Search

Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed. Cardiol Res. 2021;12(5):270-278 doi: https://doi.org/10.14740/cr1319

In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.

Management of patients presenting with acute coronary syndrome (ACS) includes invasive procedures that may increase the risk of acute kidney injury (AKI). AKI adversely affects the outcomes of such procedures and complicates the management of ACS. We have summarized several strategies for the prevention and management of AKI in this critical patient group including in the pre-procedural, intraprocedural, and post-procedural settings.Definitive prevention and management strategies for AKI in patients presenting with ACS requiring invasive management can be confounded by the variation in data outcomes. Pre-procedural hydration with normal saline when accounting for time to catheterization, radial artery access, contrast stewardship, and close monitoring of renal function after catheterization should be implemented.

Introduction Inpatient management of patients with heart failure (HF) and renal impairment is challenging. We sought to evaluate the role of pocket ultrasound (US)-guided management of this patient population. Methods We prospectively included patients with acute HF exacerbation and renal impairment admitted to the HF service in our University hospital from January 2017 to August 2018. We compared the outcomes of patients who received US-guided management with those who received standard of care management. The main study outcome was the change in estimated glomerular filtration rate (eGFR). Multivariable logistic analysis was used to adjust for basic demographics and risk factors. Results A total of 211 patients with renal impairment presenting with acute HF exacerbation (mean age 66.8 ± 14.6 years, 41% females, 62% white) were enrolled in the study, of whom 69 (32.7%) received US-guided management and 151 (68%) received standard of care management. The change in the eGFR was significantly lower in US-guided group than in the group receiving standard of care (1.1 ± 4.3% vs. − 11.15 ± 2.9%; p = 0.04). No significant difference was observed between the patient groups in the length of stay (6.45 ± 0.38 vs. 6.44 ± 0.56; days; p = 0.98) and in the 30-day HF readmission rate (hazard ratio 1.27, 95% confidence interval 0.28–5.6; p = 0.75). Conclusion Ultrasound-guided management of patients admitted with acute HF exacerbation and renal impairment may be beneficial in preserving kidney function. US provides a simple easily accessible tool to guide the management of patients with HF.

Cardiac response to prolonged, intense exercise induces phenotypic and physiologic adaptive changes that improve myocardial ability to meet oxygen demands. These adaptations, termed "athletes' heart," have been extensively studied. The importance of this entity arises from the increasing numbers of athletes as well as the drive for physical fitness in the general population leading to adaptive cardiac changes that need to be differentiated from life-threatening cardiovascular diseases. A number of pathologic entities may share phenotypic changes with the athletes' heart such as hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan's syndrome, and arrhythmogenic right ventricular cardiomyopathy. Cardiologists need to be cognizant of these overlapping findings to appropriately diagnose diseases and prevent catastrophic outcomes especially in young and healthy individuals who may not show any symptoms until they engage in intense exercise. It is equally important to recognize and distinguish normal, exercise-adaptive cardiac changes to provide accurate screening and guidance to young elite athletes. Echocardiography is a valuable modality that allows comprehensive initial evaluation of cardiac structures, function, and response to exercise. Several different echocardiographic techniques including M-Mode, 2D echo, Doppler, tissue Doppler, color tissue Doppler, and speckle tracking have been used in the evaluation of cardiac adaptation to exercise. The following discussion is a review of literature that has expanded our knowledge of the athlete's heart.

Objective To analyze the age-specific temporal trends, in-hospital outcomes and readmissions for acute heart failure (HF). Background There is a paucity of data on the age-specific differences in the trends and outcomes of hospitalizations with acute HF. Methods The National Inpatients Sample database years 2002–2016 and the National Readmissions Database years 2013–2016 were used to identify primary hospitalizations for acute HF. We analyzed the age-specific temporal trends, in-hospital outcomes, and readmissions for acute HF. Results The annual rate of hospitalizations for acute HF declined from 456 per 100,000 people in 2002 to 356 per 100,000 people in 2016 (Ptrend 34 years). Conclusions This nationwide contemporary analysis demonstrated a decline in the annual rates of hospitalizations with acute HF across all age categories except those aged 18–44 years. There was a reduction in rates of in-hospital mortality among middle-aged and older patients, but not in those aged 18–34. In-hospital mortality exhibited a dichotomous relationship with age. There was an inverse relationship between age and 30-days HF readmissions.

Background In-hospital left ventricular (LV) thrombus following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale and was the focus of this investigation. Methods We used the 2003 to 2013 Nationwide Inpatient Sample database to identify adults ≥18 years old with a principal diagnosis code of ST-elevation myocardial infarction. Patients were divided into two groups defined by the presence or absence of LV thrombus. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models were conducted to identify factors associated with LV thrombus. Results Of 1,035,888 STEMI patients hospitalized in the U. S from 2003 to 2013, 1982 (0.2%) developed acute in-hospital LV thrombus. Compared to no LV thrombus, patients with LV thrombus were more likely to have in-hospital complications; acute ischemic and hemorrhagic stroke, acute renal failure, gastrointestinal bleed, cardiogenic shock, in-hospital cardiac arrest and mortality. They also had longer mean length of stay and higher hospital charges. Factors associated with LV thrombus included: anterior/anterolateral STEMI, acute or chronic heart failure with reduced ejection fraction, atrial fibrillation, LV aneurysm, Left heart valvular disease, acute or chronic deep venous thrombosis/pulmonary embolism and alcohol abuse. Patients with LV thrombus were less likely to be female [AOR 0.66, 95% CI (0.51–0.84)]. Conclusion The identification of factors associated with early development of LV thrombus following STEMI, will help direct resources for specific high-risk group and prompt cost-effective therapies. Gender variability in LV thrombus development warrants further investigations.

