Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy.

BACKGROUND: There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy. METHODS: We used National Inpatient Sample (2000-2017) to identify adults with NSTEMI (not undergoing coronary artery bypass grafting) and concomitant IHCA. The cohort was stratified based on use of early (hospital day 0) or delayed (≥hospital day 1) coronary angiography (CAG), percutaneous coronary intervention (PCI), and medical management. Outcomes included incidence of IHCA, in-hospital mortality, adverse events, length of stay, and hospitalization costs. RESULTS: Of 6,583,662 NSTEMI admissions, 375,873 (5.7 %) underwent early CAG, 1,133,143 (17.2 %) received delayed CAG, 2,326,391 (35.3 %) underwent PCI, and 2,748,255 (41.7 %) admissions were managed medically. The medical management cohort was older, predominantly female, and with higher comorbidities. Overall, 63,085 (1.0 %) admissions had IHCA, and incidence of IHCA was highest in the medical management group (1.4 % vs 1.1 % vs 0.7 % vs 0.6 %, p < 0.001) compared to early CAG, delayed CAG and PCI groups, respectively. In adjusted analysis, early CAG (adjusted OR [aOR] 0.67 [95 % confidence interval {CI} 0.65-0.69]; p < 0.001), delayed CAG (aOR 0.49 [95 % CI 0.48-0.50]; p < 0.001), and PCI (aOR 0.42 [95 % CI 0.41-0.43]; p < 0.001) were associated with lower incidence of IHCA compared to medical management. Compared to medical management, early CAG (adjusted OR 0.53, CI: 0.49-0.58), delayed CAG (adjusted OR 0.34, CI: 0.32-0.36) and PCI (adjusted OR 0.19, CI: 0.18-0.20) were associated with lower in-hospital mortality (all p < 0.001). CONCLUSION: Early CAG and PCI in NSTEMI was associated with lower incidence of IHCA and lower mortality among NSTEMI-IHCA admissions.

Escalation strategies, management, and outcomes of acute myocardial infarction-cardiogenic shock patients receiving percutaneous left ventricular support.

BACKGROUND: There are limited national-level data on the contemporary practices of mechanical circulatory support (MCS) use in acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS: We utilized the Healthcare Cost and Utilization Project-National/Nationwide Inpatient Sample data (2005-2017) to identify adult admissions (>18 years) with AMI-CS. MCS devices were classified as intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD), or extracorporeal membrane oxygenation (ECMO). We evaluated trends in the initial device used (IABP alone, pLVAD alone or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. RESULTS: Among 327,283 AMI-CS admissions, 131,435 (40.2%) had an MCS device placed with available information on timing of placement. IABP, pLVAD, and ≥2 MCS devices were used as initial device in 120,928 (92.0%), 8202 (6.2%), and 2305 (1.7%) admissions, respectively. Most admissions were maintained on the initial MCS device with 1%-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). Urban, medium, and large-sized hospitals and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted odds ratio: 1.56, 95% confidence interval:  1.38-1.75; p < 0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices, resulting in lower in-hospital mortality. CONCLUSIONS: In this 13-year study, escalation of MCS in AMI-CS was associated with higher in-hospital mortality suggestive of higher acuity of illness. The increase in number of durable LVAD/heart transplantations alludes to the role of MCS as successful bridge strategies.

Aortic valve regurgitation following transaortic septal myectomy for obstructive hypertrophic cardiomyopathy: Incidence and influence on late outcomes.

