Outcomes of Takotsubo cardiomyopathy in hospitalized cancer patients.

BACKGROUND: Chemotherapy-induced cardiomyopathy is a critical complication of treatment for cancer. The emotional stress of a cancer diagnosis, ongoing chemotherapy, abnormal cancer-related wasting syndrome may contribute to cardiac morbidity in these patients. The burden of Takotsubo Cardiomyopathy (TCM) in cancer patients is unknown. The incidence of TCM and related outcomes in cancer patients was investigated in this study. METHODS: The 2007-2013 National Inpatient Sample (NIS) was analyzed for patients with a prior and new diagnosis of TCM with and without malignancy. Risk factors for mortality were adjusted for associated conditions by multivariable logistic regression analysis. RESULTS: From 2007 to 2013, an estimated 122,855 adults were admitted with a diagnosis of TCM. In 2013, the incidence of admissions in US of patients with coexisting TCM and malignancy was 1.13%. Patients admitted for TCM with coexisting malignancy had a significantly higher mortality (13.8 vs. 2.9%, p < 0.0001), length of stay (7 vs. 4 days, p < 0.0001) and total charges ($29,291 vs. $36,231, p < 0.0001), compared to those with no malignancy. In patients with a primary diagnosis of TCM and without any underlying malignancy, males had a higher mortality (4.02 vs. 1.03%, p < 0.0001), whereas there was no gender difference in mortality in those with coexisting malignancy (6.25 vs. 6.45%, p = 0.965). On multivariable logistic regression analysis, risk factors associated with mortality were solid cancer (OR 3.43, p = 0.008), stroke (OR 18.33, p < 0.0001) and heart failure (OR 1.918, p = 0.004). CONCLUSIONS: Outcomes are significantly worse in patients with TCM and malignancy. Hence, this patient population must be regarded as high-risk and early diagnostic consideration for TCM is warranted. Early intervention may help lower mortality, decrease resource utilization and reduce the health care costs in these patients.

Effect of Ablation for Atrial Fibrillation on Heart Failure Readmission Rates.

Atrial fibrillation (AF) and heart failure (HF) cause numerous hospital admissions. We investigated if AF increases readmissions in patients with HF and whether AF ablation alters readmissions for HF exacerbations. The 2013 Nationwide Readmissions Database was analyzed for all-cause 90-day readmissions, after discharge for HF exacerbation. Kaplan-Meier analysis was used to compare hazard rates for readmissions due to HF exacerbation, after recent ablation versus no ablation. There were 885,270 admissions for HF exacerbation of which 364,447 had coexisting AF. All-cause 90-day readmission rates were higher in patients with HF with coexisting AF versus those without AF (41.4% vs 37.6%, p <0.0001). Associated factors increasing all-cause 90-day readmissions after ablation in patients without HF were female (odds ratio [OR] 1.44, p <0.001), complication of ablation (OR 1.44, p = 0.022), coronary artery disease (OR 1.56, p <0.001), chronic lung disease (OR 1.74, p <0.001), and malnutrition (OR 10.33, p <0.001). These factors were not significant for patients with HF. HF was not a significant risk factor for complications of ablation (adjusted OR 0.82, 95% confidence interval 0.57 to 1.18). Patients who underwent ablation versus patients who were discharged after HF exacerbation without ablation had a lower rate and length of stay for the 90-day readmission episode, due to HF exacerbation (27.5% vs 41.4%, p <0.0001, and 5.58 days vs 6.60 days, p = 0.031, respectively). In conclusion, AF increased 90-day readmissions in patients with HF, and ablation for AF in patients with HF was associated with reduced frequency, length of stay, and readmissions without an increase in complication rates.

Cardiac implantable electronic device infections: Who is at greatest risk?

BACKGROUND: Cardiac implantable electronic device (CIED) infections are associated with hospitalization, mortality, increased costs, and adverse outcomes. OBJECTIVE: Determine the burden of infections for CIEDs based on device type, associated comorbidities, and clinical characteristics over a 12-year period. METHODS: Utilizing data from the National Inpatient Sample database for cases from 2000 through 2012, we identified procedures for device-related infection (DRI) using International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CIED removal with diagnosis codes for device-related infection or systemic infection. Cases were categorized into 4 groups: single-chamber pacemaker, dual-chamber pacemaker, cardiac resynchronization therapy (CRT) device, and intracardiac defibrillator (ICD). RESULTS: Of 4,144,683 device-related procedures, 85,203 (2.06%) were associated with DRI. From 2000 through 2012, procedures related to DRI increased from 1.45% to 3.41% (P < .001). The risk of infection for CRT devices was the highest, peaking in 2012 (adjusted odds ratio [OR] 2.43, P < .001). During second half of the study, comorbidities associated with DRI were diabetes (OR: 1.11, P < .001), end-stage renal disease (OR: 3.23, P < .001), hematoma (OR: 2.44, P < .001), malnutrition (OR: 2.66, P < .001), venous thromboembolism (OR: 2.37, P < .001), chronic kidney disease (OR: 1.26, P < .001), and organ transplantation (OR: 2.37, P < .001). Charges associated with CRT DRIs increased nearly 2-fold in a decade. Higher inpatient mortality related to device infection were stroke (OR: 3.19, P < .001), end-stage renal disease (OR: 2.91, P < .001), malnutrition (OR: 2.67, P < .001), cirrhosis (OR: 2.05, P = .001), and organ transplantation (OR: 2.16, P < .001). CONCLUSION: CIED infections are increasing for all device types and particularly for CRT devices. Precise reasons for rising DRI procedures remain unclear, although conditions leading to immune compromise appear significant.