Aspirin is one of the most widely used medications across the global healthcare system and is the foundation in treating ischemic heart disease, as well as secondary prevention for ischemic and valvular heart disease. Challenges arise in treating patients with cardiovascular disease who have concomitant aspirin intolerance. Through an extensive review of the literature, we provide a comprehensive background on the pharmacology of aspirin, the mechanisms behind aspirin intolerance, the importance of aspirin in cardiovascular disease, and the management of aspirin intolerance in both acute coronary syndrome and stable coronary artery disease. Our review includes a multidisciplinary approach from the internist, allergist/immunologist, and cardiologist when evaluating this important patient population.

Severe coronary artery calcification (CAC) is associated with high rate of procedural complications. The current techniques that facilitate percutaneous coronary interventions in moderate to severe CAC have significant risk of complications, including periprocedural myocardial infarction , dissection, perforation and transient atrioventricular block. Coronary Intravascular lithotripsy (IVL) is a novel technology for the treatment of moderate to severe calcified lesions. IVL uses sonic pressure waves to break down the calcium deposits with no to minimal impact on the blood vessel tissues, which makes IVL a safe option with high procedural success and minimal complications. Here, we discuss coronary IVL as a treatment option for CAC and summarize the major clinical trials performed evaluating the safety and outcome of IVL.

Heart failure is a leading global pandemic and a cause of economic burden. Although, treatments exist to help symptomatic alleviation, patient compliance and monitoring is the basis of ensuring efficacy. With devices that allow for remote wireless PA pressure monitoring such as CardioMEMS, the inconsistency in patient reporting and factors such as symptoms and hospitalizations can be reduced. A systematic review and meta-analysis utilizing the MEDLINE, Cochrane, and Scopus database was performed to identify randomized and non-randomized clinical trials evaluating baseline characteristics and hospitalizations. Five trials for the systematic review and 2 trials for the meta-analysis meeting the inclusion and exclusion criteria were included. Baseline characteristics included an average age of 64.6 years, male predominance, mean BMI of 29.6, predominance of HFrEF, hypertension the most prevalent comorbidity, and a mean PA pressure of 27.2 mm Hg. The follow-up periods ranged from 90 days to 12 months. There was a total of 64 adverse events, mostly non-serious. Patients who underwent remote PA monitoring were less likely to be hospitalized compared with patients who did not (Odds Ratio: 0.52; 95% Confidence Interval 0.39, 0.69). Remote PA pressure monitoring allows for reduced hospitalizations. With the recent and now resurging SARS-CoV-2 pandemic, devices such as CardioMEMS can allow for heart failure patients to be managed from home to not only reduce hospitalizations but for symptom prevention and management.

Amyloidosis is an infiltrative disease with severe impact on the cardiac anatomy resulting in structural changes 1 . Mitral valve insult from the infiltrative process, although rare, has been known to cause severe mitral regurgitation 4 . Due to underlying comorbidities these patients may not be surgical candidates. 17 , 18 , 19 , 20 The role of percutaneous mitral valve repair in cardiac amyloidosis has been described in a few prior cases. 4 , 15 We review the epidemiology, diagnosis, and treatment of cardiac amyloidosis. We also highlight prior cases described in the literature of cardiac amyloidosis and severe mitral regurgitation, while discussing the role of percutaneous mitral valve repair in these patients.

Soluble guanylate cyclase (sGC) agents have been shown to have possible beneficial effects in heart failure treatment. Unfortunately, the role of sGC in HFpEF has not been shown to be efficacious based on recent trials. The CAPACITY HFpEF and VITALITY-HFpEF trials independently showed that sGC does not improve 6-minute walk test (6MWT) distance or the Kansas City Cardiomyopathy Questionnaire (KCCQ) physical limitation score (PLS). The objective of this study was to analyze current data on the 6MWT and KCCQ PLS score from trials that included patients with HFpEF treated with sGC. Using MEDLINE and Cochrane databases, meta-analysis and systematic review was performed looking at data in the CAPACITY HFpEF and VITALITY-HFpEF trials. For safety analysis we evaluated serious adverse events between the CAPACITY HFpEF, VITALITY-HFpEF, SOCRATES-PRESERVED, and DILATE-1trials. A total of 2 trials were analyzed to assess 6MWT and KCCQ score. The total number of combined patients from both trials assessing 6MWT distance in sGC vs placebo therapy were 620 with 309 in the treatment group and 311 in the placebo group. The total number of combined patients from both trials assessing KCCQ score outcomes were 583 with 280 in the treatment group and 303 in the placebo group. A total of 4 trials were evaluated for safety analysis with a total of 987 patients with 529 in the treatment group and 458 in the placebo group. The analysis did not demonstrate significant difference in 6MWT (P = 0.97), KCCQ PLS (P = 0.83), or serious adverse events (P = 0.67).