OBJECTIVE: In this study, we describe the incidence, sites of valve injury, and the influence of aortic valve regurgitation (AR) on outcomes of septal myectomy for obstructive hypertrophic cardiomyopathy. METHODS: We analyzed patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from 2001 to 2022. The primary study end point was incidence of procedure-related AR, defined as the need for an unplanned aortic valve (AV) procedure or new-onset moderate AR on early postoperative echocardiography. RESULTS: There were 2807 patients who underwent transaortic septal myectomy for hypertrophic cardiomyopathy and had pre- and postoperative transthoracic echocardiograms. Procedure-related AR was observed in 55 (2%) patients; 27 (1%) required unplanned AV procedures at the time of myectomy, and 29 (1%) additional patients developed moderate AR postoperatively. During follow-up, 9 total patients underwent late AV reoperation, 1 patient who developed new moderate AR postoperatively required late AVR due to severe calcific AS, and none of the patients who had unplanned AV procedures required late reoperation. The overall cumulative incidence of AV reoperation at 10 and 15 years was 1% and 5%. The predicted probability of moderate or severe AR at 5 and 10 years was 1.4% and 1.8%, respectively. There was no difference in survival comparing patients with or without early postoperative mild or worse AR (P = .69). CONCLUSIONS: Procedure-related AR was observed in 2% of patients undergoing transaortic septal myectomy, and unplanned AV procedures were necessary for half of these patients. Intraoperative identification and valve repair mitigate the impact of cusp injury on late reintervention and survival.

Outcomes of a protocolized approach for surgical unroofing of intramural anomalous aortic origin of coronary artery in children and adults.

OBJECTIVE: Management of anomalous aortic origin of coronary arteries has been variable, and limited data are available on early and late outcomes. METHODS: We report a single institution's experience with a protocolized approach to 148 consecutive patients who underwent surgical unroofing of intramural anomalous aortic origin of coronary arteries (June 2003 to December 2020). The management algorithm included preoperative and postoperative cross-sectional and echocardiographic imaging, exercise testing, and a standardized operative technique. RESULTS: The median age of the cohort was 44.4 years (range, 4 months to 83 years); 130 patients had an anomalous right coronary artery, and 19 patients had an anomalous left coronary artery. Surgical unroofing was an isolated procedure in 118 patients (80%) and a concomitant procedure in 30 patients (20.3%). There were 2 (1%) early deaths; both were reoperations for aortic root or valve replacement. Over a median follow-up of 9.5 (interquartile range, 5-12.3) years, there were 5 late deaths, 3 due to noncardiac causes and 2 due to unknown cause. Late survival after anomalous aortic origin of coronary arteries repair at 10 and 15 years was 94.5% and 94.5%, respectively. There were no early or late deaths in the pediatric cohort with a median follow-up of 10.9 years (interquartile range, 6.9-12.1). At a median clinical follow-up of 3.9 years (interquartile range, 1.1-9.5), 36 patients had chest pain but none with evidence of ischemia related to the unroofing. CONCLUSIONS: Surgical unroofing of anomalous aortic origin of coronary arteries can be performed safely with low early mortality, even in the setting of concomitant procedures. Late survival is excellent, with the vast majority being symptom free.

No "July Effect" in the management and outcomes of acute myocardial infarction: An 18-year United States national study.

BACKGROUND: There has been conflicting reports on the effect of new trainees on clinical outcomes at teaching hospitals in the first training month (July in the United States of America). We sought to assess this "July effect" in a contemporary acute myocardial infarction (AMI) population. METHODS: Adult (>18 years) AMI hospitalizations in May and July in urban teaching and urban nonteaching hospitals in the United States were identified from the HCUP-NIS database (2000-2017). In-hospital mortality was compared between May and July admissions. A difference-in-difference analysis comparing a change in outcome from May to July in teaching hospitals to a change in outcome from May to July in nonteaching hospitals was also performed. RESULTS: A total of 1,312,006 AMI hospitalizations from urban teaching (n = 710,593; 54.2%) or nonteaching (n = 601,413; 45.8%) hospitals in the months of May and July were evaluated. May admissions in teaching hospitals, had greater comorbidity, higher rates of acute multiorgan failure (10.6% vs. 10.2%, p < 0.001) and lower rates of cardiac arrest when compared to July admissions. July AMI admissions had lower in-hospital mortality compared to May (5.6% vs. 5.8%; adjusted odds ratio 0.94 [95% confidence interval 0.92-0.97]; p < 0.001) in teaching hospitals. Using the difference-in-difference model, there was no evidence of a July effect for in-hospital mortality (p = 0.19). CONCLUSIONS: There was no July effect for in-hospital mortality in this contemporary AMI population.

Impact of Race and Ethnicity on Use and Outcomes of Septal Reduction Therapies for Obstructive Hypertrophic Cardiomyopathy.

