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Background: Regional variation in the incidence and outcomes of in-hospital cardiac arrest (IHCA) is not well studied and may have important health and policy implications., Methods and Results: We used the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients≥18 years of age who underwent cardiopulmonary resuscitation (International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes 99.60 and 99.63) for IHCA. Regional differences in IHCA incidence, survival to hospital discharge, and resource use (total hospital cost and discharge disposition among survivors) were analyzed. Of 838,465 patients with IHCA, 162,270 (19.4%) were in the Northeast, 159,581 (19.0%) were in the Midwest, 316,201 (37.7%) were in the South, and 200,413 (23.9%) were in the West. Overall IHCA incidence in the United States was 2.85 per 1000 hospital admissions. IHCA incidence was lowest in the Midwest and highest in the West (2.33 and 3.73 per 1000 hospital admissions, respectively). Compared with the Northeast, risk-adjusted survival to discharge was significantly higher in the Midwest (odds ratio, 1.33; 95% confidence interval, 1.31-1.36), South (odds ratio, 1.21; 95% confidence interval, 1.19-1.23), and West (odds ratio, 1.25; 95% confidence interval, 1.23-1.27). IHCA survival increased significantly from 2003 to 2011 in the United States and in all regions (all Ptrend<0.001). Total hospital cost was highest in the West, whereas discharge to skilled nursing facility and use of home health care among survivors was highest in the Northeast., Conclusions: We observed significant regional variation in IHCA incidence, survival, and resource use in the United States. This variation was explained only partially by differences in patient and hospital characteristics. Further studies are needed to identify other potential factors responsible for these regional differences to improve outcomes after IHCA., (© 2015 American Heart Association, Inc.)

Acute myocardial infarction in patients with end-stage renal disease (ESRD) is associated with increased risk of morbidity and mortality. Limited data are available on the contemporary trends in management and outcomes of ST-elevation myocardial infarction (STEMI) in patients with ESRD. We analyzed the 2003 to 2011 Nationwide Inpatient Sample databases to examine the temporal trends in STEMI, use of mechanical revascularization for STEMI, and in-hospital outcomes in patients with ESRD aged ≥18 years in the United States. From 2003 to 2011, whereas the number of patients with ESRD admitted with the primary diagnosis of acute myocardial infarction increased from 13,322 to 20,552, there was a decrease in the number of STEMI hospitalizations from 3,169 to 2,558 (ptrend <0.001). The overall incidence rate of cardiogenic shock in patients with ESRD and STEMI increased from 6.6% to 18.3% (ptrend <0.001). The use of percutaneous coronary intervention for STEMI increased from 18.6% to 37.8% (ptrend <0.001), whereas there was no significant change in the use of coronary artery bypass grafting (ptrend = 0.32). During the study period, in-hospital mortality increased from 22.3% to 25.3% (adjusted odds ratio [per year] 1.09; 95% confidence interval 1.08 to 1.11; ptrend <0.001). The average hospital charges increased from $60,410 to $97,794 (ptrend <0.001), whereas the average length of stay decreased from 8.2 to 6.5 days (ptrend <0.001). In conclusion, although there have been favorable trends in the utilization of percutaneous coronary intervention and length of stay in patients with ESRD and STEMI, the incidence of cardiogenic shock has increased threefold, with an increase in risk-adjusted in-hospital mortality, likely because of the presence of greater co-morbidities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: The clinician arriving at the hospital in the morning may not yet be aware of key overnight clinical activity. To address this situation at our facility, we modified our handoff software to permit continuous updating of clinical information and the automatic relay of important overnight clinical updates to relevant providers each morning., Methods: Cross-covering residents electronically entered safety concerns and clinical issues within the reporting module of the handoff software between 5 PM and 7 AM. This updated their handoff-information at shift change and permitted the generation of reports that were emailed to primary providers and reviewed before 7 AM prerounds. At 7:30 sign-out, if a resident was already aware of an issue being signed out, he/she indicated this so that sign-out could quickly proceed to the next patient. Study sign-out duration was recorded, and residents were surveyed regarding the new communication system., Results: Morning sign-out duration decreased from 25.5 to 22.7 minutes (P = 0.0338). All respondents agreed strongly (12/14, 86%) or somewhat (2/14, 14%) that daily morning events reports prevented "loss of key information between shifts" and enhanced safety greatly (10/14, 71%) or moderately (4/14, 29%).All agreed either strongly (10/14, 71%) or somewhat (4/14, 29%) that the daily report improved the quality of handoff information and strongly (12/14, 86%) or somewhat (2/14, 14%) that the report was convenient., Conclusions: The collection of key clinical handoff information and its automatic forwarding to incoming providers reduced the average duration of resident morning sign-out and significantly enhanced provider perceptions regarding patient safety and the quality of handoff information.

