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Purpose: To determine the relationship between obesity and thirty-days readmission, mortality, morbidity, and health care resource utilization in patients who underwent cardiopulmonary resuscitation (CPR) during their hospitalization in the in the United States. Method: A retrospective study was conducted using the AHRQ-HCUP NRD for the year 2014. Adults (≥ 18 years) with a primary diagnosis of CPR (1), along with a secondary diagnosis of obesity were identified using ICD-9 codes as described in the literature (2). The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity, and resource use. Propensity score (PS) using the 1:1 nearest neighbor matching without replacement was utilized to adjust for confounders (3). Results: 113,394 hospital admissions among adults with a primary and secondary diagnosis of CPR were identified, of which 14.8% were obese. 1:1 PS matching was performed based on demographic and clinical characteristics. The 30-day rate of readmission among obese and non-obese with CPR were 4.94% and 2.82% (p Conclusion: In this study, obese patients admitted with CPR have a higher 30 days of readmission rate, total hospital cost, and in-hospital mortality (p

Introduction: Cardiovascular disease is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV) infected adults, and should be managed more aggressively.Prior studies highlighted treatment disparities for Acute Coronary Syndrome (ACS) among HIV patients. This study aims at examining these disparities with the latest large cohort data. Hypothesis: HIV patient with ACS are as likely to receive cardiac revascularization related procedures compared to control group. Methods: We reviewed the Nationwide Inpatient Sample from 2013 to 2016 to identify patients with diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina) to compare rates of cardiac procedures (Catheterization, Percutaneous Coronary Intervention - PCI - and Coronary Artery Bypass Graft - CABG) among groups of population of interest (control, asymptomatic HIV, symptomatic HIV). Results: Overall, 515,016 patients with primary diagnosis of ACS where identified and among them 2066 (0.40%) of ACS patients had diagnosis of HIV (asymptomatic and symptomatic). Multivariate regression analysis showed statistically significant lower procedural rates for catheterization (OR: 0.62, 95% CI: [0.52, 0.73]), PCI (OR: 0.80, 95% CI: [0.67, 0.96]) and CABG (OR: 0.70, 95% CI: [0.52, 0.93]) in symptomatic HIV compared to control group. For asymptomatic HIV patient group, no significant change of procedural rates were found compared to control group for catheterization, PCI and CABG (respectively OR: 0.90, 95% CI: [0.78, 1.05], OR: 1.13, 95% CI: [1.00, 1.26] and OR: OR: 0.87, 95% CI: [0.72, 1.04]). Conclusions: Analysis shows a treatment disparity for ACS for symptomatic HIV patients only as symptomatic HIV affected patients received less aggressive catheterization and revascularization management after ACS, compared to control group. However, this effect was not present for the asymptomatic HIV patient group.

Background: Depression poses a major health challenge to patients with cardiovascular disease. But little is known about its impact on Non-ST-elevation myocardial infarction (NSTEMI). Methods: Using the data from the 2016 National Inpatient Sample database, we identified hospitalization with a principal diagnosis of NSTEMI with or without medical history of depression. Prevalence and baseline characteristic of NSTEMI patient with or without depression was delineated. Mortality, catheterization rate, length of stay, time to catheterization were compared using multivariate linear regression with adjustment for age, sex, race, region, hospital size, Charlson Comorbidity Index, tobacco, heart failure, diabetes, and stable coronary heart disease. Results: Depression was found in 42,914 (9.11%) of total NSTEMI admission of 470,933. A higher percentage of female and a higher prevalence of hypertension, hyperlipidemia, diabetes, and smoking (table 1) was observed in the depression group. No significant association between depression and in-hospital mortality in NSTEMI patient can be found after adjustment for confounders (odds ratio 0.88, p=0.08). However, having depression was associated with lower catheterization rate (odds ratio 0.91, p Conclusion: Depression is associated with decreased catheterization rate, increased length of stay and delayed catheterization in NSTEMI patient. Further investigation of the impact of depression on NSTEMI patient is warranted.