Background Information on impact of race and ethnicity on use and early outcomes of septal reduction therapies (SRTs) for obstructive hypertrophic obstructive cardiomyopathy are limited. Methods and Results Using the National Inpatient Sample from January 2012 through December 2019, we identified all adult admissions with a primary diagnosis of obstructive hypertrophic cardiomyopathy and those undergoing SRT. Predictors of receiving SRT and outcomes including in-hospital mortality, complications, and resource use were evaluated in racial and ethnic groups. Among a total of 18 895 adult admissions with obstructive hypertrophic cardiomyopathy, SRT was performed in 7255 (38.4%) admissions. Septal myectomy was performed in 4930 (26.1%), while alcohol septal ablation was performed in 2325 (12.3%). In adjusted analysis, Black patient (versus White patient adjusted odds ratio, 0.65 [95% CI, 0.57-0.73]; P<0.001) and Hispanic patient admissions (versus White adjusted odds ratio, 0.78 [95% CI, 0.66-0.92]; P=0.003) were less likely to receive SRT. Among admissions undergoing SRT, in-hospital mortality was significantly higher for Hispanic (adjusted odds ratio, 3.38 [95% CI, 1.81-6.30], P<0.001) and other racial and ethnic groups (adjusted odds ratio 2.02 [95% CI, 1.00-4.11]; P=0.05) compared with White patient admissions, whereas Black patient admissions had comparable mortality. Black, Hispanic, and other ethnic group patients had higher rates of SRT complications and more frequent dismissals to acute care facilities. Conclusions Among obstructive hypertrophic cardiomyopathy hospitalizations, minoritized racial groups were less likely to receive SRT. Importantly, hospitalizations of Hispanic and other ethnic patients undergoing SRT had significantly higher in-hospital mortality and complication rates. Further studies with granular echocardiographic information to assess indications for SRT are needed to better understand these differences.

Hospitalization Duration for Acute Myocardial Infarction: A Temporal Analysis of 18-Year United States Data.

Background and objectives: Primary percutaneous coronary intervention (PCI)-related outcomes in acute myocardial infarction (AMI) have improved over time, but there are limited data on the length of stay (LOS) in relation to in-hospital mortality. Materials and Methods: A retrospective cohort of adult AMI admissions was identified from the National Inpatient Sample (2000−2017) and stratified into short (≤3 days) and long (>3 days) LOS. Outcomes of interest included temporal trends in LOS and associated in-hospital mortality, further sub-stratified based on demographics and comorbidities. Results: A total 11,622,528 admissions with AMI were identified, with a median LOS of 3 (interquartile range [IQR] 2−6) days with 49.9% short and 47.3% long LOS, respectively. In 2017, compared to 2000, temporal trends in LOS declined in all AMI, with marginal increases in LOS >3 days and decreases for ≤3 days (median 2 [IQR 1−3]) vs. long LOS (median 6 [IQR 5−9]). Patients with long LOS had lower rates of coronary angiography and PCI, but higher rates of non-cardiac organ support (respiratory and renal) and use of coronary artery bypass grafting. Unadjusted in-hospital mortality declined over time. Short LOS had comparable mortality to long LOS (51.3% vs. 48.6%) (p = 0.13); however, adjusted in-hospital mortality was higher in LOS >3 days when compared to LOS ≤ 3 days (adjusted OR 3.00, 95% CI 2.98−3.02, p < 0.001), with higher hospitalization (p < 0.001) when compared to long LOS. Conclusions: Median LOS in AMI, particularly in STEMI, has declined over the last two decades with a consistent trend in subgroup analysis. Longer LOS is associated with higher in-hospital mortality, higher hospitalization costs, and less frequent discharges to home compared to those with shorter LOS.