BACKGROUND: A comparison of acute kindney injury (AKI) post-percutaneous coronary intervention (PCI) prediction models is lacking. In this study, we aim to compare the National Cardiovascular Data Registry (NCDR) CathPCI score to the Mehran score in acute coronary syndrome (ACS) vs non-ACS patients. METHODS: We included patients who received PCI at our facility between July 2015 and December 2017. We excluded patients without a pre- and/or post-PCI serum creatinine, patients on dialysis at the time of PCI and patients with missing variables required to calculate the predictive scoring model. The primary outcome of this study was AKI post-PCI. Performance of the NCDR CathPCI score and the Mehran score were evaluated by comparing the area under the receiver-operating characteristic curve (AUROC) for both scores. RESULTS: The analysis included 1,507 patients. In non-ACS patients, the Mehran score performed better than the NCDR CathPCI score with AUROC 0.75 and 0.68 respectively (p=0.014). When categorized into 4 risk groups, a Mehran score ≥ 2 had a sensitivity of 86% and a Mehran score of ≥ 3 had a specificity of 83% in non-ACS patients. In contrast, when the NCDR CathPCI score was categorized into risk groups, it was not able to predict the risk of AKI (p=0.78) with sensitivity of 0% for the intermediate and high risk group. In ACS patients, the NCDR CathPCI score was superior in predicting the risk for AKI with AUROC 0.79 versus 0.74 (p=.019). CONCLUSION: In predicting AKI post-PCI, the NCDR CathPCI score performed better in ACS populations, and the Mehran score performed better in the non-ACS population.

Background: In-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States. Methods: We used 2003 to 2014 Nationwide Inpatient Sample data to identify adults with a principal diagnosis of STEMI. Patients were divided into two groups defined by presence or absence of ischemic stroke. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models identified factors associated with ischemic stroke, national trend of in-hospital stroke incidence and in-hospital mortality. Results: Of 1,842,529 STEMI patients hospitalized from 2003 to 2014, 22,268 (1.2%) developed acute in-hospital ischemic stroke. Those with acute strokes were older (age ≥ 65 years: 70% vs 46%), more likely female (51% vs 33%), and had higher rates of atrial fibrillation (28.9% vs 12.2%) and heart failure (40.5% vs 21.1%). Age and gender adjusted incidence of in-hospital ischemic stroke following STEMI remained stable; 1.4% in 2003 and 1.5% in 2014 (P trend = 0.50). However, age and gender adjusted in-hospital mortality declined in STEMI patients with and without in-hospital ischemic stroke [AOR 0.97 (0.95–0.99) P trend = 0.03, and AOR 0.98 (0.98–0.99) P trend

BACKGROUND: Effects of malnutrition on patients with infective endocarditis (IE) have not been fully studied. Because malnutrition is associated with poor health, we hypothesized that among patients with IE, those with malnutrition would have more negative in-hospital outcomes. METHODS: The National Inpatient Sample was used to identify adults ≥18 years old with IE. We compared outcomes of in-hospital mortality, morbidity, valvular interventions, and utilization of resources between individuals with and without malnutrition. RESULTS: 11,939 adults ≥18 years were hospitalized with IE, 2035 had a secondary diagnosis for malnutrition. There were no significant differences in age (mean age ± SEM: 55.6 ± 1.0 vs 54.3 ± 0.4 years, P = .21) or sex (female: 36.7%; 743/2,035 vs 37.5%; 3,717/9,904, P = .69) in patients with and without malnutrition. Patients with malnutrition had more comorbidities (Charlson comorbidity score ≥3: 36%; 732/2,035 vs 30.7%; 3,040/9,904, P = .04). Despite similar adjusted in-hospital mortality (adjusted odds ratio [aOR], 1.4; 95% CI, 0.8–1.5; P = .23), malnourished patients were more likely to develop sepsis (aOR, 1.7; 95% CI, 1.2–2.4; P < .01) and had higher odds of mitral-valve (aOR, 1.7; 95% CI, 1.2–2.4; P < .01) repairs/replacements. Patients with malnutrition also had increased lengths of stay (adjusted mean difference [aMD], 4.7 days; 95% CI, 2.9–6.5 days; P < .01) and hospital charges (aMD, $36,052; 95% CI, $14,935–$57,168; P < .01). CONCLUSIONS: Patients with malnutrition and IE are at risk for high morbidity, valvular repairs/replacements, and use of hospital resources.