Ranolazine was developed as an antianginal agent and was approved by the Food and Drug Administration in 2006 for use in chronic stable angina pectoris. Experimental and clinical studies have shown that it also has antiarrhythmic properties based on the frequency-dependent blockade of peak sodium channel current (peak INa) and rapidly activating delayed rectifier potassium current (IKr) in the atria and blockade of late phase of the inward sodium current (late INa) in the ventricles. Recent clinical studies have revealed the efficacy of ranolazine in prevention of atrial fibrillation in patients with acute coronary syndromes, prevention as well as conversion of postoperative atrial fibrillation after cardiac surgery, conversion of recent-onset atrial fibrillation and maintenance of sinus rhythm in recurrent atrial fibrillation. Ranolazine has also been shown to reduce ventricular tachycardia and drug-refractory implantable cardioverter defibrillator shocks. The antiarrhythmic effect of ranolazine is preserved in the setting of chronic heart failure and clinical studies have demonstrated its safety in patients with heart failure. This review discusses the available preclinical and clinical data on the antiarrhythmic effects of this novel antianginal agent., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Reporting of clinically significant events represents an important mechanism by which patient safety problems may be identified and corrected. However, time pressure and cumbersome report entry procedures have discouraged the full participation of physicians. To improve the process, our internal medicine training program developed an easy-to-use mobile platform that combines the reporting process with patient sign-out., Methods: Between August 25, 2011, and January 25, 2012, our trainees entered clinically significant events into i-touch/i-phone/i-pad based devices functioning in wireless-synchrony with our desktop application. Events were collected into daily reports that were sent from the handoff system to program leaders and attending physicians to plan for rounds and to correct safety problems., Results: Using the mobile module, residents entered 31 reportable events per month versus the 12 events per month that were reported via desktop during a previous 6-month study period., Conclusions: Advances in information technology now permit clinically significant events that take place during "off hours" to be identified and reported (via handoff) to next providers and to supervisors via collated reports. This information permits hospital leaders to correct safety issues quickly and effectively, while attending physicians are able to use information gleaned from the reports to optimize rounding plans and to provide additional oversight of trainee on call patient management decisions.