Background: Myocarditis of different etiologies can either present with different types of already existing arrhythmias or be the cause of subsequent arrhythmias. Literature have shown that both scenarios hold worse prognosis and outcomes. Methods: We conducted a retrospective cohort study based on the 2016 National Inpatient Sample of adults (>18 years) hospitalized for acute myocarditis of any kind as the primary admitting diagnosis and atrial fibrillation (AF) as a secondary concomitant diagnosis based on ICD-10 codes. All-cause mortality was our primary outcome while length of stay, in-hospital arrhythmia of any kind requiring DCCV, acute respiratory failure, the rate of endotracheal intubation, ICD device insertion and VAD placement during the same hospital stay were our secondary outcomes. We used multivariate regression adjusted for age, sex, race, history of coronary artery disease, history of congestive heart failure, Charlson comorbidity index, hospital region, size and teaching status. STATA-15 was used for statistical analysis. Results: In 2016, there were 8,110 admissions for myocarditis (37.9% females), out of whom 315 (3.9%) had concomitant AF. Mean age was 40y (39.5y without AF, 59y with AF). Our results, table 1, showed that myocarditis with AF significantly increased all-cause mortality (6.3% [20 of 315] vs 1.6% [130 of 7,760], OR 8.28, p Conclusion: Atrial fibrillation appears to be an independent risk factor for higher all-cause mortality rate in myocarditis and is also associated with higher rate of ICD device and VAD implantation during the same hospital stay. Thus, patients with AF who are hospitalized for myocarditis mostly have worse in-hospital outcomes.

Background: Obstructive sleep apnea (OSA) is present in almost 60% of patients with cerebrovascular disease and it is an independent predictor of ischemic stroke. Yet, the impact of OSA on outcomes of ischemic stroke is unclear. Some, small cohort studies indicate increased short-term mortality, whereas larger studies, with more complex logistic regression models, show decreased in-hospital mortality. Lower mortality could be attributed to chronic intermittent episodes of hypoxia affecting the remodeling of cerebral collateral circulation. We thought to investigate outcomes in a large unselected population of patients presenting with acute ischemic stroke. Methods: In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample (NIS), we analyzed adult patients with acute ischemic stroke and OSA. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities and we included variables with p Results: A total of 95282 patients with acute ischemic stroke were identified. Patients with the associated diagnosis of OSA (5%) had a mean age of 66+/_0.2, vs 71+/_0.1, p Conclusion: Patients with OSA and ischemic stroke have a higher number of cardiovascular comorbidities. After adjustment with a complex multivariate regression model in a large population of patients, they have lower in-hospital mortality and lower incidence of hemiplegia. We also uncovered underdiagnosing of obstructive sleep apnea in National Inpatient Sample registry, which is a limitation of the study.

Background: Studies have shown that age is not an independent predictor of short-term and long-term neurological outcomes after cardiopulmonary resuscitation. These findings were reported for both in-hospital and out-of-hospital cardiac arrest. Yet, elderly patients are less aggressively treated and have higher mortality. We investigated the current outcomes and therapeutic approach in a large unselected population of patients. Methods: In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample, we analyzed patients >65 years of age with in-hospital cardiac arrest. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities such as ventricular arrhythmias and we included variables with p Results: A total of 39397 patients, who underwent in-hospital cardiopulmonary resuscitation (CPR) were identified. Patients >65 years of age (55%) had mean age of 78+/_0.06, vs 50+/_0.22, p65 years of age had higher mortality (OR=1.51, 95%CI =1.43-1.61, p65 years of age had lower length of stay (Coef. =-1.46, 95% CI=-1.85- -1.08), p Conclusion: Patients >65 years of age, who underwent in-hospital CPR had higher mortality, which could be related to lower utilization of healthcare resources and contribute to a shorter hospital stay and lower total charges. Furthermore, our study unravels lower utilization of a palliative care consult in a younger population of patients.

Introduction: Congestive Heart Failure (CHF) exacerbations are associated with high mortality rates and exact significant costs on the health care system. New guidelines, innovations in technology and novel pharmacological agents for treatment of patients admitted with CHF have been developed in the last decade. While they have been shown to improve outcomes independently, data is limited on the cumulative effects of these interventions. We investigated the impacts of these therapeutic modalities over 10 years, and hypothesized improved outcomes of in-hospital admission for CHF exacerbation. Methods: This is a retrospective cohort study using the 2004-2014 National Inpatient Sample, the largest publicly available inpatient database in the United States. We included women and men >18 years of age admitted between 2004 and 2014 with a primary diagnosis of CHF (using ICD-9 CM codes). The primary outcome was all-cause in-hospital mortality and the secondary outcomes were mean total hospital cost and mean length of stay (LOS). STATA 13.0 was used for data analysis; costs were adjusted for inflation using the Bureau of Labor Statistics calculator. Results: 2,254,286 patients were included in this study. The mean age was 72.6 years, and 1,142,923 patients were female (50.7%). The inpatient mortality rate was 3.9% in 2004 and decreased with statistical significance to 2.9% in 2014 (p-trend Conclusions: Over the course of 10 years, advances in care for patients with CHF have led to improvements in inpatient mortality rates, with marginally decreased hospital costs when inflation is taken into account. This likely reflects advances in comprehensive cardiovascular care, increasing use of evidence based guidelines, and introduction of novel medications and new therapeutic modalities.