Objectives This study sought to evaluate the trends and outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among patients with prior mediastinal radiation from a national database. Background There is a paucity of data about the temporal trends and outcomes of TAVR versus SAVR in patients with prior mediastinal radiation. Methods The National Inpatient Sample database years 2012 to 2017 was queried for hospitalizations of patients with prior mediastinal radiation who underwent isolated AVR. Using multivariable analysis, the study compared the outcomes of TAVR versus SAVR. The main study outcome was in-hospital mortality. Results The final analysis included 3,675 hospitalizations for isolated AVR; of whom 2,170 (59.1%) underwent TAVR and 1,505 (40.9%) underwent isolated SAVR. TAVR was increasingly performed over time (ptrend = 0.01), but there was no significant increase in the rates of utilization of SAVR. The following factors were independently associated with TAVR utilization: older age, chronic lung disease, coronary artery disease, chronic kidney disease, prior cerebrovascular accidents, prior coronary artery bypass grafting, and larger-sized hospitals, while women were less likely to undergo TAVR. Compared with SAVR, TAVR was associated with lower in-hospital mortality (1.2% vs. 2.0%, adjusted odds ratio: 0.27; 95% confidence interval: 0.09 to 0.79; p = 0.02). TAVR was associated with lower rates of acute kidney injury, use of mechanical circulatory support, bleeding and respiratory complications, and shorter length of hospital stay. TAVR was associated with higher rates of pacemaker insertion. Conclusions This nationwide observational analysis showed that TAVR is increasingly performed among patients with prior mediastinal radiation. TAVR provides an important treatment option for this difficult patient population with desirable procedural safety when using SAVR as a benchmark.

After publication of the original article [1], there is a duplicate “35.322” in the section “Study outcomes”: Secondary outcomes included combined aortic valve repairs or replacements (ICD-9 35.11, 35.22, 35.22), […]”. This should be read “(ICD-9 35.11, 35.21, 35.22)”, instead.

Additional file 2: Table S2. Demographics and hospital outcomes comparing White and Black patients age ≥ 18 and older hospitalized with infective endocarditis, National Inpatient Sample (2013–2014). Table S3. Adults age 18 years and older: Odds ratios for hospital outcomes in infective endocarditis for black and white patients.

Palliative care (PC) has become an integral component of comprehensive care provided to critically ill patients. Little is known about the utilization of palliative care following Out-of-Hospital Cardiac Arrest (OHCA) in the United States.We used the 2002-2013 National Inpatient Sample database to identify adults ≥18 years old with an ICD-9-CM principal diagnosis code of cardio-respiratory arrest or ventricular fibrillation (VF). Patients were categorized into two groups based on the presence of PC, then compared using Pearson χOf the 154,177 patients hospitalized with OHCA in the U.S, 11,260 (7.3%) had PC consultations during hospitalization. PC Utilization increased from 1.5% in 2002 to 16.7% in 2013 (P-trend 0.001). Patients who received Palliative care were older (mean age 70.7 ± 0.3 vs 65.9 ± 0.1), more likely to be female (45.8% vs 40.5%), and had higher Charlson comorbidity index ≥2 (55.8% vs 46.8%). In adjusted analyses, older age, female gender, Caucasian race, higher Charlson comorbidity index, multiorgan failure, metastatic cancer, non-shockable rhythm, admission to larger, urban and teaching hospitals were all associated with higher PC utilization.We observed significant increase in the utilization of palliative care consultations following OHCA over the study period. This was influenced by multiple patient and hospital factors. Further investigations are needed to identify the appropriate cost-effective use of palliative care following cardiac arrest.

Drug-eluting stents (DES) outperform bare-metal stents (BMS) in reducing target vessel revascularization following a percutaneous coronary intervention (PCI). Little is known about the types of stents placed in HIV-positive patients presenting with ST-segment elevation myocardial infarctions (STEMIs).We used the 2003-2013 National Inpatient Sample to identify adults of 18 years or older presenting with STEMI. We evaluated differences in stent type placed following STEMIs on the basis of HIV status. Temporal trends in the use of PCI, DES, and BMS were studied on the basis of HIV status.Of 1 695 947 patients with STEMI, 5887 (0.3%) were HIV-positive patients. Following STEMIs, HIV-positive patients were equally likely to have PCI compared with HIV-negative patients [adjusted odds ratio (AOR): 1.04, 95% confidence interval (CI): 0.89-1.21, P=0.63]. However, HIV-positive patients were less likely to have DES (AOR: 0.83, 95% CI: 0.73-0.94, P=0.003) and more likely to have BMS (AOR: 1.26, 95% CI: 1.11-1.45, P=0.001). Over the 11-year period observed, there were increases in PCI following STEMIs in both HIV-positive and HIV-negative patients (all Ptrend0.001). There were significant increases in the use of DES in HIV-negative patients [adjusted odds ratio (AOR) per year: 1.07, 95% CI: 1.06-1.09, Ptrend0.001] and significant decreases in the use of BMS (AOR per year: 0.93, 95% CI: 0.92-0.94, Ptrend0.001). Significant trends showing changed practice patterns in the use of DES and BMS among HIV-positive patients were not observed.Over a decade, there were significant increases in the use of PCI following STEMIs in both HIV-negative and HIV-positive patients. Although HIV-positive patients presenting with STEMIs were as likely as HIV-negative patients to undergo PCI, they were less likely to be treated with DES and more likely to receive BMS. Highlighting these observations will hopefully bring renewed attention to best practices for all STEMI patients.

