Intravenous Diltiazem Versus Metoprolol in Acute Rate Control of Atrial Fibrillation/Flutter and Rapid Ventricular Response: A Meta-Analysis of Randomized and Observational Studies.

BACKGROUND: Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear. METHODS: A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test. RESULTS: A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%). CONCLUSION: While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs.

Effect of Cocaine, Amphetamine, and Cannabis Use Disorders on 30-day Readmissions of Patients with Heart Failure.

There is limited evidence demonstrating whether cannabis, cocaine, amphetamine, or other stimulants use contributes to heart failure (HF) readmissions. We used the National Readmissions Database years 2016-2018 to identify patients with HF with and without substance use disorder (SUD) (defined as a composite of cannabis, cocaine, or other stimulant use disorders). The main outcome was to assess the risk of 30-day readmissions in HF patients with and without SUD. Of 978,217 HF hospitalizations that met the inclusion criteria, 34,717 (3.5%) had concomitant SUD. HF patients with SUD had significantly higher hazard for 30-day all-cause readmissions (adjusted hazard ratio [aHR] 1.16 [1.12-1.21]; P < 0.01) compared to HF patients without SUD. In conclusion, HF patients with SUD have an elevated risk of 30-day all-cause readmissions, mainly driven by cocaine and other stimulant disorders. Screening for substance use in hospitalized HF patients as well as timely referral for treatment are important to prevent HF readmissions.

Effect of leaving against medical advice on 30-day infective endocarditis readmissions.

BACKGROUND: The burden of against medical advice (AMA) discharges on the readmission rate of infective endocarditis (IE) patients has been largely ignored. METHODS: We used the National Readmissions Database, years 2016 to 2019, to identify IE patients and categorized them into those who left AMA (IE AMA) and those who were discharged to home or skilled nursing facility (SNF)/other facility (IE non-AMA). The primary outcome was 30-day all-cause readmissions difference per AMA status. RESULTS: Of 26,481 patients with IE who met the inclusion criteria, 4,310 (16.3%) left the hospital AMA. IE AMA patients were younger (mean years; 43.7 vs 34.2; p < 0.01) and had a higher prevalence of injection drug use (IDU) (89.4% vs 45.2%; p < 0.01) but fewer comorbidities compared to IE non-AMA. In adjusted analyses, IE AMA had higher hazards for 30-day readmissions compared to IE non-AMA [hazards ratio (HR): 3.1 (2.9-3.5); p < 0.01]. CONCLUSION: IE AMA are at increased risk of 30-day readmissions and higher resource utilization at the time of readmission compared to IE non-AMA. Considering the high prevalence of IDU in IE AMA, the role of mental health to curb the burden of IE readmissions is an area of further research.

Effects of atrial fibrillation on outcomes of influenza hospitalization.

Background: There is little information available on AF and its association with outcomes in adult influenza hospitalizations. Methods: The National Inpatient Sample was queried from years 2009-2018 to create a cohort of discharges containing an influenza diagnosis. AF was the primary exposure. Univariate and multivariate regression analysis was used to describe the association of AF with clinical and healthcare-resource outcomes. Finally, a doubly-robust analysis using average treatment effect on the treated (ATT) propensity score weighting was performed to verify the results of traditional regression analysis. Results: After adjustment, the presence of AF during influenza hospitalization was associated with higher odds of in-hospital mortality (aOR 1.56, 95 % CI 1.49 - 1.65), acute respiratory failure (aOR 1.22, 95 % CI 1.19 - 1.25), acute respiratory failure with mechanical ventilation (aOR 1.37, 95 % CI 1.32 - 1.41), acute kidney injury (aOR 1.09, 95 % CI 1.06 - 1.12), acute kidney injury requiring dialysis (aOR 1.61, 95 % CI 1.46 - 1.78) and cardiogenic shock (aOR 1.90, 95 % CI 1.65 - 2.20, all p-values < 0.0001). These findings were validated in our propensity score analysis using ATT weights. The presence of AF was also associated with higher total charges and costs of hospitalization, as well as a significantly longer length of stay (all p-values < 0.0001). Conclusion: AF is a cardiovascular comorbidity associated with worse clinical and healthcare resource outcomes in influenza requiring hospitalization. Its presence should be used to identify patients with influenza at risk of worse prognosis.

Thirty-Day Readmission Rate Among Patients With Hypertensive Crisis: A Nationwide Analysis.

BACKGROUND: Hypertensive crisis is a life-threatening condition, further classified as hypertensive emergency and hypertensive urgency based on the presence or absence of acute or progressive end-organ damage, respectively. Readmissions in hypertensive emergency have been studied before. We aimed to analyze 30-day readmissions using recent data and more specific ICD-10-CM coding in patients with hypertensive crisis. METHODS: In a retrospective study using the National Readmission Database 2018, we collected data on 129,239 patients admitted with the principal diagnosis of hypertensive crisis. The primary outcome was the all-cause 30-day readmission rate. Secondary outcomes were common causes of readmission, in-hospital mortality, resource utilization, and independent predictors of readmission. We also compared outcomes between patients with hypertensive urgency and hypertensive emergency. RESULTS: Among 128,942 patients discharged alive, 13,768 (10.68%) were readmitted within 30 days; the most common cause of readmission was hypertensive crisis (19%). In-hospital mortality for readmissions (1.5%) was higher than for index admissions (0.2%, P < 0.01). Mean length of stay for readmissions was 4.5 days. The mean hospital cost associated with readmissions was $10,950, and total hospital costs were $151 million. Age <65 years and female sex were independent predictors of higher readmission rates. Subgroup analysis revealed a higher readmission rate for hypertensive emergency than hypertensive urgency (11.7% vs. 10%, P < 0.01). CONCLUSIONS: All-cause 30-day readmission rates are high in patients admitted with hypertensive crisis, especially patients with hypertensive emergency. Higher in-hospital mortality and resource utilization are associated with readmission in these patients.