Background: The hospitalization rates of patients with pulmonary embolism (PE) has been on the rise. However, there is limited data recognizing the etiologies and predictors of early readmission rate in this patient population. Methods: We utilized the National Readmission Database (NRD) 2013, subset of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality (AHRQ). PE was identified using ICD 9 code (415.1X) as primary diagnosis. Co-morbidities identified by “CM_” variables provided by NRD. Primary outcome was identified as predictors of 30-day readmission rates and secondary outcomes as the leading etiologies and trends of readmission rate. To identify predictors of outcome, a two level hierarchical logistical model was used. Results: We analyzed 76,994 patients with primary diagnosis of PE. Total of 11.6% (8,934) patients were readmitted within 30 days of index hospitalization. Significant predictors of readmission were associated with end stage renal disease, drug abuse, chronic lung disease, congestive heart failure, and gastrointestinal bleed during primary admission. In addition, female gender, those admitted to teaching hospital and with longer length of stay (LOS) had higher 30-day readmission rate. Remarkably, elderly age (age>75 years) was not associated with increase in readmission rates. The leading etiologies besides DVT/PE for readmission were sepsis/septic shock, cancer, heart failure and pneumonia. Conclusion: The rising hospitalization rate of patients with pulmonary embolism, imposes a higher burden on the cost of health care. We identified important predictors and etiologies of 30-day readmission rate. These findings may help in prevention of hospital readmissions and may decrease the cost of care.

We describe our experience with the Advanced Cardiac Admission Program (ACAP) at our institution. The ACAP program is a hospital-wide implementation of critical pathways-based management of all cardiac patients. Data review of patients admitted for acute coronary syndromes from the ACAP–PAIN database and a comparative study of outcomes before and after implementation of the pathways-based assessment and treatment protocols. In the pre-ACAP and post-ACAP patient groups, antiplatelet use at admission improved from 50% to 75% (p

Subacute pericardial tamponade can present without signs of cardiogenic shock. Symptoms and signs lack both sensitivity and specificity.We conducted a case-control study in consecutive hospitalized patients with moderate-to-large pericardial effusion who had no evidence of hemodynamic compromise upon admission. Patients with pericardial effusion drained for diagnostic and/or therapeutic purposes served as cases, and patients who were not drained served as controls. Demographic, clinical, and laboratory data were obtained by retrospective chart review. Echocardiograms were reviewed by 2 independent observers. Pericardial effusion scoring index was calculated for each patient based on effusion size, echocardiographic assessment of hemodynamics, and clinical factors.A total of 48 patients were included in the study: 27(56%) patients had pericardial effusion drained and 21(44%) had clinical follow-up without drainage. Pericardial effusion drainage was surgical in 60% of the cases with the mean time to drainage of 2.5 days. No significant difference was seen between the groups in terms of clinical hemodynamic parameters such as blood pressure or heart rate upon initial presentation. The mean pericardial effusion scoring index was 6.0 for cases and 3.3 for controls showing a wide separation between the groups (P0.01). The area under the curve for receiver operator characteristic was 0.91 (95% confidence interval, 0.82-1.00).The pericardial effusion scoring index obtained at the initial presentation in patients without immediate hemodynamic compromise showed a high accuracy in identifying patients who required pericardial effusion drainage downstream.