Aims To investigate trends in survival to hospital discharge, in-hospital expenditures, and post-acute-care disposition following out-of-hospital cardiac arrest (OHCA) in the United States. Methods We performed this nationwide serial cross-sectional study using data from the National Inpatient Sample on all patients (age >18years) hospitalized with OHCA between January 1, 1995, and December 31, 2013. Our main outcome measure was survival to hospital discharge. We fitted multivariable regression models with survival, in-hospital expenditures, and post-acute-care disposition as our dependent variables. Results Of 247,684 patients included in this study, 58.8% were men; mean age was 67 years. Overall trend of survival to discharge was unchanged ( P trend =0.56) but a non-significant linear trend increase (49.9% [95% CI, 39.8%–60.0%] in 1995 to 54.0% [95% CI 46.3%–61.8%] in 2013) was noted. Survival improved for patients with VF arrest rhythm but not for those with non-VF arrest rhythm. Increasing age, female gender, non-Caucasian race, high comorbidity burden, non-private primary insurance, non-VF-arrest rhythm and weekend arrest were all negatively associated with neurologically-intact survival. The cost of hospitalization increased from $18,287 ($683) in 2001 to $21,092 ($514) in 2013 at an average annual rate of $261 ( P trend P trend Conclusions Overall survival to discharge following out-of-hospital cardiac arrest remained static between 1995 and 2013. Renewed national efforts are needed to warrant better knowledge translation and wider implementation of the best available science in order to improve outcomes.

Data addressing the use of respiratory support in acute coronary syndromes are lacking. To address this evidence gap, we characterized prognostic impact and trends in utilization of invasive mechanical ventilation (IMV) and non-invasive ventilation (NIV) in patients hospitalized with ST-segment elevation myocardial infarction (STEMI) from 2002 through 2013 using the National Inpatient Sample. Multivariable logistic regression was performed to identify patient, hospital, and clinical characteristics associated with requiring IMV or NIV within 24-hours of hospitalization. Multivariable Cox proportional hazards regression was used to quantify the magnitude of in-hospital mortality associated with IMV and NIV use. Between 2002 and 2013, we identified 1,867,114 STEMI patients. Age, sex, higher comorbidity burden and chronic pulmonary disease were significantly associated with need for respiratory support. The use of IMV and NIV increased at average annual rates of 6.6% and 14.3%, respectively (Ptrend < 0.001). Age- and sex-adjusted mortality rates are high but declined for STEMI patients requiring IMV (44.7% in 2002 to 37.6% in 2013, Ptrend = 0.002) and NIV (11.6% in 2002 to 6.8% in 2013, Ptrend < 0.001). Compared to STEMI patients with no ventilation need, a requirement for IMV or NIV was associated with increased adjusted in-hospital mortality (hazard ratio [HR]: 2.5; p < 0.001 and [HR]: 1.7; p < 0.001, respectively). In conclusion, approximately 1 in 23 patients hospitalized with STEMI will require respiratory support in the form of IMV or NIV. STEMI patients who require respiratory support have a high risk of death, though rates of in-hospital mortality have decreased over time.

Objective Obesity contributes to diagnostic and management challenges for many hospitalized patients. The impact of obesity on in-hospital outcomes in patients with infective endocarditis has not been studied and was the focus of this investigation. Method We used the 2013 and 2014 Nationwide Inpatient Sample to identify adults ≥18 years of age with a principle diagnosis of endocarditis. We divided the sample into 2 groups based on presence of absence of obesity. Multivariate linear and logistic regression analysis was used to compare in-hospital mortality, valvular replacement, length of stay (LOS), and hospitalization charges. Results A total of 24 494 adults 18 years and older were hospitalized with infective endocarditis, of which 2625 were classified as obese. Patients with obesity were older (mean age, 57.8 ± 0.3 vs 54.3 ± 0.6 years; P < .01), more likely to be female (50.1% vs 36.1%; P < .01), and had more comorbidities (Charlson comorbidity score ≥ 3, 50.6% vs 28.8%; P < .01). Multivariate regression analysis found no differences between the 2 groups for mortality or repairs or replacements for any valve. On evaluation of resource utilization, patients with obesity had longer average LOS (13.9 days; confidence interval [CI], 12.7–15.1 vs 12.4 days; CI, 12.0–12.8; P = .016) and higher total hospital charges (US $160 789.90; CI, $140.922.40–$180 657.50 vs US $130 627.20; CI, $123 916.70–$137 337.70; P Conclusions . Obesity does not significantly impact in-hospital mortality or surgical valvular interventions among patients hospitalized with infective endocarditis, but obesity is associated with increased utilization of hospital resources.

BackgroundIn patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved.Methods and findingsPatients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003-2004 [aOR 1.7; (1.16-2.57), pConclusionsMajor foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003-2004 was absent by 2013-2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability.

