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Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189–0.279, and ≥ 80: OR 0.265, 95% CI 0.195–0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766–0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809–0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491–0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125–1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016. • NSTEMI patients ≥80 years get PCI-DES one artery at <50% of the rate in <80 years. • Intervention is equally beneficial in both patients <80 and ≥ 80 years. • Women are 21.5% less likely to get intervention for NSTEMI compared to men. • Non-white race has a 16.8% less likelihood of intervention. • Non-Medicare/Medicaid: 40% lower mortality in age < 80; 16% higher intervention. [ABSTRACT FROM AUTHOR]

Coronary physiology is a routine diagnostic tool when assessing whether coronary revascularization is indicated. The iFR-SWEDEHEART trial demonstrated similar clinical outcomes when using instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) to guide revascularization. The objective of this analysis was to assess a cost-minimization analysis of iFR-guided compared with FFR-guided revascularization. In this cost-minimization analysis we used a decision-tree model from a healthcare perspective with a time-horizon of one year to estimate the cost difference between iFR and FFR in a Nordic setting and a United States (US) setting. Treatment pathways and health care utilizations were constructed from the iFR-SWEDEHEART trial. Unit cost for revascularization and myocardial infarction in the Nordic setting and US setting were derived from the Nordic diagnosis-related group versus Medicare cost data. Unit cost of intravenous adenosine administration and cost per stent placed were based on the average costs from the enrolled centers in the iFR-SWEDEHEART trial. Deterministic and probabilistic sensitivity analyses were carried out to test the robustness of the result. The cost-minimization analysis demonstrated a cost saving per patient of $681 (95% CI: $641 - $723) in the Nordic setting and $1024 (95% CI: $934 - $1114) in the US setting, when using iFR-guided compared with FFR-guided revascularization. The results were not sensitive to changes in uncertain parameters or assumptions. IFR-guided revascularization is associated with significant savings in cost compared with FFR-guided revascularization. • Coronary physiology to guide revascularization improves clinical outcome. • Instantaneous wave-free ratio and Fractional flow reserve provide similar clinical outcome. • Revascularization guided by Instantaneous wave-free ratio is cost saving compared to Fractional flow reserve. [ABSTRACT FROM AUTHOR]

This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy ('drip-and-ship') for ST-segment elevation myocardial infarction (STEMI) in the United States. During 2009–2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. A total of 27,454 STEMI admissions receiving a 'drip-and-ship strategy', 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11–0.27]; p <.001) but not CA without revascularization (OR 0.72 [95% CI 0.42–1.21]; p =.21) was associated with lower in-hospital mortality. The fibrinolysis alone cohort had higher use of do-not-resuscitate status (12.8%) and fewer discharges to home (56.6%) compared to cohorts undergoing CA without (1.7%; 86.9%) and with (0.3% and 91.2%) revascularization, respectively. Presence of complications, do-not-resuscitate status, and higher comorbidity were predictive of lower CA and revascularization use. Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes. • 27,454 STEMI admissions receiving a 'drip-and-ship' strategy in the United States between 2000 and 2016. • 96% and 86% received subsequent coronary angiography and revascularization. • Use of revascularization after fibrinolysis was associated with lower in-hospital mortality. [ABSTRACT FROM AUTHOR]