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

The estimated number of out-of-hospital care arrest cases is about 300,000 per year in the United States. Two landmark studies published in 2002 demonstrated that the use of therapeutic hypothermia after cardiac arrest decreased mortality and improved neurologic outcome. Based on these studies, the International Liaison Committee on Resuscitation and the American Heart Association recommended the use of therapeutic hypothermia after cardiac arrest. Therapeutic hypothermia is defined as a controlled lowering of core body temperature to 32 degrees C to 34 degrees C. This temperature goal represents the optimal balance between clinical effect and cardiovascular toxicity. Therapeutic hypothermia does require resources to implement-including device, close nursing care, and monitoring. It is important to select patients who have potential for benefit from this technique which is a limited resource and carries potential complications. A collaborative team approach involving physicians and nurses is critical for successful development and implementation of this kind of a protocol. In 2004, the "Advanced Cardiac Admission Program" was launched at the St. Luke's Roosevelt Hospital Center of Columbia University in New York. The program consists of a series of projects, which have been developed to bridge the gap between published guidelines and implementation during "real world" patient care. In this article, we are reporting our latest project for the comprehensive management of survivors of out-of-hospital cardiac arrest. The pathway is divided into 3 steps: Step I, From the field through the emergency department into the cardiac catherization laboratory and to the critical care unit; Step II, Induced invasive hypothermia protocol in the critical care unit (this step is divided into 3 phases: 1, invasive cooling for the first 24 hours; 2, rewarming; 3, maintenance); Step III, Management post the rewarming phase including the recommendation for out-of-hospital therapy and the ethical decision to define goal of care. We hope that this novel pathway will bridge the gap between the complex guidelines and the actual clinical practice and will improve the survival and neurologic condition of patients suffering cardiac arrest.

About 65 million Americans, one fourth of the adult population in the United States, and over 1 billion people worldwide have hypertension (HTN). HTN therefore is present in 1 of every 4 patients admitted to any US hospital. Surprisingly, no guidelines are available for the management of inpatient HTN. Based on a comprehensive search of the literature we are proposing a pathway for the management of HTN in nonpregnant hospitalized patients. The pathway provides a definition and clinical assessment of HTN for patients admitted to the hospital. The assessment is followed by an organ/system based therapeutic approach specifying timing, blood pressure goals, recommended antihypertensive drug therapy and the sequence of add-on drugs. The pathway specifically discusses assessment and management of HTN in patients with (1) acute aortic syndrome, (2) acute neurologic syndrome, (3) acute coronary syndrome, (4) congestive heart failure, (5) renal failure, and (6) secondary forms. Finally, the pathway provides a step by step recommendation for the management of in hospital HTN and of hypertensive emergencies.

Introduction: Implantable cardioverter defibrillators (ICD) prolong survival in patients with heart failure, reduced left ventricular ejection fraction (LVEF Methods: PubMed database was queried to identify prospective randomized controlled trials comparing class III antiarrhytmics to placebo on a standard background medical therapy in patients with an ICD and prior history of sustained VA (spontaneous/ treated/ induced) and/or sudden cardiac death. Information on appropriate ICD therapy, hospitalization and mortality was extracted. Fixed effect analysis was used when I2 ≤ 25% and p >0.1, otherwise random effect analysis was performed. Results: After reviewing 2931 articles, seven trials that studied Amiodarone, Sotalol, Azimilide or Celivarone were included. A total of 2117 patients (87% males, mean age 63.8 years, mean LVEF 32.8%) were analyzed. 50.6% of the patients had at least one appropriate ICD therapy delivered and 4.5% died during the follow up. Antiarrhythmic drug usage significantly reduced the number of patients receiving ICD therapy by 55% (OR=0.45, 95% confidence interval [CI] 0.26-0.77, P=.004). There was no significant difference in mortality between treatment and placebo arms. Only 2 of the 7 trials reported number of hospitalizations and the sample size was insufficient for analysis. Conclusions: Class III antiarrhythmics significantly reduced ICD therapy for VA with no significant change in mortality.

Background: Advanced cardiac life support is a corner stone in the management of cardiac arrest and epinephrine is an important part of its armamentarium. Randomized controlled trials and observational studies have demonstrated inconsistent results regarding the benefits of epinephrine in out-of-hospital cardiac arrest. We conducted a meta-analysis to evaluate mortality and neurological outcomes. Methods: All randomized controlled trials regarding out of hospital cardiac resuscitation were sought using PubMed and Scopus databases from 1963 until June 2015. We calculated the chances of patients surviving to hospital admission and through discharge as well as having a good neurological outcome. Data was analyzed with RevMan 5.2 software. Results: Epinephrine was found to be associated with a higher rate of hospital arrival but not survival to discharge. Epinephrine also had numerically less favorable neurologic outcomes neurological but despite that this was seen in all trials this did not reach statistical significance (OR 0.71, CI95% 0.45-1.12, p 0.14). Conclusion: There is no data to support the use of epinephrine in out-of-hospital cardiac arrest patients. Increased unjustified financial and perhaps social costs seem to be present. Larger randomized controlled trials are needed.