Differences in Stroke or Systemic Thromboembolism Readmission Risk After Hospitalization for Atrial Fibrillation and Atrial Flutter.

Background Although atrial fibrillation (AF) and atrial flutter (AFL) are different arrhythmias, they are assumed to confer the same risk of stroke and systemic thromboembolism (STE) despite a lack of available evidence. In this study, we investigated the difference in the risk of stroke or STE after AF and AFL hospitalizations. Methodology The National Readmission Database (NRD) 2018 was used to identify AF and AFL patients using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and were followed until the end of the calendar year to identify stroke or STE readmissions. Survival estimates were calculated, and a Cox proportional hazards model was used to calculate the adjusted hazards ratio (aHR) and compare the risk of stroke or STE readmissions between AF and AFL groups. Results A total of 215,810 AF and 15,292 AFL patients were identified. AFL patients were more likely to be younger (66 vs. 70 years), male (68% vs. 47%), and had higher prevalence of obesity (25% vs. 22%), obstructive sleep apnea (14% vs. 12%), diabetes mellitus (31% vs. 26%), and alcohol use (6.9% vs. 5.5%) (all p < 0.01). After adjusting for potential patient and hospital-level characteristics, there was a statistically significant decrease in one-year stroke or STE readmission risk in AFL patients compared to AF patients (aHR 0.79 (0.66-0.95); p = 0.01). Conclusions AFL patients are commonly younger males with a higher burden of medical comorbidity. There is a decrease in the one-year risk of stroke or STE events in AFL patients compared to AF. The predictors of stroke and STE are similar in both AFL and AF groups. Further studies with longer follow-up and anticoagulation data are needed to verify the results.

Effect of Diabetes Mellitus on 30 and 90-Day Readmissions of Patients With Heart Failure.

The prevalence of diabetes mellitus (DM) in hospitalized heart failure (HF) patients is increasing over time. However, the effect of DM on short-term readmissions for HF is not well established. We investigated the effects of DM on readmissions of HF patients. All adult hospitalizations with a primary diagnosis of HF were identified in the National Readmission Database (NRD) for 2018 and were categorized into those with and without a secondary diagnosis of DM. The primary outcome was to assess risk difference in 30 and 90-day all-cause readmissions. Multivariate Cox survival analysis and multivariate Cox regression were performed to estimate the readmission risk difference in HF patients with and without DM. Of 925,637 HF hospitalizations that met the inclusion criteria, 441,295 (47.6%) had concomitant DM. Diabetics hospitalized for HF had higher prevalence of obesity (37.3% vs 19.5%), kidney disease (58.4% vs 29.2%) and coronary disease (61.1% vs 51.0%), compared to HF hospitalizations without DM. In adjusted analyses, DM was associated with higher hazards for all-cause [hazards ratio (HR), 30 days: 1.04 (1.02-1.06); 90 days: 1.07 (1.05-1.09)], HF [HR, 30 days: 1.05 (1.02-1.07); 90 days: 1.08 (1.05-1.10)] and myocardial infarction (MI) [HR, 30 days: 1.26 (1.12-1.41); 90 days: 1.38 (1.25-1.52)] readmissions. In conclusion, in patients with HF-related hospitalizations, the presence of DM was associated with a higher risk of 30 and 90-day all-cause, HF and MI readmissions.

Gender differences, outcomes and trends among nonagenarian with atrial fibrillation: insight from National Inpatient Sample database.

BACKGROUND: Nonagenarians (NG), individuals aged ≥ 90 years, constitute an increasing proportion of hospitalizations presenting with atrial fibrillation (AF). However, not much is known about demographics, clinical outcomes, and trends of hospitalizations. Therefore, we analyzed data about hospitalizations and clinical outcomes among NGs with AF over ten years from 2005 to 2014 using a publically available database, the National Inpatient Sample. METHODS: All hospitalizations and major outcomes of subjects ≥ 90 years with a primary diagnosis of AF (ICD-9-CM code 427.31) over a ten-year period were assessed in this study by multivariate logistic regression analysis. RESULTS: There were more females than males (176,268 females, 51,384 males) in this analysis. The number of hospitalizations for AF among NG increased by 50% (17,295 in 2005 to 25,830 in 2014). Males were more likely to undergo cardioversion (6.14% of males vs. 5.06% of females, P < 0.0001). Over this period, in-hospital mortality declined from 3.21% in 2005 to 2.38% in 2014 ( P = 0.0041), with higher in-hospital mortality in males (3.23% in males vs. 2.76% in females, P = 0.0138), mean length of hospitalization decreased from 4.53 days to 4.13 days (P < 0.0001), the prevalence of congestive heart failure fell from 0.48% to 0.23% ( P = 0.0257), and the use of anticoagulation increased from 6.09% to 14.54% (P < 0.0001). In a multivariate analysis, hospital admission on the weekend, Elixhauser comorbidity index, CHA 2DS2VASc score, acute respiratory failure, and the length of hospital stay were associated with a higher risk of in-hospital mortality. CONCLUSIONS: From 2005 to 2014, AF-related hospitalizations among NGs increased, more so in in females population, mortality trends improved, rates of anticoagulation increased, and cardioversions increased. Despite the decreasing trend of in-hospital mortality since 2005, the relatively high mortality rate in males warrants further studies.

ST segment elevation caused by ostial right coronary artery obstruction in infective endocarditis: a case report.

BACKGROUND: Acute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation. CASE PRESENTATION: A 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up. CONCLUSIONS: ACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.