The nationwide epidemiological data on Kounis Syndrome (KS), still remains indistinct in the United States (US) after it was first reported in 1991. We assessed the prevalence of KS among patients primarily hospitalized for allergic/hypersensitivity/anaphylactic reactions. We then compared baseline demographics, comorbidities, and outcomes of KS with patients with only allergic/hypersensitivity/anaphylactic reactions using the National Inpatient Sample, 2007–2014. The cohort comprised of 235,420 patients primarily hospitalized with allergy/hypersensitivity/anaphylactic reactions. Of these, 2616 [1.1%; 0.2% unstable angina, 0.2% ST-elevation myocardial infarction & 0.7% non-ST-elevation myocardial infarction] patients experienced ACS and were identified as having KS. Patients with KS were older (mean 65.9 ± 14.1 vs. 57.2 ± 17.8 yrs), more often White (71.1% vs. 58.6%), male (46.4% vs. 39.9%) and Medicare enrollees (58.9% vs. 41.5%) admitted non-electively (96.8% vs. 95.3%) as compared to non-KS group (p < 0.001). The hospitalizations with KS demonstrated higher all-cause in-hospital mortality (7.0% vs. 0.4%, p < 0.001), prolonged hospitalization stay (mean 5.8 ± 6.0 vs. 3.0 ± 3.9 days, p < 0.001), higher hospitalization charges ($52,656 vs. $20,487, p < 0.001) and more frequent transfers to other facilities. The rates of stroke (1.0% vs. 0.2%), arrhythmias (30.4% vs. 12.4%), venous thromboembolism (1.6% vs. 1.0%), and diagnostic and therapeutic coronary interventions were also found to be significantly higher in patients with KS (p < 0.05). Patients with KS had increased odds of in-hospital mortality [unadjusted OR: 18.52; 95% CI: 15.74–21.80, p < 0.001 & adjusted OR: 9.74, 95% CI: 8.08–11.76, p < 0.001] compared to non-KS group. Overall US prevalence of KS among patients hospitalized for allergic/hypersensitivity/anaphylactic reactions is 1.1% with a subsequent all-cause inpatient mortality rate of 7.0%. • Total of 235,420 hospitalizations occurred with allergic/hypersensitivity/anaphylactic reactions from 2007-2014. • Prevalence of KS among these patients was 1.1% [0.2% UA, 0.2% STEMI & 0.7% NSTEMI] with all-cause mortality of 7.0%. • KS patients were older more often White, male and admitted non-electively as compared to non-KS group. • The KS group demonstrated higher in-hospital mortality (7.0% vs. 0.4%) as compared to the non-KS group. • Rates of stroke (1.0% vs.0.2%), arrhythmia (30.4% vs. 12.4%) and VTE (1.6% vs. 1.0%) were significantly higher in KS group. • The KS group had higher rates of coronary interventions and resource utilization as compared to the non-KS group. [ABSTRACT FROM AUTHOR]

There are limited data on prolonged invasive mechanical ventilation (IMV) and tracheostomy use in intubated acute myocardial infarction with cardiogenic shock (AMI-CS) patients. Using the National Inpatient Sample, all admissions with AMI-CS requiring IMV between January 1, 2000, and December 31, 2014, were included. Prolonged IMV was defined as IMV use >96 h. Outcomes of interest included temporal trends in use of prolonged IMV and tracheostomy, in-hospital mortality, and resource utilization. In this 15-year period, 185,589 intubated AMI-CS admissions met the inclusion criteria. Prolonged IMV (>96 h) and tracheostomy use were noted in 68,544 (36.9%) and 10,645 (5.7%), respectively. Prolonged IMV and tracheostomy were used more commonly in younger patients. The cohort with prolonged IMV had higher organ failure and greater use of cardiac and non-cardiac organ support. Temporal trends showed a decline in prolonged IMV (adjusted odds ratio {aOR} 0.61 [95% confidence interval {CI} 0.57–0.65]) and tracheostomy use (aOR 0.80 [95% CI 0.70–0.90]) in 2014 compared to 2000. Prolonged IMV (aOR 0.45 [95% CI 0.44–0.47]; p < 0.001) and tracheostomy (aOR 0.28 [95% CI 0.27–0.29]; p < 0.001) were associated with lower in-hospital mortality with a decreasing trend between 2000 and 2014 in intubated AMI-CS admissions. Patients with prolonged IMV and tracheostomy use had nearly three-fold higher health care costs, and four-fold longer hospital stays. In this cohort of intubated AMI-CS admissions, prolonged IMV and tracheostomy showed a temporal decrease between 2000 and 2014. Prolonged IMV and tracheostomy use was associated with high resource utilization. • Prolonged mechanical ventilation and tracheostomy were used in 37% and 6% of admissions with cardiogenic shock complicating acute myocardial infarction. • During this 15-year national study, there was a temporal decrease in the use of prolonged mechanical ventilation and tracheostomy in this population. • Use of prolonged mechanical ventilation and tracheostomy were associated with high in-hospital and post-hospitalization resource utilization. [ABSTRACT FROM AUTHOR]