Incidence and Burden of Tricuspid Regurgitation in Patients With Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is considered a risk factor for isolated tricuspid valve regurgitation (TR) in the absence of other known etiologies. OBJECTIVES: This study sought to identify the incidence of clinically significant isolated TR and its impact in patients with AF. METHODS: A population-based record linkage system was used to identify adult patients with new-onset AF. Patients with evidence of moderate or greater tricuspid valve disease, left-sided valve disease, pulmonary hypertension, prior cardiac surgery, impaired left ventricular systolic/diastolic function at baseline were excluded. The remaining patients (n = 691) were followed over time to identify development of moderate or greater TR and assess its impact on subsequent survival. RESULTS: A total of 232 patients (33.6%) developed moderate or greater TR. Among these, 73 patients (10.6%) had isolated TR without significant underlying structural heart disease. Incidence rate of any moderate or greater TR was 3.9 cases and that of isolated TR was 1.3 cases per 100 person-years. Permanent/persistent AF and female sex were associated with increased risk of developing TR, whereas rhythm control was associated with lower risk of TR. Over a median clinical follow-up of 13.3 years (IQR: 10.0-15.9 years), development of any moderate or greater TR (HR: 2.92; 95% CI: 2.29-3.73; P < 0.001) and isolated significant TR (HR: 1.51; 95% CI: 1.03-2.22; P = 0.03) were associated with an adjusted increased risk of subsequent mortality. CONCLUSIONS: In this population-based cohort of patients with AF, nearly one-third developed moderate or greater TR over time. Incident significant TR and incident isolated significant TR portend a worse survival in patients with AF.

Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States.

Objective: To evaluate the prevalence, management and outcomes of concomitant aortic stenosis (AS) in admissions with acute myocardial infarction (AMI). Methods: We used the HCUP-NIS database (2000-2017) to identify adult AMI admissions with concomitant AS. Outcomes of interest included prevalence of AS, in-hospital mortality, use of cardiac procedures, hospitalization costs, length of stay, and discharge disposition. Results: Among a total of 11,622,528 AMI admissions, 513,688 (4.4 %) were identified with concomitant AS. Adjusted temporal trends revealed an increase in STEMI and NSTEMI hospitalizations with concomitant AS. Compared to admissions without AS, those with AS were on average older, of female sex, had higher comorbidity, higher rates of NSTEMI (78.9 % vs 62.1 %), acute non-cardiac organ failure, and cardiogenic shock. Concomitant AS was associated with significantly lower use of coronary angiography (45.5 % vs 64.4 %), percutaneous coronary intervention (20.1 % vs 42.5 %), coronary atherectomy (1.7 % vs. 2.8 %) and mechanical circulatory support (3.5 % vs 4.8 %) (all p < 0.001). Admissions with AS had higher rates of coronary artery bypass surgery and surgical aortic valve replacement (5.9 % vs 0.1 %) compared to those without AS. Admissions with AMI and AS had higher in-hospital mortality (9.2 % vs. 6.0 %; adjusted OR 1.12 [95 % CI 1.10-1.13]; p <0.001). Concomitant AS was associated with longer hospital stay, more frequent palliative care consultations and less frequent discharges to home. Conclusions: In this 18-year study, an increase in prevalence of AS in AMI hospitalization was noted. Concomitant AS was associated with lower use of guideline-directed therapies and worse clinical outcomes among AMI admissions.

Impact of Active and Historical Cancers on the Management and Outcomes of Acute Myocardial Infarction Complicating Cardiogenic Shock.

BACKGROUND: There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with concomitant cancer. METHODS: A retrospective cohort of adult AMI-CS admissions was identified from the National Inpatient Sample (2000-2017) and stratified by active cancer, historical cancer, and no cancer. Outcomes of interest included in-hospital mortality, use of coronary angiography, use of percutaneous coronary intervention, do-not-resuscitate status, palliative care use, hospitalization costs, and hospital length of stay. RESULTS: Of the 557,974 AMI-CS admissions during this 18-year period, active and historical cancers were noted in 14,826 (2.6%) and 27,073 (4.8%), respectively. From 2000 to 2017, there was a decline in active cancers (adjusted odds ratio, 0.70 [95% CI, 0.63-0.79]; P < .001) and an increase in historical cancer (adjusted odds ratio, 2.06 [95% CI, 1.89-2.25]; P < .001). Compared with patients with no cancer, patients with active and historical cancer received less-frequent coronary angiography (57%, 67%, and 70%, respectively) and percutaneous coronary intervention (40%, 47%, and 49%%, respectively) and had higher do-not-resuscitate status (13%, 15%, 7%%, respectively) and palliative care use (12%, 10%, 6%%, respectively) (P < .001). Compared with those without cancer, higher in-hospital mortality was found in admissions with active cancer (45.9% vs 37.0%; adjusted odds ratio, 1.29 [95% CI, 1.24-1.34]; P < .001) but not historical cancer (40.1% vs 37.0%; adjusted odds ratio, 1.01 [95% CI, 0.98-1.04]; P = .39). AMI-CS admissions with cancer had a shorter hospitalization duration and lower costs (all P < .001). CONCLUSION: Concomitant cancer was associated with less use of guideline-directed procedures. Active, but not historical, cancer was associated with higher mortality in patients with AMI-CS.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes.