Inhospital morbidity and mortality are increased in hyperglycemia. Normalization of blood glucose levels using intensive insulin infusion protocols improves clinical outcomes. Insulin infusion algorithms have been shown to be safe and effective; however, a major obstacle in their implementation is their complexity. We have developed a novel pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing complemented by "catchup" insulin dosing. The "wheel" serves as a treatment guide. It is made up of 4 concentric circles. The inner circle features blood glucose ranges and the 3 outer circles correspond to increasing rates of insulin infusion. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the critical care unit setting. Our protocols eliminate reliance on the familiar "sliding scale" insulin administration schemes with the introduction of "catchup" insulin dosing to supplement the basic regimen. This pathway is comprehensive yet simple and provides guidelines for treatment of hyperglycemia for all patients screened to a critical care unit or to a stepdown unit.

Acute heart failure poses a major healthcare problem. Recent guidelines for heart failure address management of outpatient chronic heart failure but do not address inpatient management. We present a unique, simple, yet comprehensive pathway that focuses on the differential diagnosis of new-onset heart failure and acute decompensation of chronic heart failure. An algorithm is presented for the optimal management of the patient with chronic heart failure who presents to the emergency room with acute symptomatic decompensation. The treatment algorithm provides recommendations for daily management and adjustments of therapy, which is primarily focused on a safe and rapid diuresis to the point of discharge from the acute care setting.

Background: Bare metal stents (BMS) are a reasonable option even in the modern era of superior outcomes with 2nd generation drug eluting stents mainly because of the need for short term dual antiplatelet platelet therapy (DAPT). Current guidelines recommend a minimum of 1 month of DAPT following BMS use. The safety of limiting DAPT to one month has not been clearly established. Methods: We searched PubMed, Scopus and ClinicalTrials.gov databases till May 2014 for randomized clinical trials (RCTs) that compared short ( 6 months) after BMS. Risks ratios (RRs) with 95% confidence interval (CI) for the composite outcome of cardiac death or myocardial infarction (MI) and for major bleeding were calculated using random-effects model. Results: We included 3 RCTs in this analysis. A total of 2654 patients received short term DAPT and 2612 patients received long term DAPT (9 to 24 months). The rates of cardiac death or MI were significantly higher in the short-term DAPT group (9.1%) compared to the prolonged DAPT group (7.0%)which corresponds to a 30% increase in the risk of cardiac death or MI (RR: 1.30, 95% CI: 1.08 to 1.57; p=0.005, figure). On the other hand, short-term DAPT was associated with numerically lower major bleeding events (4.0% vs 5.0%) when compared with prolonged DAPT but this did not reach statistical significance (p=0.06). Conclusion: Short-term DAPT as compared with prolonged treatment is associated with an increased risk of cardiac death or MI.

Background: In the US, 2 million people are evaluated for syncope annually. Published literature shows that of all ethnicities, African Americans (AA) are more likely to have comorbidities like hypertension, diabetes & lifestyle risk factors that translate to poorer outcome. Having published short-term outcomes showing worse outcome for AA with syncope, we followed up these patients over 5 years to evaluate long-term outcomes. Methods: 3044 patients were prospectively followed after presenting with syncope. Patients were separated into five ethnic groups: Caucasians(30%), AA(30%), Hispanics(20%), Asians(3%) and others(17%). Patients or relatives were interviewed at least yearly during the follow-up period of 5 years. The primary endpoint was a composite of readmission for syncope, myocardial infarction, stroke or death. Results: AA were older with mean age of 68±20 years, had hypertension (72% vs. 60%, p Conclusions: AA who are admitted with unexplained syncope are identified according to the SELF pathway as high risk group that can likely be attributed to the presence of comorbidities and warrants hospitalization for further work-up and optimizing medical management.

