Patlolla, Sri Harsha

Introduction: Racial disparities in outcomes of acute myocardial infarction (AMI) and cardiac arrest (CA) exist. This study assessed the racial differences in the management and outcomes of CA complicating AMI to better inform clinical care. Hypothesis: We hypothesized that racial minorities would have worse outcomes with AMI-CA as compared to white patients. Methods: During 2012-2017, AMI admissions with a concomitant diagnosis of CA were identified from the National Inpatient Sample. Race was classified as white, black and others (Hispanic, Asian or Pacific Islander, Native American, Others). The primary outcome was racial disparities in in-hospital mortality. Secondary outcomes included racial disparities in invasive procedures and hospitalization characteristics. Results: We identified 3,504,225 admissions for AMI in the study period, of which 182,750 (5.2%) were complicated by CA. 74.8% were white, 10.7% were black and 14.5% belonged to other races. Black and other race AMI-CA admissions received less frequent early coronary angiography (41.4% vs 50.2% vs 52.8%), coronary angiography (61.9% vs 70.2% vs. 73.1% %), PCI (44.6% vs 53.0% vs 58.1%), CABG and mechanical circulatory support compared to white and other races. The mean time to coronary angiography was highest among blacks (3.4 ± 4.2 days) and lowest among whites (3.0 ± 3.7 days). Black and other races had significantly higher unadjusted mortality, however in a multivariable logistic regression analysis with white race as referent, black race was associated with lower in-hospital mortality (OR 0.95 [95% CI 0.91-0.99]; p =0.007) whereas other races had higher in-hospital mortality (OR 1.11 [95% CI 1.08-1.15]; p <0.001) compared to white race. AMI-CA admissions of black race had longer length of hospital stay, higher rates of palliative care consultation, less frequent DNR status use, and fewer discharges to home. Admissions of other races had higher use of DNR status and higher hospitalization costs compared to whites and blacks. Conclusions: Significant racial disparities exist in in-hospital mortality among AMI admissions complicated with CA. Further quantitative and qualitative research into the equitable care of racial minorities with AMI-CA is needed to address this disparity.

Background: There is a paucity of contemporary data on the burden of intracranial hemorrhage (ICH) complicating acute myocardial infarction (AMI). This study sought to evaluate the temporal trends, predictors, and outcomes of ICH in AMI. Methods: The National Inpatient Sample (2000–2017) was used to identify adult (>18 years) AMI admissions with ICH. In-hospital mortality, hospitalization costs, length of stay, and measure of functional ability were the outcomes of interest. The discharge destination along with use of tracheostomy and percutaneous endoscopic gastrostomy were used to estimate functional burden. Results: Of a total 11,622,528 AMI admissions, 23,422 (0.2%) had concomitant ICH. Compared to those without, the ICH cohort was on average older, female, of non-White race, had greater comorbidities, and had higher rates of arrhythmias (all p < 0.001). Female sex, non-White race, ST-segment elevation AMI presentation, use of fibrinolytics, mechanical circulatory support, and invasive mechanical ventilation were identified as individual predictors of ICH. The AMI admissions with ICH received less frequent coronary angiography (46.9% vs. 63.8%), percutaneous coronary intervention (22.7% vs. 41.8%), and coronary artery bypass grafting (5.4% vs. 9.2%), as compared to those without (p < 0.001). ICH was associated with a significantly higher in-hospital mortality (41.4% vs. 6.1%; adjusted OR 5.65 (95% CI 5.47–5.84); p < 0.001), longer hospital length of stay, higher hospitalization costs, and greater use of percutaneous endoscopic gastrostomy (all p < 0.001). Among ICH survivors (N = 13, 689), 81.3% had a poor functional outcome at discharge. Conclusions: ICH causes a substantial burden in AMI due to associated higher in-hospital mortality and poor functional outcomes.