OBJECTIVES: There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. METHODS: We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. RESULTS: The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. CONCLUSIONS: Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Newer P2Y12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12 inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS). PATIENTS AND METHODS: MEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y12 inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y12 inhibitors and clopidogrel in patients with AMI-CA/CS. RESULTS: Eight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y12 cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies). CONCLUSION: In patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y12 inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.

Influence of Household Income on Management and Outcomes of Acute Myocardial Infarction Complicated by Cardiogenic Shock.

The impact of socioeconomic status on care and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains understudied. Hence, adult admissions with AMI-CS were identified from the National Inpatient Sample database (2005 to 2017) and were divided into quartiles on the basis of median household income for zip code (0 to 25th, 26th to 50th, 51st to 75th, and 76th to 100th). In-hospital mortality, use of cardiac and noncardiac procedures, and resource utilization were compared between all 4 income quartiles. Among a total of 7,805,681 AMI admissions, cardiogenic shock was identified in 409,294 admissions (5.2%) with comparable prevalence of cardiogenic shock across all 4 income quartiles. AMI-CS admissions belonging to the lowest income quartile presented more often with non-ST-elevation myocardial infarction and had comparable use of coronary angiography and percutaneous coronary intervention but lower use of early coronary angiography, early percutaneous coronary intervention, mechanical circulatory support devices, and pulmonary artery catheterization than higher income quartiles. In the adjusted analysis, admissions belonging to the 0 to 25th income quartile (odds ratio [OR] 1.17 [95% confidence interval [CI] 1.15 to 1.20], p <0.001), 26th to 50th quartile (OR 1.11 [95% CI 1.09 to 1.14], p <0.001), and 51st to 75th income quartile (OR 1.06 [95% CI 1.04 to 1.09], p <0.001) had higher adjusted in-hospital mortality than the highest income quartile (76th to 100th). Lowest income quartile admissions had lower rates of palliative care consultations and higher rates of do-not-resuscitate status than the higher income quartiles. Hospitalization charges and length of stay were higher for admissions belonging to the highest income quartile. In conclusion, lowest income quartile AMI-CS admissions were associated with higher rates of non-ST-elevation myocardial infarction, lower use of mechanical circulatory support devices, and higher in-hospital mortality.

Concomitant Sepsis Diagnoses in Acute Myocardial Infarction-Cardiogenic Shock: 15-Year National Temporal Trends, Management, and Outcomes.

