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Percutaneous mechanical circulatory support (pMCS) devices are increasingly used in patients with cardiogenic shock as a bridge to recovery or bridge to decision to advanced heart failure therapies. Gastrointestinal bleeding (GIB) is a common complication that can be catastrophic. Because of the paucity of data describing the association of GIB with pMCS, we analyzed this population using the United States National Inpatient Sample database. We performed a retrospective study in patients with pMCS devices who had GIB during the index hospitalization using the National Inpatient Sample. Multivariate logistic regression analysis was performed to determine independent predictors of GIB in these patients. A total of 466,627 patients were included. We observed an overall increase in the incidence of adjusted GIB from 2.9% to 3.5% (p = 0.0025) from 2005 to 2014. In comparison to patients without GIB, those with GIB had significantly higher in-hospital mortality, length of stay, and hospitalization cost. In addition to the usual co-morbid conditions, the presence of small bowel and colonic ischemia, colon cancer, diverticulosis, chronic liver disease, and peptic ulcer disease were noted to be significant predictors of GIB for all (p0.001). In conclusion, patients with pMCS and GIB have higher in-hospital mortality, longer length of stay, and higher cost of hospitalization. Awareness of patient risk factors for bleeding and gastrointestinal disorders are important before the use of mechanical circulatory support devices because they are associated with a substantially higher risk for bleeding.

The extent of diastolic dysfunction is of clinical importance in the risk stratification and management of Takotsubo cardiomyopathy (TC) patients. Standard echocardiographic indices for diastolic dysfunction have robust predictive ability in other diseases, however, these have not been validated in TC. This study compares Doppler metrics of diastolic function against catheterization measured filling pressures in TC.Patients with TC who met our inclusion and exclusion criteria were evaluated with echocardiography and catheterization obtained within 24 hours. Both LVEDP (Left Ventricular End Diastolic Pressure) and LV Pre-A diastolic pressures were obtained from catheterization tracings. The echocardiographic parameters for diastolic function were extracted using the American Society of Echocardiography (ASE) recommendations and a previously validated regression equation for mean left atrial pressure (mLAP).A total of 51 patients with TC were included. Patient were predominantly females (72.5%), with mean age 58 ± 13, and mean ejection fraction 24 ± 10%. The E/e' (septal, average, and lateral), and calculated mean LAP correlated positively with catheterization LV pre-A, with fair to moderate correlation (coefficients range: 0.38 to 0.44). The t-test mean difference between the LV pre-A pressure and calculated mLAP was 0.77 ± 7.34 mmHg (95% CI ± 14.68 mmHg) suggesting inconsistent measures. The mLAP also exhibited poor diagnostic ability to discriminate elevated LV pre-A diastolic pressure with a ROC area under the curve of 0.69 (95% CI 0.50 - 0.88).Commonly used echocardiographic parameters for diastolic function demonstrated less than optimal correlation, with poor sensitivity and specificity, when compared to invasively measured LVEDP or LV-pre-A wave diastolic pressures in TC. Precise characterization of LV filling pressure in TC using contemporary noninvasive echocardiographic parameters appears challenging. Invasive measurements of filling pressure should remain the gold standard for optimal risk stratification and management of TC.

Although renal function may improve after left ventricular assist devices (LVAD) implantation, acute kidney injury (AKI) requiring hemodialysis (HD) therapy can occur postoperatively. We used data from the National Readmissions Database to calculate annual rates of in-hospital outcomes and readmissions among patients who underwent implantation and developed acute kidney injury (AKI) requiring hemodialysis (HD) for years 2012-2015. We identified 178 (weighted 469) patients with AKI requiring HD after LVAD implantation. In-hospital mortality was significantly higher among LVAD recipients who required HD for AKI compared with those who did not (42.38% vs. 8.38%, p < 0.001). Rates of in-hospital mortality (from 52.1% in 2012 to 33.9% in 2014, p = 0.046) and length of stay (from 60.3 days in 2012 to 47.1 days in 2014, p = 0.003) decreased significantly, whereas there was a trend toward reduced hospital cost (from $320,414 in 2012 to $267,285 in 2014, p = 0.076) during the study period. However, postoperative bleeding increased significantly (p = 0.01). Acute kidney injury requiring HD after implantation was not associated with significantly higher rates of readmissions compared with LVAD recipients without AKI on HD, after adjustment for clinical and hospital characteristics (41.4% vs. 30.5%; odds ratio 1.28; 95% confidence interval [CI]: 0.85-1.95; P = 0.239). However, 5.42% of these patients required maintenance hemodialysis in readmissions. In-hospital mortality and length of stay are decreasing but remain unacceptably high in patients requiring HD for AKI after LVAD implantation but remain higher than LVAD recipients without AKI on HD. A minority of these patients who survive hospital discharge require maintenance hemodialysis.