Abstract Background Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States. Methods Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients. Results A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS. Conclusions The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted. Highlights • Myocardial injury after non-cardiac surgery (MINS) is a common complication. • Patients with MINS are older and more likely to have cardiovascular risk factors. • Among patients with MINS, only 47.5% were discharged on aspirin and a statin. • Few patients with MINS are prescribed medical therapy for cardiovascular disease. [ABSTRACT FROM AUTHOR]

Background Although cerebrovascular accident (CVA) is a relatively infrequent complication of acute myocardial infarction (AMI), the occurrence of CVA in patients with AMI is associated with increased morbidity and mortality. We wanted to assess post-AMI CVA rate in the United States and identify the associated patient characteristics, comorbidities, type of AMI, and utilization of invasive procedures. Methods This is an observational study from the Nationwide Inpatient Sample, 2006-2008. Using multivariate regression models, we assessed predictive risk factors for post-AMI CVA among patients admitted for AMI. Results Among the 1,924,413 patients admitted for AMI, the overall rate of CVA was 2% (ischemic stroke: 1.47%, transient ischemic attack [TIA]: 0.35% and hemorrhagic stroke: 0.21%). In this sample of AMI patient, higher incidence of CVA was associated with: CHF (adjusted odds ratio [AOR] 1.71; 95% confidence interval [CI], 1.58-1.84,), age over 65 AOR, 1.65; 95% CI, 1.60-1.70, alcohol abuse AOR, 1.60; 95% CI, 1.49-1.73, cocaine use AOR, 1.48; 95% CI, 1.29-1.70, atrial fibrillation AOR, 1.43; 95% CI, 1.39-1.46, Black race AOR, 1.35; 95% CI, 1.30-1.40, female gender AOR, 1.32; 95% CI, 1.29-1.35, peripheral vascular disease [PVD] AOR, 1.26; 95% CI, 1.22-1.30, coronary artery bypass graft (CABG) AOR, 1.22; 95% CI, 1.17-1.27, P <0.0001, STEMI AOR, 1.17; 95% CI, 1.14-1.20 and teaching hospitals AOR, 1.09; 95% CI, 1.06-1.12. Conclusion Female gender, older age (age≥65), black ethnicity, comorbidities including CHF, PVD, atrial fibrillation as well as STEMI and undergoing CABG were associated with the highest risk of CVA post-AMI. [ABSTRACT FROM AUTHOR]

Abstract: Background: Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged≥65years with STEMI needed further investigation. Methods: We used the 2001–2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65–79 and≥80years. Results: During 2001–2010, of 4,017,367 patients aged ≥65years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65–79 and ≥80years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend <0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80years (150 versus 116, Ptrend =0.02) but not in patients aged 65–79years (63 versus 59, Ptrend =0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age≥80years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65years of age who underwent PCI for STEMI. Conclusions: In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010. [Copyright &y& Elsevier]

Abstract: Disparity in the quality of care for cardiovascular conditions as it relates to income level is well established. Our analysis of the publicly available data from the Department of Health and Human Services Hospital Compare initiative suggests that this problem also pertains to the management of acute myocardial infarction (AMI). Our analysis revealed a direct correlation between the income level and the proportion of patients meeting the ACC/AHA Guideline recommended door-to-balloon (D2B) time of 90 min or less and door-to-needle (D2N) time of 30 min or less, for primary PCI (PPCI) and fibrinolytic administration, respectively. More importantly, hospitals as a group fail to meet these guideline-recommended standards. Further work is needed in this area to better understand this disparity. [Copyright &y& Elsevier]

Abstract: The cost and length of hospitalization for acute myocardial infarction in the US are significantly higher for the Hispanic population. However, differences in comorbidities and procedure utilization do not fully explain this disparity. Additional process measures are needed to better describe these differences. [Copyright &y& Elsevier]