OBJECTIVES: Mixed cardiogenic-septic shock is common and associated with high mortality. There are limited contemporary data on concomitant sepsis in acute myocardial infarction complicated by cardiogenic shock (AMI-CS). DESIGN: Observational study. SETTING: Twenty percent stratified sample of all community hospitals (2000-2014) in the United States. PARTICIPANTS: Adults (> 18 yr) with AMI-CS with and without concomitant sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes of interest included inhospital mortality, development of noncardiac organ failure, complications, utilization of guideline-directed procedures, length of stay, and hospitalization costs. Over 15 years, 444,253 AMI-CS admissions were identified, of which 27,057 (6%) included sepsis. The sepsis cohort had more comorbidities and had higher rates of noncardiac multiple organ failure (92% vs 69%) (all p < 0.001). In 2014, compared with 2000, the prevalence of sepsis increased from 0.5% versus 11.5% with an adjusted odds ratio (aOR) 11.71 (95% CI, 9.7-14.0) in ST-segment elevation myocardial infarction and 24.6 (CI, 16.4-36.7) (all p < 0.001) in non-ST segment elevation myocardial infarction. The sepsis cohort received fewer cardiac interventions (coronary angiography [65% vs 68%], percutaneous coronary intervention [43% vs 48%]) and had greater use of mechanical circulatory support (48% vs 45%) and noncardiac support (invasive mechanical ventilation [65% vs 41%] and acute hemodialysis [12% vs 3%]) (p < 0.001). The sepsis cohort had higher inhospital mortality (44.3% vs 38.1%; aOR, 1.21; 95% CI, 1.18-1.25; p < 0.001), longer length of stay (14.0 d [7-24 d] vs 7.0 d [3-12 d]), greater hospitalization costs (×1,000 U.S. dollars) ($176.0 [$85-$331] vs $77.0 [$36-$147]), fewer discharges to home (22% vs 44%) and more discharges to skilled nursing facilities (51% vs 28%) (all p < 0.001). CONCLUSIONS: In AMI-CS, concomitant sepsis is associated with higher mortality and morbidity highlighting the need for early recognition and integrated management of mixed shock.

Sex disparities in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States.

BACKGROUND: There have been limited large scale studies assessing sex disparities in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI). METHODS AND RESULTS: Using the National Inpatient Sample (2000-2017), we identified adult admissions (≥18 years) with AMI and CA. Outcomes of interest included sex disparities in coronary angiography (early [hospital day zero] and overall), time to angiography, percutaneous coronary angiography (PCI), mechanical circulatory support (MCS) use, in-hospital mortality, hospitalization costs, hospital length of stay and discharge disposition. In the period between January 1, 2000-December 31, 2017, 11,622,528 admissions for AMI were identified, of which 584,216 (5.0%) were complicated by CA. Men had a higher frequency of CA compared to women (5.4% vs. 4.4%; p < 0.001). Women were on average older (70.4 ± 13.6 vs 65.0 ± 13.1 years), of black race (12.6% vs 7.9%), with higher comorbidity, presenting with non-ST-segment-elevation AMI (36.4% vs 32.3%) and had a non-shockable rhythm (47.6% vs 33.3%); all p < 0.001. Women received less frequent coronary angiography (56.0% vs 66.2%), early coronary angiography (32.0% vs 40.2%), PCI (40.4% vs 49.7%), MCS (17.6% vs 22.0%), and CABG (8.3% vs 10.8%), with a longer median time to angiography (all p < 0.001). Women had higher in-hospital mortality (52.6% vs 40.6%, adjusted odds ratio 1.13 [95% confidence interval 1.11-1.14]; p < 0.001), shorter length of hospital stays, lower hospitalization costs and less frequent discharges to home. CONCLUSION: Despite no difference in guideline recommendations for men and women with AMI-CA, there appears to be a systematic difference in the use of evidence-based care that disadvantages women.

Hospital-Level Disparities in the Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction.

There are limited contemporary data evaluating the relation between hospital characteristics and outcomes of patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). As such, we used the National Inpatient Sample database (2000 to 2017), to identify adult admissions with primary diagnosis of AMI and concomitant CA. Interhospital transfers were excluded, and hospitals were classified based on location and teaching status (rural, urban nonteaching, and urban teaching) and bed size (small, medium, and large). Among 494,083 AMI-CA admissions, 9.3% received care at rural hospitals, 43.4% at urban nonteaching hospitals, and 47.3% at urban teaching hospitals. Compared with urban nonteaching and teaching hospitals, AMI-CA admissions at rural hospitals received lower rates of cardiac and noncardiac procedures. Admissions to urban teaching hospitals had higher rates of acute organ failure, concomitant cardiogenic shock, and cardiac and noncardiac procedures. When hospitals were stratified by bed size, 9.8% of AMI-CA admissions were admitted to small capacity hospitals, 26.0% to medium capacity, and 64.2% to large capacity hospitals. The use of cardiac and noncardiac procedures was lower in small hospitals with higher rates of use in medium and large hospitals. In-hospital mortality was higher in urban nonteaching (adjusted odds ratio [OR] 1.17; 95% confidence interval [CI]1.14 to 1.20; p <0.001) and urban teaching hospitals (adjusted OR 1.36; 95% CI 1.32 to 1.39; p <0.001) compared with rural hospitals. Compared with small hospitals, medium (adjusted OR 1.11; 95% CI 1.08 to 1.14; p <0.001) and large hospitals (adjusted OR 1.22; 95% CI 1.19 to 1.25; p <0.001) were associated with higher in-hospital mortality. In conclusion, AMI-CA admissions to large and urban hospitals had higher in-hospital mortality compared with small and rural hospitals potentially owing to greater acuity.