To investigate patterns of neurologic "awakening" in out-of-hospital cardiac arrest (OHCA) patients using different criteria for prognostication post-arrest.Data was collected on 194 OHCA survivors to hospital admission. Patients were assigned to one of two groups based on whether they received therapeutic hypothermia (TH). Three separate criteria were used to assess neurologic "awakening": motor-GCS=6, total-GCS ≥ 9, and CPC=1 or 2. Demographics, arrest characteristics and intensive care events were compared using unpaired t-test, Chi-square or nonparametric Wilcoxon rank-sum test as appropriate. Primary outcome was the time from arrest to neurologic awakening.Of 194 OHCA survivors, TH was implemented in 94 patients (48%). Compared to conventional care patients, hypothermia treated patients were more likely to be younger (58 vs. 69 years, p0.01),), and have a shockable arrest rhythm (27% vs. 10%, p0.01). Using the three criteria (m-GCS=6, t-GCS ≥ 9CPC=1 or 2), median time to awakening for patients in the hypothermia group versus the conventional therapy group were 6 [4,9] vs. 3 [2,5] days, 3 [3,5] vs. 2 [2,3] days, and 3 [3,6] vs. 2 [2,4] days respectively (all p0.01) and prognostication using these criteria on day 3 yielded discordant results about which patients achieved awakening.Patients undergoing therapeutic hypothermia achieve meaningful neurologic "awakening" beyond 72 h post-arrest. Use of different criteria for the assessment of neurologic "awakening" can yield different prognostication predictions which calls for standardization and validation of a single definition of "awakening" by the resuscitation community.

In-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States and was the focus of this investigation. We used the 2003 to 2014 Nationwide Inpatient Sample database to identify adults ≥ 18 years old with a

Background The role of fever in trauma patients remains unclear. Fever occurs as a response to release of cytokines and prostaglandins by white blood cells. Many factors, including trauma, can trigger release of these factors. Objectives To determine whether (1) fever in the first 48 hours is related to a favorable outcome in trauma patients and (2) fever is more common in patients with head trauma. Method Retrospective study of trauma patients admitted to the intensive care unit for at least 2 days. Data were analyzed by using multivariate analysis. Results Of 162 patients studied, 40% had fever during the first 48 hours. Febrile patients had higher mortality rates than did afebrile patients. When adjusted for severity of injuries, fever did not correlate with mortality. Neither the incidence of fever in the first 48 hours after admission to the intensive care unit nor the number of days febrile in the unit differed between patients with and patients without head trauma (traumatic brain injury). About 70% of febrile patients did not have a source found for their fever. Febrile patients without an identified source of infection had lower peak white blood cell counts, lower maximum body temperature, and higher minimum platelet counts than did febrile patients who had an infectious source identified. The most common infection was pneumonia. Conclusions No relationship was found between the presence of fever during the first 48 hours and mortality. Patients with traumatic brain injury did not have a higher incidence of fever than did patients without traumatic brain injury. About 30% of febrile patients had an identifiable source of infection. Further studies are needed to understand the origin and role of fever in trauma patients. (American Journal of Critical Care. 2015; 24:e1–e5)

The aim of this study was to investigate patient outcomes after hospitalization for out-of-hospital cardiac arrest in the United States. We used the 2002 to 2013 Nationwide Inpatient Sample database to identify adults ≥18 years with an International Classification of Diseases, Ninth Revision, Clinical Modification, principal diagnosis code of cardiorespiratory arrest (427.5) or ventricular fibrillation (VF) (427.41). In 4 predefined federal geographic regions: Northeast, Midwest, South, and West, means and proportions of survival, survival stratified by initial rhythm, hospital charges, and cost were estimated. Multiple linear and logistic regression models were conducted. Of the 154,177 patients with out-of-hospital cardiac arrest hospitalized in the United States, 25,873 (16.8%) were in the Northeast, 38,296 (24.8%) in the Midwest, 57,305 (37.2%) in the South, and 32,703 (21.2%) in the West. Variability in survival was noted in VF arrests; compared with the Northeast, survival was higher in the Midwest and South (adjusted odds ratio [AOR] 1.16, 95% confidence interval [CI] 1.02 to 1.32 and AOR 1.24, 95% CI 1.09 to 1.40, respectively), with no difference detected in the West (AOR 0.93, 95% CI 0.82 to 1.06). No variability in survival was noted after non-VF arrests (p0.05). Hospital charges rose significantly across all regions of the United States (p-trend0.001) and were higher in the West compared with the Northeast (hospital charges$109,000/admission, AOR 1.76; 95% CI 1.50 to 2.06). In conclusion, nationwide, we observed significant regional variability in survival of hospitalized patients after out of hospital VF cardiac arrest, no survival variability after non-VF arrests, and a steady increase in hospital charges.