Background: There is a paucity of data regarding the complications and in-hospital mortality after catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease., Objective: The purpose of this study was to determine the temporal trends in utilization, in-hospital mortality, and complications of catheter ablation of postinfarction VT in the United States., Methods: We used the 2002-2011 Nationwide Inpatient Sample (NIS) database to identify all patients ≥18 years of age with a primary diagnosis of VT (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 427.1) and who also had a secondary diagnosis of prior history of myocardial infarction (ICD-9-CM 412). Patients with supraventricular arrhythmias were excluded. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Temporal trends in catheter ablation, in-hospital complications, and in-hospital mortality were analyzed., Results: Of 81,539 patients with postinfarct VT, 4653 (5.7%) underwent catheter ablation. Utilization of catheter ablation increased significantly from 2.8% in 2002 to 10.8% in 2011 (Ptrend < .001). The overall rate of any in-hospital complication was 11.2% (523/4653), with vascular complications in 6.9%, cardiac in 4.3%, and neurologic in 0.5%. In-hospital mortality was 1.6% (75/4653). From 2002 to 2011, there was no significant change in the overall complication rates (8.4% to 10.2%, Ptrend = .101; adjusted odds ratio [per year] 1.02, 95% confidence interval 0.98-1.06) or in-hospital mortality (1.3% to 1.8%, Ptrend = .266; adjusted odds ratio [per year] 1.03, 95% confidence interval 0.92-1.15)., Conclusion: The utilization rate of catheter ablation as therapy for postinfarct VT has steadily increased over the past decade. However, procedural complication rates and in-hospital mortality have not changed significantly during this period., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: The influence of admission source (nursing home [NH] versus community-dwelling) on treatment strategies and outcomes among elderly patients with ST-elevation myocardial infarction (STEMI) has not been investigated., Participants: Nationwide Inpatient Sample databases from 2003 to 2010 were used to identify 270,117 community-dwelling and 4082 NH patients 75 years of age or older with STEMI., Design: Retrospective observational study., Measurements: Propensity scores for admission source were used to assemble a matched cohort of 3081 community-dwelling and 3132 NH patients, who were balanced on baseline demographic and clinical characteristics. Bivariate logistic regression models were then used to determine the associations of NH with in-hospital outcomes among matched patients., Results: In-hospital mortality was significantly higher in patients with STEMI presenting from a NH as compared with community-dwelling patients (30.5% versus 27.6%; odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03-1.29; P = .012). Overall, NH patients were less likely to receive reperfusion (thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting) (11.5% versus 13.4%; OR 0.84, 95% CI 0.72-0.98; P = .022). However, rates of percutaneous coronary intervention alone were similar in both groups (9.9% in NH versus 9.1% in community-dwelling; OR 1.10, 95% CI 0.93-1.30; P = .276). Mean length of stay was also similar in both groups (5.68 ± 5.40 days in NH versus 5.69 ± 4.98 days in community-dwelling, P = .974)., Conclusion: Compared with their community-dwelling counterparts, older NH patients are less likely to receive reperfusion therapy for STEMI and have higher in-hospital mortality., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States., Methods and Results: We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978)., Conclusions: There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p<0.001) and ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (24.3% vs 20.5%, p<0.001). Smokers had a higher rate of survival to hospital discharge compared with nonsmokers (28.2% vs 24.1%, adjusted odds ratio 1.06, 95% confidence interval 1.05 to 1.08, p<0.001). Smokers were less likely to have a poor neurologic status after IHCA compared with nonsmokers (3.5% vs 3.9%, adjusted odds ratio 0.92, 95% confidence interval 0.89 to 0.95, p<0.001). In conclusion, among patients aged ≥18 years who underwent CPR for IHCA, we observed a higher rate of survival in smokers than nonsmokers-consistent with the "smoker's paradox." Smokers were also less likely to have a poor neurologic status after IHCA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Magnesium, the fourth most abundant cation in the human body, is involved in several essential physiological, biochemical, and cellular processes regulating cardiovascular function. It plays a critical role in modulating vascular smooth muscle tone, endothelial cell function, and myocardial excitability and is thus central to the pathogenesis of several cardiovascular disorders such as hypertension, atherosclerosis, coronary artery disease, congestive heart failure, and cardiac arrhythmias. This review discusses the vasodilatory, anti-inflammatory, anti-ischemic, and antiarrhythmic properties of magnesium and its current role in the prevention and treatment of cardiovascular disorders.

Background: The reported incidence of peripartum cardiomyopathy (PPCM) in the United States varies widely. Furthermore, limited information is available on the temporal trends in incidence and outcomes of PPCM., Methods and Results: We queried the 2004-2011 Nationwide Inpatient Sample databases to identify all women aged 15 to 54 years with the diagnosis of PPCM. Temporal trends in incidence (per 10 000 live births), maternal major adverse events (MAE; defined as in-hospital mortality, cardiac arrest, heart transplant, mechanical circulatory support, acute pulmonary edema, thromboembolism, or implantable cardioverter defibrillator/permanent pacemaker implantation), cardiogenic shock, and mean length of stay were analyzed. From 2004 to 2011, we identified 34 219 women aged 15 to 54 years with PPCM. The overall PPCM rate was 10.3 per 10 000 (or 1 in 968) live births. PPCM incidence increased from 8.5 to 11.8 per 10 000 live births (Ptrend<0.001) over the past 8 years. MAE occurred in 13.5% of patients. There was no temporal change in MAE rate, except a small increase in in-hospital mortality and mechanical circulatory support (Ptrend<0.05). Cardiogenic shock increased from 1.0% in 2004 to 4.0% in 2011 (Ptrend<0.001). Mean length of stay decreased during the study period., Conclusion: From 2004 to 2011, the incidence of PPCM has increased in the United States. Maternal MAE rates overall have remained unchanged while cardiogenic shock, utilization of mechanical circulatory support, and in-hospital mortality have increased during the study period. Further study of the mechanisms underlying these adverse trends in the incidence and outcomes of PPCM are warranted., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Regional differences in the treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI) within the United States remain poorly understood., Hypothesis: Treatment choice and outcomes in patients with STEMI differ between regions within the United States., Methods: We used the 2003 to 2010 Nationwide Inpatient Sample databases to identify all patients age ≥ 40 years hospitalized with STEMI. Patients were divided into 4 groups according to region: Northeast, Midwest, South, and West. Multivariable logistic regression was used to identify differences in treatment choice and outcomes (in-hospital mortality, acute stroke, and cardiogenic shock) among the 4 regions., Results: Of 1,990,486 patients age ≥ 40 years with STEMI, 350,073 (17.6%) were hospitalized in the Northeast, 483,323 (24.3%) in the Midwest, 784,869 (39.4%) in the South, and 372,222 (18.7%) in the West. Compared with the Northeast, patients in the Midwest, South, and West were less likely to receive medical therapy alone and more likely to receive percutaneous coronary intervention and coronary artery bypass grafting. Risk-adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.05-1.09, P <0.001), South (OR: 1.03, 95% CI: 1.01-1.05, P = 0.001), and West (OR: 1.06, 95% CI: 1.04-1.08, P <0.001), as compared with the Northeast. When adjusted further for regional variation in treatment selection, risk-adjusted in-hospital mortality was even higher in the Midwest, West, and South., Conclusions: Despite higher reperfusion and revascularization rates, STEMI patients in the Midwest, West, and South have paradoxically higher risk-adjusted in-hospital mortality as compared with patients in the Northeast., (© 2014 Wiley Periodicals, Inc.)

