Mamas, Mamas A.

Background Elderly patients have a higher burden of comorbidities that influence clinical outcomes. We aimed to compare in‐hospital outcomes in patients ≥80 years old to younger patients, and to determine the factors associated with increased risk of major adverse events (MAE) after left atrial appendage closure. Methods and Results The National Inpatient Sample was used to identify discharges after left atrial appendage closure between October 2015 and December 2018. The primary outcome was in‐hospital MAE defined as the composite of postprocedural bleeding, vascular and cardiac complications, acute kidney injury, stroke, and death. A total of 6779 hospitalizations were identified, of which, 2371 (35%) were ≥80 years old and 4408 (65%) were <80 years old. Patients ≥80 years old experienced a higher rate of MAE compared with those aged <80 years old (6.0% versus 4.6%, P =0.01), and this difference was driven by a numerically higher rate of cardiac complications (2.4% versus 1.8%, P =0.09) and death (0.3% versus 0.1%, P =0.05) among individuals ≥80 years old. In patients ≥80 years old, higher odds of in‐hospital MAE were observed in women (1.61‐fold), and those with preprocedural congestive heart failure (≈2‐fold), diabetes (≈1.5‐fold), renal disease (≈2.6‐fold), anemia (≈2.7‐fold), and dementia (≈5‐fold). In patients <80 years old, a higher risk of in‐hospital MAE was encountered among women (≈1.4‐fold) and those with diabetes (≈1.3‐fold), renal disease (≈2.6‐fold), anemia (≈2‐fold), and dyslipidemia (≈1.2‐fold). Conclusions Patients ≥80 years old had higher rates of in‐hospital MAE compared with patients aged <80 years old. Female sex and the presence of heart failure, diabetes, renal disease, and anemia were factors associated with in‐hospital MAE among both groups.

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST‐segment–elevation myocardial infarction in the National Inpatient Sample (2016–2018). We used propensity‐score matching to calculate average treatment effects of pPCI for in‐hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74–0.81; P <0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73–0.79; P <0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (−8.4% [−9.3% to −7.6%], P <0.001), and women (−9.5% [−10.8% to −8.3%], P <0.001) ( P interaction=0.16). This persisted in age‐stratified analyses (≥85, 65–84, 45–64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in‐hospital mortality in men and women. Nonetheless, risk‐adjusted rates of pPCI remain lower in women in contemporary US practice.

Objective This manuscript aims to explore the impact of race/ethnicity and socioeconomic status on in-hospital complication rates after left atrial appendage closure (LAAC). Methods The US National Inpatient Sample was used to identify hospitalisations for LAAC between 1 October 2015 to 31 December 2018. These patients were stratified by race/ethnicity and quartiles of median neighbourhood income. The primary outcome was the occurrence of in-hospital major adverse events, defined as a composite of postprocedural bleeding, cardiac and vascular complications, acute kidney injury and ischaemic stroke. Results Of 6478 unweighted hospitalisations for LAAC, 58% were male and patients of black, Hispanic and ‘other’ race/ethnicity each comprised approximately 5% of the cohort. Adjusted by the older Americans population, the estimated number of LAAC procedures was 69.2/100 000 for white individuals, as compared with 29.5/100 000 for blacks, 47.2/100 000 for Hispanics and 40.7/100 000 for individuals of ‘other’ race/ethnicity. Black patients were ~5 years younger but had a higher comorbidity burden. The primary outcome occurred in 5% of patients and differed significantly between racial/ethnic groups (p<0.001) but not across neighbourhood income quartiles (p=0.88). After multilevel modelling, the overall rate of in-hospital major adverse events was higher in black patients as compared with whites (OR: 1.60, 95% CI 1.22 to 2.10, p<0.001); however, the incidence of acute kidney injury was higher in Hispanics (OR: 2.19, 95% CI 1.52 to 3.17, p<0.001). No significant differences were found in adjusted overall in-hospital complication rates between income quartiles. Conclusion In this study assessing racial/ethnic disparities in patients undergoing LAAC, minorities are under-represented, specifically patients of black race/ethnicity. Compared with whites, black patients had higher comorbidity burden and higher rates of in-hospital complications. Lower socioeconomic status was not associated with complication rates.

Aim We sought to determine the racial and ethnical disparities in the delivery of TAVR and to evaluate the in-hospital outcomes and utilization of TAVR stratified by patient ethnicity. Method Using a national inpatient sample database between 2011 and 2015, we identified all adult patients who had TAVR. Races were identified and white race was set as control. Multiple logistic regression analysis was performed for the primary outcome of in-hospital mortality. Results Out of 58 174 patients who underwent TAVR, 50 809 (87.3%) were white, 2327 (4.0%) were black, 2311 (4.0%) were Hispanic, 640 (1.1%) Asian, 105 (0.2%) Native American and 1982 (3.4%) of other ethnicities. We found a statistically significant linear uptrend in the utilization of TAVR in patients of all races between the years 2011 and 2015. White, black, Hispanic and Native American patients had a downward linear trend for mortality during the studied years ( P ≤ 0.005 for all). Black patients had lower in-hospital mortality [2.8 vs. 3.6%, odds ratio (OR) = 0.62; 95% confidence interval (CI) 0.44, 0.81 P < 0.001] compared with white patients, whereas Hispanic patients and Native Americans had higher in-hospital mortality compared with white patients (4.5% OR 1.26; 95% CI 1.01, 1.56 P = 0.041), (9.5% OR 4.44; 95% CI 2.25, 8.77 P < 0.001), respectively. Conclusion Overall, TAVR utilization is associated with lower mortality. There is a rising trend in utilization of TAVR in the black population with a significantly favorable mortality trend compared with the white population.