Outcomes and risk factors of late failure of valve-sparing aortic root replacement.

OBJECTIVE: Retention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. METHODS: From January 1994 through June 2017, 342 patients (mean age 47.8 ± 15.5 years, 253 [74%] male) underwent VSARR. The most common etiologies were connective tissue disease (n = 143, 42%) followed by degenerative aortic aneurysm (n = 131, 38%). Aortic regurgitation (moderate or greater) was present in 35% (n = 119). RESULTS: Reimplantation technique was used in 90% patients (n = 308). Valsalva graft was used in 38% patients (n = 131) and additional cusp repair was done in 15% (n = 50). Operative mortality was 1% (n = 5). The median follow-up time was 8.79 years (interquartile range, 4.08-13.51). The cumulative incidence of reoperation (while accounting for the competing risk of death) was 8.4%, 12.8%, and 17.1% at 5, 10, and 15 years, respectively. There were no differences in survival and incidence of reoperation between root reimplantation and remodeling. Larger preoperative annulus diameter was associated with greater risk of reoperation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19, P = .01). The estimated probability of developing severe aortic regurgitation after VSARR was 8% at 10 years postoperatively. Operative mortality, residual aortic regurgitation at dismissal, and survival improved in recent times with more experience. CONCLUSIONS: VSARR is a viable and safe option with good long-term outcomes and low rates of late aortic valve replacement. Dilated annulus preoperatively was associated with early repair failure.

Influence of Body Mass Index on the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in the United States, 2008-2017.

BACKGROUND: There are limited data on influence of body mass index (BMI) on outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS: Adult AMI-CS admissions from 2008 to 2017 were identified from the National Inpatient Sample and stratified by BMI into underweight (<19.9 kg/m2), normal-BMI (19.9-24.9 kg/m2) and overweight/obese (>24.9 kg/m2). Outcomes of interest included in-hospital mortality, invasive cardiac procedures use, hospitalization costs, and discharge disposition. RESULTS: Of 339,364 AMI-CS admissions, underweight and overweight/obese constitute 2356 (0.7%) and 46,675 (13.8%), respectively. In 2017, compared to 2008, there was an increase in underweight (adjusted odds ratio [aOR] 6.40 [95% confidence interval {CI} 4.91-8.31]; p < 0.001) and overweight/obese admissions (aOR 2.93 [95% CI 2.78-3.10]; p < 0.001). Underweight admissions were on average older, female, with non-ST-segment-elevation AMI-CS, and higher comorbidity. Compared to normal and overweight/obese admissions, underweight admissions had lower rates of coronary angiography (57% vs 72% vs 78%), percutaneous coronary intervention (40% vs 54% vs 54%), and mechanical circulatory support (28% vs 46% vs 49%) (p < 0.001). In-hospital mortality was lower in underweight (32.9% vs 34.1%, aOR 0.64 [95% CI 0.57-0.71], p < 0.001) and overweight/obese (27.6% vs 38.4%, aOR 0.89 [95% CI 0.87-0.92], p < 0.001) admissions. Higher hospitalization costs were seen in overweight/obese admissions while underweight admissions were discharged more often to skilled nursing facilities. CONCLUSION: Underweight patients received less frequent cardiac procedures and were discharged more often to skilled nursing facilities. Underweight and overweight/obese AMI-CS admissions had lower in-hospital mortality compared to normal BMI.