Aims To identify factors that associated with early care withdrawal in out-of-hospital cardiac arrest patients. Methods Data was collected from 189 survivors to hospital admission. Patients were classified by survival status upon hospital discharge, and those who died were categorized into withdrawal vs. no withdrawal of care. Those who had care withdrawn were further subdivided into early care withdrawal i.e. ≤72h vs. late withdrawal >72h. Multivariable adjusted odds ratios were used to assess factors associated with early care withdrawal. Results Of 189 patients with cardiac arrest, only 36 had advanced directives (19%) and 99 (52%) had care withdrawn. Most patients whose care was withdrawn died in hospital (94/99, 95%), and the remainder died in hospice. Care was withdrawn early ≤72h in the majority of patients (59/94, 63%). Median time to early care withdrawal was 2 days IQR (1–3). Factors associated with early care withdrawal were age ≥75 years, poor initial neurologic exam, multiple co morbidities, multi-organ failure, lactic acid ≥10mmolL −1 , Caucasian race and absence of bystander CPR. Advance directives did not appear to determine early care withdrawal. Conclusions Although most cardiac arrest patients do not have advance directives, care is often withdrawn in more than 50% and in many before the accepted time for neurological awakening (72h). The decision to withdraw care is influenced by older age, race, preexisting co morbidities, multi-organ failure, and a poor initial neurological exam. Further studies are needed to better understand this phenomenon and other sociological factors that guide such decisions.

Purpose Accurate assessment of volume status and estimation of central venous pressure is critical in directing management of acute heart failure (HF) patients . We evaluated the impact of hand carried ultrasound (US) in guiding therapy for HF patients with uncertain volume status on physical examination (PE) or with worsening serum creatinine (Cr). Methods We prospectively included patients admitted to the hospital with acute HF exacerbation and had uncertain volume status or worsening Cr to undergo US-guided management between January 2017 to October 2018. HF team provided initial management plan based on standard of care (PE, symptoms and lab results), then they were provided with US estimation of intravascular volume (by assessing inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Primary outcome was percent change of initial plan after providing US results. Logistic regression was used to compare the percent change in plan by HF type. Results A total of 151 (Age 64±15,46% females, 78% white) patients were included during study duration. 47(31%) patients had HF with preserved ejection fraction (HFpEF), and 104 (69%) patients had HF with reduced ejection fraction (HFrEF). A change in plan was observed in 77.5% of the patients after using ultrasound. No difference in percent change of plan between HFrEF (81%) and HFpEF patients (70%), (OR 1.7, 95% CI: 0.73, 3.9, p= 0.2). Conclusion Ultrasound management of patients with HF and uncertain volume status or worsening Cr may significantly impact management decisions regardless of HF type, Further studies are needed to explore whether these changes improve outcomes of this population.

Purpose Inpatient management of patients with heart failure (HF) and chronic kidney disease (CKD) is challenging. We studied the role of hand carried ultrasound (US) in directing clinical care. Methods We conducted a prospective non-randomized study of patients admitted with acute heart failure with chronic kidney disease between January, 2017 and August of 2018. Patients were divided into two groups; US-guided management group and standard of care group. Multivariate linear regression analyses were used to compare length of stay and percent change in eGFR. Multivariate Cox proportional hazard regression analysis was used to compare HF readmission between the two groups. Models were adjusted for age, sex, race, BMI, hypertension and diabetes. Results We included 221 patients (mean age 67±14, 42% females, 69% HFrEF and 31% HFpEF). 71 (32%) patients underwent US-guided management and 150 (68%) had standard of care management. The US-guided group had less reduction in eGFR (-1%, 95% CI: -9.1, 7.1) compared to standard of care group (-11.2%, 95% CI: -16.7, 5.7, p=0.04). No significant difference in the length of stay was observed (6.4±1.2 days vs 6.6±0.8, p=0.7). Finally, no significant difference in HF readmission between the two groups (HR 0.9, 95% CI: 0.51, 1.6, p=0.73) (Figure). Conclusion US-guided management of patients admitted with acute HF exacerbation and chronic kidney disease may be beneficial in preserving kidney function. Multi-center studies with longer follow up time are needed to evaluate the impact of hand carried US on hospital readmissions.

Purpose Evaluation of intravascular volume is an essential component of clinical management of acute heart failure (HF) patients. Correlation between physical examination and ultrasound measurements has not been well studies and was the focus of this investigation. Methods We prospectively studied patients admitted to the medical floor with acute heart failure exacerbation between January 2017 to October 2018. Assessment of volume status by physical examination (PE) was performed by heart failure team, and classified patient's volume status into (0- euvolemic, 1- Mildly overloaded, 2- Moderately overloaded, 3- Severely overloaded), then central venous pressure (CVP) was measured using hand carried US (assessment of inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Spearman's correlation was used to correlate between PE findings and US-estimated CVP. Finally, the distribution of CVP for each PE category was provided (Figure). Results A total of 186 (Age 64±15,42% females) patients were included during study duration. (34%) patients had HF with preserved ejection fraction (HFpEF), and 104 (66%) patients had HF with reduced ejection fraction (HFrEF). The correlation between PE and US-estimated CVP was moderate at best (rho=0.41, p Conclusion Physical exam is moderately correlated with US-estimated CVP and is unreliable in directing therapy for acute HF exacerbation. Further investigations are needed to integrate hand carried US in the daily management of heart failure patients.