AbstractBackgroundSex‐based differences in transcatheter aortic valve replacement (TAVR) outcomes have been previously documented. However, whether these differences persist with contemporary third generation transcatheter heart valves (THVs) is unknown.MethodsWe utilized Vizient's clinical database/resource manager (CDB/RM™) to identify patients who underwent TAVR between January 1, 2018 and March 31, 2020 to compare in‐hospital outcomes between males and females. The primary endpoint was in‐hospital mortality. Secondary endpoints included key in‐hospital complications, length of stay, discharge disposition, and cost. Unadjusted, propensity‐score matched and risk‐adjusted analyses of outcomes were performed.ResultsDuring the study period, 44,280 patients (24,842 males, 19,438 females) underwent TAVR. The primary endpoint of in‐hospital mortality was higher in females than in males (1.6 vs. 1.1% p < .001) in unadjusted analysis and persisted following propensity matching (1.6 vs. 0.9%, p < .001) and multivariable logistic regression with various risk‐adjustment models. In the most comprehensive model adjusting for age, race, and clinical comorbidities, female sex was associated with 34% greater odds of in‐hospital death (95% CI 20–50%, p < .001). Unadjusted and risk‐adjusted rates of post‐TAVR stroke, vascular complication, and blood transfusion were higher in females. Moreover, females demonstrated longer hospitalizations, higher costs and reduced rates of independent discharge home.ConclusionSex‐based differences in TAVR in‐hospital outcomes persist in contemporary practice with third generation transcatheter heart valves. Further research is needed to assess the reasons for these observed disparities and to identify effective mitigation strategies.

Abstract Aims Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI. Methods and results All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group. Conclusion Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.

Abstract Background The management of patients with severe but asymptomatic aortic stenosis (AS) is a challenge of daily practice. Evidence on early aortic valve replacement (AVR) versus symptom-driven approach is controversial. Methods Electronic databases were searched and articles comparing early-AVR with conservative management for severe asymptomatic AS were identified. The pooled unadjusted odds ratio (OR) was computed using a random-effects model. Results A total of 10 studies (observational=9, and randomized clinical trials=1) consisting of 5,291 patients were included. On a mean follow up duration of 4 years, the odds of early-AVR vs conservative management were in favour for early intervention in terms of cardiovascular mortality (OR 0.26, 95% CI 0.13–0.53, p=0.0002, figure-1) and all-cause mortality (OR 0.27, 95% CI: 0.17–0.41, p≤00001). The number needed to treat (NNT) by performing early AVR (either SAVR or TAVR) to prevent one death secondary to either cardiovascular or all-cause was 8 (95% CI: 6–10), and 5 (95% CI, 4.2–5.4) respectively. The odds of all-cause mortality in a selected patient population undergoing surgical AVR (SAVR) (OR 0.17, 95% CI 0.10–0.29, p≤0.00001) or transcatheter AVR (TAVR) (OR 0.45, 95% CI 0.31–0.64, p≤0.0001) were significantly lower compared to patients who were managed conservatively. A subgroup sensitivity analysis based on severe vs. very severe AS and early vs. symptom based AVR also mirrored the findings of overall results. Conclusions Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early-AVR compared to conservative management. Figure 1 Funding Acknowledgement Type of funding source: None

Objective To estimate the risk of in-hospital complications after left atrial appendage closure (LAAC) in relationship with comorbidity burden. Methods Cohort-based observational study using the US National Inpatient Sample database, 1 October 2015 to 31 December 2017. The main outcome of interest was the occurrence of in-hospital major adverse events (MAE) defined as the composite of bleeding complications, acute kidney injury, vascular complications, cardiac complications and postprocedural stroke. Comorbidity burden and thromboembolic risk were assessed by the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Score (ECS) and CHA2DS2-VASc score. MAE were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The associations of comorbidity with in-hospital MAE were evaluated using logistic regression models. Results A total of 3294 hospitalisations were identified, among these, the mean age was 75.7±8.2 years, 60% were male and 86% whites. The mean CHA2DS2-VASc score was 4.3±1.5 and 29.5% of the patients had previous stroke or transient ischaemic attack. The mean CCI and ECS were 2.2±1.9 and 9.7±5.8, respectively. The overall composite rate of in-hospital MAE after LAAC was 4.6%. Females and non-whites had about 1.5 higher odds of in-hospital AEs as well participants with higher CCI (adjusted OR (aOR): 1.19, 95% CI: 1.13 to 1.24, p<0.001), ECS (aOR: 1.06, 95% CI: 1.05 to 1.08, p<0.001) and CHA2DS2-VASc score (aOR: 1.08, 95% CI: 1.02 to 1.15, p=0.01) were significantly associated with in-hospital MAE. Conclusion In this large cohort of LAAC patients, the majority of them had significant comorbidity burden. In-hospital MAE occurred in 4.6% and female patients, non-whites and those with higher burden of comorbidities were at higher risk of in-hospital MAE after LAAC.