Background: Although extracorporeal membrane oxygenation (ECMO) is used for hemodynamic support for in-hospital cardiac arrest (IHCA) complicating acute myocardial infarction (AMI), there are limited data on the outcomes stratified by the timing of initiation of this strategy. Methods: Adult (>18 years) AMI admissions with IHCA were identified using the National Inpatient Sample (2000–2017) and the timing of ECMO with relation to IHCA was identified. Same-day vs. non-simultaneous ECMO support for IHCA were compared. Outcomes of interest included in-hospital mortality, temporal trends, hospitalization costs, and length of stay. Results: Of the 11.6 million AMI admissions, IHCA was noted in 1.5% with 914 (<0.01%) receiving ECMO support. The cohort receiving same-day ECMO (N = 795) was on average female, with lower comorbidity, higher rates of ST-segment-elevation AMI, shockable rhythm, and higher rates of complications. Compared to non-simultaneous ECMO, the same-day ECMO cohort had higher rates of coronary angiography (67.5% vs. 51.3%; p = 0.001) and comparable rates of percutaneous coronary intervention (58.9% vs. 63.9%; p = 0.32). The same-day ECMO cohort had higher in-hospital mortality (63.1% vs. 44.5%; adjusted odds ratio 3.98 (95% confidence interval 2.34–6.77); p < 0.001), shorter length of stay, and lower hospitalization costs. Older age, minority race, non-ST-segment elevation AMI, multiorgan failure, and complications independently predicted higher in-hospital mortality in IHCA complicating AMI. Conclusions: Same-day ECMO support for IHCA was associated with higher in-hospital mortality compared to those receiving non-simultaneous ECMO support. Though ECMO-assisted CPR is being increasingly used, careful candidate selection is key to improving outcomes in this population.

AbstractBackgroundThere are limited data on the seasonal variation in acute myocardial infarction (AMI) in the contemporary literature.HypothesisThere would be decrease in the seasonal variation in the management and outcomes of AMI.MethodsAdult (>18 years) AMI admissions were identified using the National Inpatient Sample (2000‐2017). Seasons were classified as spring, summer, fall, and winter. Outcomes of interest included prevalence, in‐hospital mortality, use of coronary angiography, and percutaneous coronary intervention (PCI). Subgroup analyses for type of AMI and patient characteristics were performed.ResultsOf the 10 880 856 AMI admissions, 24.3%, 22.9%, 22.2%, and 24.2% were admitted in spring, summer, fall, and winter, respectively. The four cohorts had comparable age, sex, race, and comorbidities distribution. Rates of coronary angiography and PCI were slightly but significantly lower in winter (62.6% and 40.7%) in comparison to the other seasons (64‐65% and 42‐43%, respectively) (P < .001). Compared to spring, winter admissions had higher in‐hospital mortality (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.06‐1.08), whereas summer (aOR 0.97; 95% CI 0.96‐0.98) and fall (aOR 0.98; 95% CI 0.97‐0.99) had slightly lower in‐hospital mortality (P < .001). ST‐segment elevation (10.0% vs 9.1%; aOR 1.07; 95% CI 1.06‐1.08) and non‐ST‐segment elevation (4.7% vs 4.2%; aOR 1.07; 95% CI 1.06‐1.09) AMI admissions in winter had higher in‐hospital mortality compared to spring (P < .001). The primary results were consistent when stratified by age, sex, race, geographic region, and admission year.ConclusionsCompared to other seasons, winter admission was associated with higher in‐hospital mortality in AMI in the United States.

Objective Previous studies have postulated a causal role of patent foramen ovale (PFO) in the aetiology of embolic stroke in the general population. We hypothesised that the presence of concomitant PFO and atrial fibrillation (AF) will add incremental risk of ischaemic stroke to that linked to AF alone. Methods We analysed data on 3069 consecutive patients (mean age 69.4±12.2 years; 67.1% men) undergoing transoesophageal echocardiography-guided electrical cardioversion (ECV) for AF between May 2000 and March 2012. PFO was identified by colour Doppler and agitated saline contrast study. All patients were followed up after ECV for first documentation of ischaemic stroke. Outcomes were compared using Cox regression models. Results The prevalence of PFO was 20.0% and the shunt direction was left-to-right in the majority of patients (71.4%). Patients with PFO had a higher frequency of obstructive sleep apnoea (21.7% vs 17.1%, p=0.01) and higher mean peak left atrial appendage emptying velocity (38.3±21.8 vs 36.1±20.4 cm/s; p=0.04) compared with those without PFO. Otherwise, baseline characteristics were similar between groups. During a mean follow-up period of 7.3±4.6 years, 214 patients (7.0%) had ischaemic stroke. Multivariable analysis showed no significant association between PFO and ischaemic stroke (HR, 0.82 (95% CI 0.57 to 1.18)). PFO shunt direction was strongly associated with stroke: HR, 1.91 (95% CI 1.16 to 3.16) for right-to-left shunt and HR, 0.58 (95% CI 0.36 to 0.93) for left-to-right shunt. Conclusions The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke.