Inpatient management of patients with heart failure (HF) and chronic kidney disease (CKD) is challenging. We studied the role of using Pocket Ultrasound (US)-guided management of this patient population. We prospectively included patients with acute HF exacerbation and CKD admitted to HF service in

Introduction Heart transplant patients are at high risk of organ rejection and require close monitoring with frequent endomyocardial biopsies (EMB), especially during their first post-transplant year. We encountered a hypercellular, atypical endocardial lesion composed of enlarged, pleomorphic cells in a 54-year-old male heart transplant recipient 7.5 months post-transplantation. Our initial impression was post-transplant lymphoproliferative disorder or malignancy. We later identified two additional cases with similar histopathologic findings and hypothesized that these were actually reactive changes or so called epithelial-mesenchymal transition (EMT). EMTs have not been previously reported in EMB from heart transplant recipients and we identified 3 cases in less than a one year time period. Methods For these 3 cases, we further evaluated their clinical history and analyzed the EMB with additional immunostains (CD3, CD68, CD20, PAX-5, Kappa, Lambda, WT1, CK AE1/3, CD34, adenovirus, and EBV) to determine the etiology of the lesions. Right heart EMB are conducted at our institution weekly for the first 8 weeks and then every 3 months thereafter. Results All 3 patients had undergone orthotopic heart transplant replacement 2-7 months prior to having the EMB in which the lesions were observed and received similar induction and immune suppression regimens (MMF and tacrolimus). The IHC stains showed that the atypical-appearing cells were forming a new layer on the endocardial surface and were transitioning from epithelial-like (AE1/3+) to mesenchymal-like (CD34+), and were thus undergoing EMT. Underlying this reactive process was mixed inflammation including macrophages and scattered aggregates of CD3+ T cells; there was no evidence of a lymphoproliferative disorder and EBV was negative. All 3 patients had similar EM findings. Their subsequent biopsies showed similar lesions, although slightly less cellular, with increased fibrosis. Graft function remained normal in all patients. Conclusion The presence of atypical appearing cells on EMB can raise suspicion for rejection or post-transplant lymphoproliferative disorder; however, this appears to often be a reparative process, namely EMT. Similar to reports in kidney transplant patients on tacrolimus, EMT does not seem to play a role in the development of allograft rejection. Due to our small sample size, further investigation is needed.

Aims to explore the association between post return of spontaneous circulation (ROSC) hemoglobin level and survival with good neurological outcome following out-of-hospital cardiac arrest. Methods We studied adults with non-traumatic out-of-hospital cardiac arrest who achieved ROSC within 50min of collapse. We quantified the association between post ROSC hemoglobin level and good neurological outcome (defined as Cerebral Performance Category score of 1or 2), using multivariate logistic regression analyses. The impact of Post ROSC hemoglobin level ≥10gdl −1 and time varying hemoglobin level ≥10gdl −1 on time to Survival with good outcome was assessed using Cox proportional hazard models. Results Of 931 cardiac arrest patients, 146 (16%) achieved ROSC and 30 survived to discharge with a good neurological outcome. Of those with post ROSC hemoglobin level ≥10gdl −1 , 28% (27/98) had good outcome, whereas of those with level −1 only 6% (3/48) had good outcome (CPC P =0.003). The use of blood transfusions and therapeutic hypothermia were comparable in both good and bad outcome groups. An immediate post ROSC hemoglobin level ≥10gdl −1 was significantly associated with good neurological outcome (AOR 8.31 95% CI 1.89–36.52 P =0.005). Patients with post ROSC hemoglobin ≥10gdl −1 were more likely to achieve good outcome earlier (HR 6.02 95% CI 1.75–20.72 P =0.004). Conclusions Post ROSC hemoglobin level ≥10gdl −1 is associated with survival with good neurological outcome. The importance of time to achieve such level and the role of blood transfusion warrants further investigation.

Background: The intent of the 5-yearly Resuscitation Guidelines is to improve outcomes. Previous studies have yielded conflicting reports of a beneficial impact of the 2005 guidelines on out-of-hospital cardiac arrest (OHCA) survival. Using a national database, we examined survival before and after the introduction of both the 2005 and 2010 guidelines. Methods: We used the 2000 through 2012 National Inpatient Sample database to select patients ≥18 years admitted to hospitals in the United States with non-traumatic OHCA (ICD-9 CM codes 427.5 & 427.41). A quasi-experimental (interrupted time series) design was used to compare monthly survival trends. Outcomes for OHCA were compared pre- and post- 2005 and 2010 resuscitation guidelines release as follows: 01/2000-09/2005 vs. 10/2005-9/2010 and 10/2005-9/2010 vs. 10/2010-12/2012. Segmented regression analyses of interrupted time series data were performed to examine changes in survival to hospital discharge. Results: For the pre- and post- guidelines periods, 81600, 69139 and 36556 patients respectively survived to hospital admission following OHCA. Subsequent to the release of the 2005 guidelines, there was a statistically significant worsening in survival trends (β= -0.089, 95% CI -0.163 – -0.016, p =0.018) until the release of the 2010 guidelines when a sharp increase in survival was noted which persisted for the period of study (β= 0.054, 95% CI -0.143 – 0.251, p =0.588) but did not achieve statistical significance (Figure). Conclusion: National clinical guidelines developed to impact outcomes must include mechanisms to assess whether benefit actually occurs. The worsening in OHCA survival following the 2005 guidelines is thought provoking but the improvement following the release of the 2010 guidelines is reassuring and worthy of perpetuation.