Background: According to the design of published and validated SELF pathway, patients with syncope are stratified according to the SELF-1 criteria (Short period, Early-rapid onset, Loss of consciousness, Full recovery) and SELF-2 Criteria (Structural heart disease, abnormal electrocardiogram, and arrhythmia/AFib/AFl). Methods: 3044 patients were prospectively followed after presenting to our emergency department for the evaluation of syncope. Patients were divided into four groups: Group A (SELF +/+) who met both SELF-1 and 2 criteria, Group B (SELF +/-) who met SELF-1 criteria but not SELF-2, Group C (SELF -/+) who met SELF-2 criteria but not SELF-1 and Group D (SELF -/-) who met neither SELF criteria. The primary endpoint was a composite of readmission for syncope, myocardial infarction (MI), stroke or death. Follow-up was 5 years. Results: Group A included 1001 patients (33%), Group B included 359 patients (12%), Group C had 880 patients (29%) and Group D had 804 patients (26%). Patients who met SELF-2 criteria, i.e., patients in Groups A and C, had significantly worse outcome (Group A: HR 1.85; 95% CI: 1.47-2.36; p Conclusions: Using the SELF-pathway for patients presenting with syncope effectively identifies high risk patients who merit hospitalization and close follow-up post-discharge. These include patients with structural heart disease, abnormal EKG and abnormal telemetry, as well as patients with diabetes, CAD and CHF. This has important implications for the evaluation of a common disease that poses a significant economic burden on healthcare systems.

Background: The ACAP program consists of strategies for implementing ACC/AHA guidelines for various cardiac disorders, one of which is the SELF pathway, which covers the spectrum of care from presentation to discharge in patients with syncope. Patients are stratified according to SELF-1 (Short period, Early onset, Loss of consciousness, Full recovery) and SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia). Methods: 3044 patients were prospectively followed for syncope. They were divided into 4 groups: Group A (SELF +/+) who met both SELF 1 and 2 criteria, Group B (SELF +/-) who met SELF-1 criteria but not SELF-2, Group C (SELF -/+) who met SELF-2 criteria alone and Group D (SELF -/-) who met neither criteria. These groups were further separated into males and females. The primary endpoint was composite of readmission for syncope, myocardial infarction, stroke or death. Follow-up was 5 years. Results: Females were older than males (69+/-21 years), had more hypertension (65% vs. 63%) and syncopal episodes (18% vs. 16%). Males were more likely to be diabetic (25% vs. 24%), have coronary artery disease (21% vs. 16%; p=0.001), heart failure (11% vs. 9%) and smoking (65% vs. 42%; p Conclusions: The SELF-pathway for patients with syncope helps identify at-risk subgroups in our patient population. Females with SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia) had significantly worse long-term outcome compared to males regardless of manner of syncopal presentation.

Background: Coronary Computed Tomography Angiography (CCTA) has been deemed appropriate to use in evaluating chest pain in the emergency department (ED). However, concerns remain regarding downstream resource utilization post CCTA. We performed a meta-analysis of existing studies to address whether there is an increase in downstream testing in patients undergoing CCTA vs. the standard of care. Methods: We performed a search of PubMed and Scopus databases from 1966 through October 2012. We evaluated the number of hospital readmissions and subsequent visits to the ED after the initial evaluation. In addition, we evaluated the total number of left heart cardiac catheterizations (CATH), and the need for late non-invasive tests. We used fixed effect analysis when the I 2 was up to 50% and the P at least 0.05, otherwise we used random effect. Results: Out of 2333 articles, 4 randomized controlled trials and 3 prospective studies with control groups were included in the analysis. Out of 4466 patients, 2508 underwent CCTA as the initial test and 1958 were assigned to standard of care (SOC) as defined by the investigators which included evaluation with stress testing. In patients evaluated with CCTA, there was a 36% reduction in the chance of future hospital admissions (OR: 0.64, 95%CI: 0.41-0.99; p=0.04) (Figure) and a trend towards fewer ED revisits (OR: 0.63, 95%CI: 0.38-1.07, p=0.09). The total CATH and late non-invasive testing utilization was similar among the groups (p=0.48 and 0.32). Conclusions: A meta-analysis of the existing literature suggests that the use of CCTA to evaluate chest pain in the ED results in a reduction in hospital readmissions and ED revisits without an increase in downstream testing.