Takotsubo Syndrome (TS) patients are at high risk of developing atrial fibrillation. We sought to investigate the outcomes and economic impact of atrial fibrillation on TS patients utilizing the National Inpatient Sample.Patients with TS were identified in the National Inpatient Sample (NIS) database between 2010 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and subsequently were divided into two groups, those with and without atrial fibrillation. The primary outcome was all-cause in-hospital mortality in the two groups. Secondary outcomes were in-hospital complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding factors.Among the study population, the prevalence of atrial fibrillation was 17.57%. After matching, the atrial fibrillation group had no significant increase of in-hospital mortality (OR: 1.13; 95% CI: 0.94-1.35, p = 0.211). However, atrial fibrillation patients were more likely to develop cardiac arrest and ventricular arrhythmias (OR: 1.51, 95% CI: 1.26-1.80, p 0.0001), have higher rate of major cardiac complications when combined as a single endpoint in-hospital complication (OR: 1.16, 95% CI: 1.04-1.29, p: 0.006), also they were more likely to stay longer in hospital (OR: 1.13, 95% CI: 1.08-1.19, p 0.0001), and have increased cost of hospitalization (OR: 1.13, 95% CI 1.07-1.20, p 0.0001).Atrial fibrillation does not increase in-hospital mortality in patients presenting with TS. However atrial fibrillation is associated with an increased risk of ventricular arrhythmias, length of stay, non-routine discharges and cost of hospitalization.

Background Left ventricular assist device (LVAD) implantation has historically been underutilized in women compared with men. It was hypothesized that the introduction of continuous-flow LVADs would lead to more LVAD implantations in women and possibly narrow the gender gap. Methods Patients who underwent LVAD implantation between 2009 and 2014 were identified using the national inpatient sample. Results A total of 3511 patients (17,251 when weighted) underwent LVAD implantation in the United States between 2009 and 2014. Mean age was 56 years and there were 817 women in the study sample (23.32%). LVAD implantations in women doubled from 2009 to 2014, but men continued to receive LVAD 3 times more than women. Inpatient mortality after LVAD placement was similar between men and women (13.42% women vs 12.85% men; odds ratio, 1.05; P = .16). Most common complications after LVAD implantation in both genders included acute kidney injury, bleeding requiring blood transfusion, and postoperative sepsis. There were no gender-specific differences in the incidence of periprocedural complications, including postoperative cardiac tamponade, postoperative thromboembolism, or sepsis. In addition, no significant difference was found in length of stay and median hospitalization cost. The use of extracorporeal membrane oxygenation did not differ between men and women. Subgroup analysis in patients older than 65 years of age showed higher in-hospital mortality but no differences between genders. Conclusions The number of women undergoing LVAD implantation has increased with the introduction of continuous-flow LVADs, but a gender gap still exists. Most major in-hospital outcomes after LVAD implantation are similar between genders.

Background Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD). Objectives Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes. Methods We selected ESLD records from the Nationwide Inpatient Sample (2007–2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4). Results Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures. Conclusions Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.

Background Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP. Methods Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS). Results The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P

