the trends and predictors of drug eluting stent (DES) utilization from 2006 to 2011 to further expound the inter‐hospital variability in their utilization.BackgroundWe queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) between 2006 and 2011 using ICD‐9‐CM procedure code, 36.06 (bare metal stent) or 36.07 (drug eluting stents) for Percutaneous Coronary Intervention (PCI). Annual hospital volume was calculated using unique identification numbers and divided into quartiles for analysis.Methods and ResultsWe built a hierarchical two level model adjusted for multiple confounding factors, with hospital ID incorporated as random effects in the model. About 665,804 procedures (weighted n = 3,277,884) were analyzed. Safety concerns arising in 2006 reduced utilization DES from 90% of all PCIs performed in 2006 to a nadir of 69% in 2008 followed by increase (76% of all stents in 2009) and plateau (75% in 2011). Significant between‐hospital variation was noted in DES utilization irrespective of patient or hospital characteristics. Independent patient level predictors of DES were (OR, 95% CI, P‐value) age (0.99, 0.98–0.99, <0.001), female(1.12, 1.09–1.15, <0.001), acute myocardial infarction(0.75, 0.71–0.79, <0.001), shock (0.53, 0.49–0.58, <0.001), Charlson Co‐morbidity index (0.81,0.77–0.86, <0.001), private insurance/HMO (1.27, 1.20–1.34, <0.001), and elective admission (1.16, 1.05–1.29, <0.001). Highest quartile hospital (1.64, 1.25–2.16, <0.001) volume was associated with higher DES placement.ConclusionThere is significant between‐hospital variation in DES utilization and a higher annual hospital volume is associated with higher utilization rate of DES. © 2015 Wiley Periodicals, Inc.

Background: Contemporary data regarding percutaneous closure of atrial septal defect/patent foramen ovale (ASD/PFO) are lacking. We evaluated the current trends in utilization of ASD/PFO closure in adults and investigated the effect of annual hospital volume on in‐hospital outcomes. Methods: We queried the Nationwide Inpatient Sample between the years 2001 and 2010 using the International Classification of Diseases (ICD‐9‐CM) procedure code for percutaneous closure of ASD/PFO with device. Hierarchical mixed effects models were generated to identify the independent multivariate predictors of outcomes. Results: A total of 7,107 percutaneous ASD/PFO closure procedures (weighted n = 34,992) were available for analysis. A 4.7‐fold increase in the utilization of this procedure from 3/million in 2001 to 14/million adults in 2010 in US (P < 0.001) was noted. Overall, percutaneous ASD/PFO closure was associated with 0.5% mortality and 12% in‐hospital complications. The utilization of intracardiac echocardiography (ICE) increased 15 fold (P < 0.001) during the study period. The procedures performed at the high volume hospitals [2nd (14–37 procedures/year) and 3rd (>38 procedures/year) tertile] were associated with significant reduction in complications, length of stay and cost of hospitalization when compared to those performed at lowest volume centers (<13 procedures/year). Majority (70.5%) of the studied hospitals were found to be performing <10 procedures/year hence deviating from the ACC/AHA/SCAI clinical competency guidelines. Conclusions: Low hospital volume is associated with an increased composite (mortality and procedural complications) adverse outcome following ASD/PFO closure. In the interest of patient safety, implementation of the current guidelines for minimum required annual hospital volume to improve clinical outcomes is warranted. © 2014 Wiley Periodicals, Inc.