Background: Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI)., Methods and Results: We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group., Conclusions: The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.

Objectives: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the 'bridge to recovery'., Methods: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator., Results: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury., Conclusions: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from 'bridge to recovery' to heart transplantation for the management of this critically ill population., (© 2014 S. Karger AG, Basel.)

Introduction: The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation., Material and Methods: We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis., Results: Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality., Conclusions: A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Background: Previous studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies., Methods: We used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment., Results: Among 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P <.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD)., Conclusion: Compared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Despite the widespread availability of plasmapheresis as a therapy, thrombotic thrombocytopenic purpura is associated with significant morbidity and mortality. There is a paucity of data on the predictors of poor clinical outcome in this population. Acute myocardial infarction is a recognized complication of thrombotic thrombocytopenic purpura. Little is known about the magnitude of this problem, its risk factors, and its influence on mortality in patients hospitalized with thrombotic thrombocytopenic purpura., Methods: We used the 2001-2010 Nationwide Inpatient Sample database to identify patients aged ≥18 years with the diagnosis of thrombotic thrombocytopenic purpura (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 446.6) who also received therapeutic plasmapheresis (ICD-9-CM code 99.71) during the hospitalization. Patients with acute myocardial infarction were identified using the Healthcare Cost and Utilization Project Clinical Classification Software code 100. Stepwise logistic regression was used to determine independent predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura patients., Results: Among the 4032 patients (mean age 47.5 years, 67.7% women, and 36.9% white) with thrombotic thrombocytopenic purpura who also underwent plasmapheresis, in-hospital mortality was 11.1%. Independent predictors of increased in-hospital mortality were older age (odds ratio [OR] 1.03; 95% confidence interval [CI], 1.02-1.04; P <.001), acute myocardial infarction (OR 1.89; 95% CI, 1.24-2.88; P = .003), acute renal failure (OR 2.75; 95% CI, 2.11-3.58; P <.001), congestive heart failure (OR 1.66; 95% CI, 1.17-2.34; P = .004), acute cerebrovascular disease (OR 2.68; 95% CI, 1.87-3.85; P <.001), cancer (OR 2.49; 95% CI, 1.83-3.40; P <.001), and sepsis (OR 2.59; 95% CI, 1.88-3.59; P <.001). Independent predictors of acute myocardial infarction were older age (OR 1.03; 95% CI, 1.02-1.04; P <.001), smoking (OR 1.60; 95% CI, 1.14-2.24; P = .007), known coronary artery disease (OR 2.59; 95% CI, 1.76-3.81; P <.001), and congestive heart failure (OR 2.40; 95% CI, 1.71-3.37; P <.001)., Conclusion: In this large national database, patients with thrombotic thrombocytopenic purpura had an in-hospital mortality rate of 11.1% and an acute myocardial infarction rate of 5.7%. Predictors of in-hospital mortality were older age, acute myocardial infarction, acute renal failure, congestive heart failure, acute cerebrovascular disease, cancer, and sepsis. Predictors of acute myocardial infarction were older age, smoking, known coronary artery disease, and congestive heart failure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

