In-hospital outcomes and postdischarge mortality in patients with acute coronary syndrome and atrial fibrillation.

BACKGROUND: It is unclear whether advances in management of acute coronary syndrome (ACS) and introduction of novel oral anticoagulants have changed outcomes in patients with ACS with concomitant atrial fibrillation (AF). OBJECTIVE: This study aimed to examine the incidence of AF in patients admitted for ACS and to evaluate its association with adverse outcomes, given the recent advances in management of both diseases. METHODS: Natural language processing search algorithms identified AF in patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021. Hierarchical generalized linear mixed modeling was used to assess the association between AF and in-hospital mortality, bleeding, and stroke outcomes; marginal Cox regression modeling was used to assess the association between AF and postdischarge mortality. RESULTS: Of 12,315 patients admitted for ACS, 3018 (24.5%) had AF with 1609 (53.3%) newly diagnosed. AF patients more commonly received anticoagulation with an oral anticoagulant (80.4% vs 12.3%) or heparin (61.9% vs 56.9%), had lengthier intensive care unit stay (72 vs 49 hours), and underwent fewer percutaneous coronary interventions (31.9% vs 53.1%). In-hospital bleeding, stroke, and mortality were higher in the AF group (15.3% vs 5.0%, 7.4% vs 2.4%, and 6.9% vs 2.1%, respectively). AF was an independent risk factor for all in-hospital outcomes (odds ratios of 2.5, 2.7, and 2.0 for bleeding, stroke, and mortality, respectively) as well as for postdischarge mortality (hazard ratio, 1.3; 95% CI, 1.2-1.5). CONCLUSION: AF is present in 25% of ACS patients and increases risk of in-hospital and postdischarge adverse outcomes. Additional data are required to direct optimal management.

Clinical significance of unexplained persistent sinus tachycardia in women with structurally normal heart during the peripartum period.

BACKGROUND: Persistent sinus tachycardia (ST) is frequently encountered during pregnancy and peripartum period and its etiology often remains elusive. We sought to examine the possible association between unexplained persistent ST and obstetric outcomes. METHODS: A case control study was conducted using chart review of women admitted in labor to one of 7 hospitals of Northwell Health between January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified patients with persistent ST during the peripartum period, defined as a heart rate of more than 100 bpm for more than 48 h. A control group was created by randomly subsampling those who did not meet the inclusion criteria for sinus tachycardia. Obstetric outcomes were measured as mother's length of stay (LOS), pre-term labor (PTL), admission to the neonatal ICU (NICU), and whether she received cesarean-section (CS). RESULTS: Seventy-eight patients with persistent ST were identified, out of 141,769 women admitted for labor throughout the Northwell Health system. 23 patients with ST attributable to infection or hypovolemia from anemia requiring transfusion and 55 with unclear etiology were identified. After adjusting for age and parity, pregnant mothers with ST were 2.35 times more likely to have a CS than those without (95% CI: 1.46-3.81, p = 0.0005) and had 1.38 times the LOS (1.21- 1.56, p < 0.0001). Among mothers with ST, those with unexplained ST were 2.14 times more likely to have a CS (1.22-3.75, p = 0.008). CONCLUSION: Among pregnant patients, patients with ST have higher rates of CS.This association is unclear, however potential mechanisms include catecholamine surge, indolent infection, hormonal fluctuations, and medications. More studies are needed to explore the mechanism of ST in pregnant woman to determine the clinical significance and appropriate management.

Characteristics and outcomes of patients with COVID-19 in an intensive care unit of a community hospital; retrospective cohort study.

Background: The limited data available so far has shown a high mortality rate among COVID-19 patients admitted to the ICU. Possible risk factors for poor outcomes in this type of patients need to be analyzed so we can identify strategies to reduce mortality. Objective: Characterized the COVID-19 experience in Community hospital ICU. Methods: Single center retrospective cohort study involving all adult patients admitted to the ICU with severe COVID-19 infection. Results: 132 patients were admitted to ICU during the study period. There was a preponderance for males and the most common ethnicity was Hispanic. The overall mortality was 69%, and mortality after intubation was 76%. In the multivariable analysis older Age (OR = 15.7), Obesity (OR = 2.92) and Mechanical Ventilation (OR = 12.0) were found to be a significant independent risk factor for increased mortality. Conclusion: Our study confirms the high mortality rate in patients critically ill with COVID-19 requiring ICU care especially among older age group, mechanically ventilated and obese patients. Overall outcomes are comparable to larger tertiary care centers. Our findings highlight the need to plan for optimal resource allocation and tailoring therapies to target the disease so as to improve outcomes.

A Case of Severe QTc Prolongation During Targeted Temperature Management - What Can We Learn?

BACKGROUND QTc prolongation during targeted temperature management (TTM) post cardiac arrest is a known effect of hypothermia, but its significance is unclear. Several studies suggest that temporary prolongation during TTM is not prognostic and does not potentiate fatal arrhythmias; however, there are limited cases of patients presenting with QTc intervals >700 milliseconds. CASE REPORT We describe a case in which a 57-year-old woman with diabetes, hypertension, and atrial fibrillation presented with concern for stroke. The hospital course was complicated by cardiac arrest requiring TTM, which was stopped early due to significant QTc prolongation of 746 milliseconds. CONCLUSIONS TTM is beneficial post resuscitation for good neurological outcomes, but it also has known adverse cardiac effects such as QTc prolongation. The significance of QTc prolongation during TTM is unclear as several studies have shown no increased incidence of malignant arrhythmias. One case report in the literature describes the incidence of torsades de pointes due to QTc prolongation during TTM. Further study and guidelines regarding electrocardiogram monitoring are needed to determine the importance of QTc prolongation during TTM.