Abstract Aims The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction-cardiogenic shock (AMI-CS). Methods and results A retrospective cohort of AMI-CS admissions using the National Inpatient Sample (2000–2014) was identified. Admissions with concomitant cardiac surgery or non-AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in-hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non-PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000–2014, 364 001 admissions with AMI-CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non-teaching (7.1%) and rural hospitals (5.4%); P &lt; 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in-hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04–1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P &lt; 0.001). In 6200 propensity-matched pairs, in-hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94–1.08]). Right heart catheterization was used in 12.5% of non-PAC admissions and was a marker of greater severity but did not indicate worse outcomes. Conclusions In AMI-CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

Background: There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). Methods and Results: Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93–0.98]; P <0.001) and West (aOR, 0.96 [95% CI, 0.94–0.98]; P =0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01–1.06]; P =0.002). The Midwest (aOR, 1.68 [95% CI, 1.62–1.74]; P <0.001), South (aOR, 1.86 [95% CI, 1.80–1.92]; P <0.001), and West (aOR, 1.93 [95% CI, 1.86–2.00]; P <0.001) had higher discharges to home. Conclusions: There remain significant regional disparities in the management and outcomes of AMI-CS.

Anomalous coronary artery is an uncommon congenital cardiac anomaly that is often detected incidentally on coronary angiography. It has rarely been reported in the donor heart of patients who have undergone cardiac transplantation. Here, we report a case of a 72-year-old patient who received a second heart transplant and has been identified to have an anomalous left main coronary artery originating from the right coronary sinus on postoperative coronary angiography.

e13096 Background: Several studies have reported the association between atrial fibrillation (AF) and malignant cancer. Recently, results from a large cohort within the Women’s Health Study showed increased incident risk of breast, colon and lung cancer in patients with AF. Therefore, we performed a systematic review to assess the available evidence and a meta-analysis to define the strength of this association. Methods: MEDLINE, Cochrane and Scopus databases were searched for all prospective studies that reported the association between AF and presence of cancer. The HR for incident risk of common cancers was recorded (Breast, Lung, Colorectal) in patients with and without AF. Lung cancer was excluded because the data required for the analysis was not consistently reported. The DerSimonian-Laird random effects meta-analysis was performed to derive pooled Hazard Ratio (HR) estimates for incident risk of colorectal and breast cancer in patients with AF. Q-test was used to assess between-study heterogeneity; I2 statistic was computed to expresses the percentage of the total observed variability due to study heterogeneity. Results: A total of 390,479 participants in 3 prospective studies were included in the analysis. Mean age of participants was 66.3 ± 6.5 with mean follow up for 12.6 years. Patients with atrial fibrillation had 27% more risk of developing colorectal cancer [HR 1.27 (1.07-1.51) p < 0.005, I2= 73%] and 14% more risk of developing breast cancer [HR 1.14 (1.03-1.26) p = 0.01, I2= 37%] as compared to those without atrial fibrillation. Applying these hazard ratios to age adjusted yearly incidence ratios from 2000-2015, one in 5824 new onset AF cases will develop CRC and one in 7474 new onset AF cases will develop breast cancer. Conclusions: There is small but statistically significant increase in risk of subsequent diagnosis of colorectal or breast cancer diagnosis in patients with AF. Shared risk factors such as old age or systemic disease processes may explain this association. While the results of this analysis raise interesting questions for future search, these results should not be used as basis to initiate cancer screening for an occult cancer in a patient with AF.