We analyzed the Nationwide Inpatient Sample database from 2002 to 2010 to examine the temporal trends in incidence of acute kidney injury (AKI), AKI requiring dialysis, and associated in-hospital mortality in patients ≥75 years of age hospitalized with acute myocardial infarction and undergoing early (within 24 hours) percutaneous coronary intervention. Of 2,225,707 patients ≥75 years of age with acute myocardial infarction, 233,508 (10.5%) underwent early percutaneous coronary intervention, of which 21,961 (9.4%) developed AKI and 1,257 (0.54%) developed AKI requiring dialysis. From 2002 to 2010, the incidence of AKI increased from 5.6% to 14.2% (p for trend <0.001) and that for AKI requiring dialysis decreased (0.6% to 0.4%; p for trend 0.018). Compared with 2002, multivariable-adjusted odds ratios and 95% confidence intervals for AKI, AKI requiring dialysis, and in-hospital mortality in 2010 were 1.87 (1.71 to 2.05), 0.20 (0.15 to 0.27) and 0.74 (0.60 to 0.90), respectively. In conclusion, among hospitalized adults ≥75 years of age, from 2002 to 2010, there was an increase in AKI, but there was paradoxical decrease in AKI requiring dialysis and in-hospital mortality, potentially reflecting increased health-care provider awareness resulting in early recognition and implementation of renal-protective strategies and diagnosis-related group creep., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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 ≥65 years 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 ≥80 years., Results: During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, 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 ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, 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 ≥65 years 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., (© 2013.)

Objectives: To investigate the etiologies of syncope and predictors of all-cause mortality, rehospitalization, and cardiac syncope in consecutive elderly patients presenting with syncope to our emergency department., Participants: Participants were 352 consecutive patients aged 65 years or older with syncope admitted to hospital from the emergency department., Design: Observational retrospective study., Measurements: Review of medical records for history, physical examination, medications, and tests to determine causes of syncope. Cox stepwise logistic regression analysis was performed to identify significant independent prognostic factors for rehospitalization with syncope, all-cause mortality, and cardiac syncope., Results: Of 352 patients, mean age 78 years, the etiology of syncope was diagnosed in 243 patients (69%). Vasovagal syncope was diagnosed in 12%, volume depletion in 14%, orthostatic hypotension in 5%, cardiac syncope in 29%, carotid sinus hypersensitivity in 2%, and drug overdose/others in 7% of patients. During a mean follow-up of 24 months, 10 patients (3%) were readmitted to the hospital for syncope and 39 (11%) died. Stepwise logistic regression analysis identified history of congestive heart failure (OR 5.18; 95% CI 1.23-21.84, P = .0257) and acute coronary syndrome (OR 5.95; 95% CI 1.11-31.79, P = .037) as independent risk factors for rehospitalization. Significant independent prognostic factors for mortality were diabetes mellitus (OR 2.08; 95% CI 1.09-3.99, P = .0263), history of smoking (OR 2.23; 95% CI 1.10-4.49, P = .0255), and use of statins (OR 0.37; 95% CI 0.19-0.72, P = .0036). Independent risk factors for predicting a cardiac cause of syncope were an abnormal electrocardiogram (OR 2.58; 95% CI 1.46-4.57, P = .0012) and reduced ejection fraction (OR 2.92; 95% CI 1.70-5.02, P < .001). The San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores did not predict mortality or rehospitalization in our study population., Conclusions: Significant independent risk factors for rehospitalization for syncope were congestive heart failure and acute coronary syndrome. Significant independent risk factors for mortality were diabetes mellitus, history of smoking, and use of statins (inverse association)., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Rheumatoid Arthritis (RA) is a chronic progressive inflammatory joint disorder that affects 0.5% - 1% of the general population. This review article discusses cardiovascular manifestations of rheumatoid arthritis, pathogenesis of these manifestations, and therapy. This disease not only affects the joints, but it also involves other organ systems. The majority of these patients suffer significant morbidity and mortality from cardiovascular disease. Cardiovascular manifestations of RA include predilection for accelerated atherosclerosis and endothelial dysfunction resulting in coronary artery disease (CAD), stroke, congestive heart failure, and peripheral arterial disease. Some studies have shown that the risk of developing CAD in RA patients is the same as for patients with diabetes mellitus. These patients should be treated with aggressive medical therapy such as disease modifying antirheumatic drugs, tumor necrosis factor alpha inhibitors, and corticosteroids and with appropriate control of risk factors such as smoking, dyslipidemia, hypertension, and obesity. Other manifestations include pericarditis, myocarditis, and vasculitis.