Background: Due to the population aging, atrial fibrillation (AF) is becoming a more prevalent disease, it also commonly presents as a cardiac surgery complication. Randomized controlled trials (RCT) concerning anti-oxidant vitamins for atrial fibrillation (AF) prophylaxis have yielded inconsistent outcomes. Similar inconsistencies were found in other cardiovascular studies, as the HOPE and FATS studies, suggesting that vitamin E in special may not be helpful, perhaps harmful. Methods: All randomized controlled trials on anti-oxidant vitamins supplementation for atrial fibrillation prevention for patients undergoing cardiac surgery were sought in Medline and Cochrane databases during May 2012. Data was extracted by 3 reviewers. Results: Seven studies were found, three with vitamin C, two with Vitamin E and two combining both. We found an overall significant 60% decrease in the overall chance for AF occurrence mostly driven by (Figures1A and 1B) as the studies with vitamin E or vitamin C and E combined (Figures 1 C and 1D) did not show a statistically significant difference. When all studies with Vitamin E alone or in combination with Vitamin C (Figure 1E). Conclusions: Vitamin C supplementation decreases the incidence of post cardiac surgery AF but the data on Vitamin E is inconsistent, it may even decrease the Vitamin C benefit. As vitamin self-supplementation is extremely common in the US, large trials are extremely important not only for benefit confirmation but to exclude potential harms.

Background: We developed a novel pathway for management of patients with Acute Coronary Syndrome (ACS), designed with the acronym of PAIN (P) Priority Risk, (A) Advanced Risk, (I) Intermediate Risk, and (N) Negative Risk that reflects patients most immediate risk stratification upon admission. Our objective was to compare the patient risk stratification upon admission using the PAIN pathway to the Framingham Risk Score (FRS). Methods: A total of 6911 ACS patients admitted to a NYC hospital from Sept., 2004, to Dec., 2010, were enrolled in our prospective ACAP-ACS registry. Patients were stratified and treated according to the PAIN pathway. Mean risk factors for patients in the PAIN pathway were compared with the FRS. Results: The study population consisted of 3761 men (54%) with a mean age 60 ± 14 years and 3150 women (46%) with mean age 66 ± 15 years. On initial stratification P patients had 3.01 traditional risk factors, A patient had 3.50, I patients with 4.3 risk factors, and N patient had 1.9, P Conclusion: I patients according to our PAIN pathway had more risk factors which correlate with a higher risk for future cardiac events as calculated from the Framingham Risk Score. H population would benefit the most from a more aggressive intervention compared to others.

BACKGROUND: To look for the association between Insurance coverage (IC) and Long term Outcomes (O) after discharge following ACS admission from ACAP-PAIN (AP) registry. METHODS: The AP registry had 5526 hospitalized patients admitted with a diagnosis of ACS enrolled between 2006-2010. Long-term outcomes (composite of death, AMI, and ACS readmission) were evaluated during a Follow-up period of 4 yrs. Patients were stratified into 5 medical insurance groups: Government (Gov) (n = 2571), Managed Government (MGov) (n = 1229), HMO (n = 630), Commercial (Com) (n = 863), and other (O) (n = 233). RESULTS: Composite endpoint at the end of the follow up was seen in 29%, 23%, 16%, 15%, and 12%, (p CONCLUSIONS: The results of this population-based study demonstrate that ACS patients with any government insurance status have an increased long term morbidity and mortality. This may be explained at least partially by the patients’ characteristics.

Background: According to the design of our SELF pathway, patients are stratified twice using the acronyms SELF-A (Short period, Early-rapid onset, Loss of consciousness, Full recovery) and SELF-B (Structural heart disease, abnormal Ecg, and arrhythmia Fib/FL). We assessed the short and Long-term outcome according to this approach. Methods: 1468 patients were prospectively followed after presenting to our emergecy department for the evaluation of syncope. Patients were divided into Group I (SELF +/+) who met both SELF A and B criteria and group II (SELF -/-) who didnot meet these criteria.The primary endpoint was a composite of readmission for syncope, myocardial infarction (MI), stroke or death. Follow-up was 494 ± 120 days. Results: 644 (44%) patients were included in group I and 824 (64%) patients in group II. Group I were older (73 ± 15 years vs. 58 ± 22 years), with more evidence of hypertension (74% vs. 41%), diabetes (24% vs. 15%), heart failure (15% vs. 5%), and coronary disease (26% vs. 10%); p Conclusions: Using the SELF-pathway for patients presenting with syncope effectively identifies high risk patients who merit hospitalization for further work-up. This has important implications for the evaluation of a common disease that poses a significant economic burden on healthcare systems.

