Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death.

OBJECTIVE: To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS). METHODS: We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death. RESULTS: We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment. CONCLUSIONS: The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.

Hospital and ICU patient volume per physician at peak of COVID pandemic: State-level estimates.

BACKGROUND: In anticipation of patient surge due to COVID-19, many states are working to increase the available healthcare workforce. To help inform state policies and initiatives aimed at physician deployment during COVID-19, we used predictions of peak patient volume for hospitals and intensive care units (ICU) and regional physician workforce estimates to measure patient to physician ratios at the peak of the pandemic for each state. METHODS: We estimated the number of potentially available physicians based on Medicare Part B billings for the care of hospitalized and critically ill patients in 2017, adjusted for attrition due to exposure to SARS-CoV-2 and relevant experience. We used estimates from the Institute of Health Metrics and Evaluation to determine the number of hospitalized and ICU patients expected at the peak of the pandemic in each state. We then determined the expected ratio of patients per physician for each state at the peak of the pandemic. RESULTS: The median number of hospitalized patients per physician was 13 (low estimate) to 18 (high estimate). At the high estimate of hospitalized patients, 35 states would have a patient to physician ratio of more than 15:1 (patient to physician ratios above 15:1 have been associated with poor outcomes). For ICU patients, the median number of patients each physician would treat across states would be 8-11 patients. Nine states would experience patient to physician ratios above 15:1 at the higher end of estimates. Patient-physician ratios decreased if the available physician pool was broadened to include physicians without recent experience treating hospitalized patients, and physicians in surgical specialties with experience treating acutely hospitalized patients. CONCLUSIONS/IMPLICATIONS: We estimate that most states will have sufficient physician capacity to manage hospitalized patients at the peak of the pandemic. However, at the high estimates of hospitalized patients, some Midwestern states will experience high patient to provider ratios that may adversely affect patient outcomes. LEVEL OF EVIDENCE: State.

COVID-19 and cardiac arrhythmias.

BACKGROUND: Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk. OBJECTIVES: The purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality. METHODS: We reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia. RESULTS: Among 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66-13.18) and NSVT (OR 8.92; 95% CI 1.73-46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02-1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95-48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality. CONCLUSION: Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.

Association of Medicaid Expansion With Cardiovascular Mortality.

Importance: Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear. Objective: To investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults. Design, Setting, and Participants: This study used a longitudinal, observational design, using a difference-in-differences approach with county-level data from counties in 48 states (excluding Massachusetts and Wisconsin) and Washington, DC, from 2010 to 2016. Adults aged 45 to 64 years were included. Data were analyzed from November 2018 to January 2019. Exposures: Residence in a Medicaid expansion state. Main Outcomes and Measures: Difference-in-differences of annual, age-adjusted cardiovascular mortality rates from before Medicaid expansion to after expansion. Results: As of 2016, 29 states and Washington, DC, had expanded Medicaid eligibility, while 19 states had not. Compared with counties in Medicaid nonexpansion states, counties in expansion states had a greater decrease in the percentage of uninsured residents at all income levels (mean [SD], 7.3% [3.2%] vs 5.6% [2.7%]; P < .001) and in low income strata (19.8% [5.5%] vs 13.5% [3.9%]; P < .001) between 2010 and 2016. Counties in expansion states had a smaller change in cardiovascular mortality rates after expansion (146.5 [95% CI, 132.4-160.7] to 146.4 [95% CI, 131.9-161.0] deaths per 100 000 residents per year) than counties in nonexpansion states did (176.3 [95% CI, 154.2-198.5] to 180.9 [95% CI, 158.0-203.8] deaths per 100 000 residents per year). After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 (95% CI, 1.8-6.9) fewer deaths per 100 000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states. Conclusions and Relevance: Counties in states that expanded Medicaid had a significantly smaller increase in cardiovascular mortality rates among middle-aged adults after expansion compared with counties in states that did not expand Medicaid. These findings suggest that recent Medicaid expansion was associated with lower cardiovascular mortality in middle-aged adults and may be of consideration as further expansion of Medicaid is debated.