Syncope: Outcomes and Conditions Associated with Hospitalization.

PURPOSE: Syncope is a perplexing problem for which hospital admission and readmission are contemplated but outcomes remain uncertain. Our purpose was to determine the incidence of admissions and readmissions for syncope and compare associated conditions, in-hospital outcomes, and resource utilization. METHODS: The 2005-2011 California Statewide Inpatient Database was utilized. Patients of age ≥18 years admitted under International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 ("syncope or collapse") were selected. Records with a primary discharge diagnosis of syncope were classified as primary syncope. Primary outcome was mortality and secondary outcome measures were cardiopulmonary resuscitation, mechanical ventilation, discharge disposition, length of stay, frequency of readmission and hospital charges. RESULTS: An estimated 1.52 ± 0.02% admissions every year are related to syncope. Among admissions for syncope, in 42.1%, the cause remained unknown; 23% of syncope admissions were for recurrent episodes. The top 5 associated new diagnoses were hypokalemia (0.24%), ventricular tachycardia (0.17%), atrial fibrillation (0.16%), dehydration (0.12%), and hyponatremia (0.12%). Mortality rates are lower for primary vs secondary syncope (0.2% vs 1.4%; P <.0001). Greatest risk factors for mortality in primary syncope were pulmonary hypertension (odds ratio 12.3; 95% confidence interval, 3.34-45.04) and metastatic cancer (odds ratio 7.22; 95% confidence interval, 4.50-11.58). Major adverse events showed a decreasing trend for patients with multiple syncope admissions. Older patients and defibrillators or pacemaker recipients are admitted more often but experience negligible adverse events. Over a decade, median hospital charge for a single syncope admission has increased by 1.5 times. CONCLUSIONS: Despite a good prognosis, syncope is a frequent cause for hospitalization, particularly in the elderly. Present evaluation strategies are expensive and lack diagnostic value.

Analysis of outcomes of percutaneous coronary intervention in metastatic cancer patients with acute coronary syndrome over a 10-year period.

BACKGROUND: Early medical palliative care has been shown to improve overall survival of patients with metastatic cancer, but the role of cardiac surgical interventions in such patients is not clear. The limited life expectancy of these patients often poses a dilemma to clinicians and involves a detailed analysis of the risks and benefits of such interventions. This study examines the outcomes of percutaneous coronary intervention (PCI) in patients with metastatic cancer. METHODS: The National Inpatient Database of USA was used to identify patients aged ≥ 1 8 years who had a diagnosis of metastatic cancer and acute coronary syndrome (ACS) between 2000 and 2009 using ICD-9-CM codes. These were categorized into ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). The utilization of PCI was also identified using ICD-9-CM codes. The outcomes studied were in-hospital mortality, length of hospital stay and discharge disposition. The association between various outcomes and use of cardiac catheterization was assessed using multivariate regression models. RESULTS: There were 49,515 patients with metastatic disease who were discharged with a diagnosis of ACS. Of these, 15,964 had STEMI and 33,551 had NSTEMI. 3981 patients (24.9%) with STEMI and 3209 patients (9.6%) with NSTEMI received percutaneous coronary intervention. Caucasian male patients under age 65 years were more likely to receive PCI in the setting of an ACS. The hospital characteristics associated with higher use of PCI included academic affiliation, large bedsize, private for-profit hospitals and Midwestern and Western regions of USA. The adjusted odds of receiving PCI in this group of patient have gradually increased by 1.14 every year in last decade (95% CI 1.11-1.16). The beneficial effect of PCI on in-hospital mortality has declined in NSTEMI such that by 2009, there was no significant difference between patients who received PCI and those who did not receive PCI. This has remained unchanged for STEMI patients.C ONCLUSIONS: In metastatic cancer patients with ACS, the rate of PCI has increased over the last decade. In the current era, metastatic cancer patients with NSTEMI may perform equally well without PCI in terms of in-hospital mortality. The decision to provide such care may be considered on an individual basis based on the extent of their medical comorbidity and tumor burden.

Risk Factors and Outcomes of Gastrointestinal Bleeding in Left Ventricular Assist Device Recipients.

Increasing use of left ventricular assist devices (LVADs) has been accompanied by rising incidence of gastrointestinal bleeding (GIB). Objectives of this study were to determine the yearly incidence of GIB in LVAD recipients, compare outcomes of continuous-flow (CF) and pulsatile-flow LVAD eras, and investigate for risk factors. The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database from 2005 to 2010 was analyzed. Primary outcome of interest was incidence of GIB in LVAD recipients. Multivariate logistic regression model was used to examine independent associations of GIB with risk factors and outcomes. An estimated 8,879 LVAD index admissions and 8,722 readmissions in LVAD recipients over 6 years were analyzed. The yearly incidence of GIB after LVAD implantation increased from 5% in 2005 to 10% in 2010. On multivariate regression analysis, the odds of GIB was 3.24 times greater (95% confidence interval 1.53 to 6.89) in the era of CF LVADs than in the era of pulsatile-flow LVADs. Compared to their younger counterparts, in LVAD recipients aged >65 years, the adjusted odds of GIB was 20.5 times greater (95% confidence interval 2.24 to 188). GIB did not significantly increase the inhospital mortality but increased the inpatient length of stay. In conclusion, the incidence of GIB in LVAD recipients has increased since the use of CF LVADs has increased, leading to greater inpatient lengths of stay and hospital charges. Older recipients of CF LVADs appear to be at a greater risk of GIB.