Background: The OESIL risk score for the evaluation of syncope is widely used and is based on the presence of 4 risk factors: abnormal ECG, a previous history of cardiovascular diseases, absence of prodromal symptoms, and age greater than 65 years. We assessed the appropriateness of our novel SELF-SYNCOPE pathway in comparison to this score. Methods: According to the design of our syncope pathway, patients are risk stratified twice using the acronyms of SELF-A (Short period, Early-rapid onset, Loss of consciousness, Full recovery) and SELF-B (Structural heart disease, abnormal Ecg, and arrhythmia Fib/FL). 1462 patients were prospectively followed and were divided into four groups according to having SELF-A and SELF-B criteria. 762 patients met group I (SELF A+/B+) and group IV (SELF A-/B-) and were compared to the OESIL risk score. Results: Group I patients were older and more likely to have hypertension (74% vs. 45%), diabetes (25% vs. 16%), heart failure (9% vs. 3%), and coronary disease (21% vs. 4%); p Conclusions: Using a simple novel pathway for patients presenting with unexplained syncope effectively identifies high risk patients as validated by the OESIL risk score.

Background: Syncope results in emergency department (ED) visits and hospital admissions. African-American (AA) patients often have multiple co-morbidities that translate to poorer outcome. We thought to evaluate the effect of AA race on outcome in patients with unexplained syncope. Methods: We evaluated 902 consecutive patients with unexplained pre-syncope/syncope between September 2007 and January 2009; all patients were enrolled in a prospective institutional registry. The primary endpoint was a composite of readmission for syncope, myocardial infarction (MI), stroke or death. In this study, we compared the outcome of AA to non African-American patients (non-AA). Results: There were 252 (28%) AA patients and 650 (72%) non-AA patients. When compared to non-AA patients, AA patients were older (64 ± 20 years vs. 59 ± 23 years, p Conclusions: African-American patients presenting with unexplained syncope have significantly worse 1-year outcome than non-AA. This is likely due in part to a higher incidence of significant co-morbidities in AA patients.

PURPOSE To compare the utilization of evidence-based (EB) cardiac therapies and clinical outcomes of cardiac care on general medicine inpatient services under teaching and nonteaching services at an academic hospital. METHODS In 2005 we implemented the Advanced Cardiac Admission Protocol (ACAP) for all cardiac patients admitted to our hospital. 4170 patients were admitted with ACS or HF were assigned to a resident-staffed teaching service ( n = 3890) or to a hospitalist-nonteaching service ( n = 280). We compared utilization of EB therapies, hospital readmission rate at 30 days, length of hospital stay (LOS), and all-cause mortality at 90 days. RESULTS The cohort mean age was 63 ± 15 years, 55% males. 34% had diabetes, 74% were hypertensive and 41% had hyperlipidemia. Mean LVEF was 50 ± 22% and mean TIMI risk score was 2.7 ± 1.5. There were no difference between both services in regards to the utilization of all EB therapies, BB (62 vs. 63%), ACEi (56 vs. 57%), ASA (83 vs. 80%), anticoagulation (58 vs. 63) and Statins (68 vs. 67%). Clinical outcomes including LOS (4.95 days vs. 5.14 days; P = .24), readmission rate (10.5% vs. 11%; P = .21), and all-cause mortality (4.0% vs. 3.4%; P = .64) were similar. CONCLUSIONS At our academic hospital, implementation of a standardized novel pathway for cardiac patients led to comparable outcomes between teaching and nonteaching services.

The management of patients after cardiac arrest is a prominent example of complexity on many levels of decisions. We designed a pathway for the management of survivors of cardiac arrest, guiding such decisions as cardiac catheterization, induction of therapeutic hypothermia, placement of defibrillator, and ethical decision making for life support. Our pathway outlines the comprehensive management of patients from the field through the emergency room, the cardiac catheterization laboratory, the cardiac care unit, step down unit, and the rehabilitation center. Involving patients and their families is a novel addition to a clinical pathway. We used the power of survivors' stories to inspire and educate clinicians in the utility of our multidisciplinary pathway approach. This approach may serve as a model for patient-centered care in medicine.