To evaluate the impact of chronic thrombocytopenia (cTCP) on outcomes of transcatheter valvular procedures such as aortic valve implantation (TAVI), MitraClip, permanent pacemaker (PPM), implantable-cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), left atrial appendage closure, and pericardiocentesis. Impact of cTCP on clinical outcomes following TAVI, Mitraclip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis procedures is not well described. Utilizing the National Inpatient Sample and (ICD-9-CM) procedural codes, we evaluated patients (age ≥18 years) who underwent these procedures, from January 1, 2009 to December 31, 2014, with or without cTCP as a chronic condition variable indicator. Propensity score matching model implemented to derive 2 matched groups. Propensity score matching created 47,292 and 47,351 hospitalizations matched pairs with and without cTCP, respectively. Patients with cTCP were older (mean age, 74.27 vs 72.26 years; absolute standardized differences [ASD] = 15.6) and less likely to be female (36.76% vs 43.74%, ASD = -14.31). They experienced higher in-hospital mortality (3.0% vs 2.0%; odds ratio [OR], 1.53; 95% confidence interval [CI], 1.27 to 1.83) and higher odds of vascular injury requiring surgery (2.63% vs 1.10%; OR, 2.43; 95% CI, 1.93 to 3.05). Postoperative hematoma and bleeding were 2-fold higher (4.57% vs 2.24%; OR, 2.08; 95% CI, 1.77 to 2.45) and 3-fold higher (6.34% vs 2.45%; OR, 2.69; 95% CI, 2.31 to 3.13) respectively among cTCP patients. They had greater health-care cost ($47,163 vs $35,763, p0.0001) and longer hospital stay (mean 9.26 days vs 6.84 days, p0.0001). In conclusion, cTCP patients had higher risk of complications after TAVI, MitraClip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis, including a 1.5-fold increased risk of in-hospital mortality.

Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation–acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients ( Pinteraction= .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.

Introduction Whether readmission to non-index hospitals (where the initial procedure was not performed) could result in adverse outcomes and increased utilization of healthcare resources compared with readmission to index hospitals after transcatheter aortic valve replacement (TAVR) remains unclear. Methods From January 2012 to September 2015, a nationwide readmission database was queried to identify those who were older than 50 years and had endovascular TAVR, using the International Classification of Disease, 9th Revision, Clinical Modification code 35.05. Elective readmissions were excluded. In-hospital outcomes were compared between the index and non-index hospital readmissions. A multivariable logistic regression analysis was performed to identify predictors of non-index hospital readmissions. Results A total of 6808 readmissions were identified of which 2564 (37.7%) were readmitted to non-index hospitals. Residents at smaller counties, metropolitan non-teaching hospitals, or hospitals at large metropolitan areas were predictors of non-index readmissions. In-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.20), acute myocardial infarction (aOR 0.83, p = 0.53), pacemaker placement (aOR 0.97, p = 0.90), acute kidney injury (aOR 0.98, p = 0.84), and stroke (aOR 1.03, p = 0.90) were similar between index and non-index readmissions but bleeding events requiring transfusions were more frequently observed in readmissions at non-index hospitals (aOR 1.32, p = 0.025). Hospital cost (15,410 dollars vs. 16,390 dollars, p = 0.25) and length of stay (5.70 days vs. 5.65 days, p = 0.85) were comparable between groups. Conclusions Non-index readmissions post-TAVR was relatively common but did not result in increased hospital mortality or healthcare utilization. Our results are reassuring for TAVR recipients with limited access to index hospitals.

Background and aim Surgical aortic valve replacement (SAVR) is the most common valvular surgery and thus needs to be widely available including minorities and socially disadvantaged patients. SAVR outcomes at safety-net hospitals, which serve a high percentage of these patients, are limited. We aimed to compare the outcomes of SAVR at different safety-net burden hospitals. Methods Nationwide Inpatient Sample from 2005 to 2011 was queried to identify SAVR performed for over the age of 50. The safety-net burden of hospitals was calculated as the number of admission to a hospital in a year who were uninsured or insured by Medicaid divided by the total number of admissions for the respective year. Hospitals were categorized into quintiles of safety-net rate and then into three categories based on the safety-net burden (low burden hospitals [LBHs], lowest quintile, medium burden hospitals [MBHs], 2nd-4th quintiles; and high burden hospitals [HBHs], highest quintile). Results A total of 85 441 SAVR were included. In unadjusted models, in-hospital mortality was higher in HBHs compared with LBHs but became nonsignificant after adjustments for patient and hospital-level characteristics. Major perioperative complications and hospital costs were similar, but hospital stay was longer at HBHs compared with LBHs. At MBHs, acute kidney injury requiring dialysis and bleeding requiring transfusion was lower compared with LBHs. Length of stay and cost were shorter and lower at MBHs compared with LBHs. Nonroutine discharge was similar for HBHs and MBHs compared with LBHs. Conclusion SAVR outcomes are reassuring at MBHs and HBHs.

Safety-net hospitals (SNHs) are hospitals that serve a higher proportion of patients insured by Medicaid or uninsured and have been reported to have poor outcomes compared with non-SNHs. Procedural and clinical outcomes of ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) at SNHs have not been well described. Nationwide Inpatient Sample from 2005 to 2011 was queried to identify STEMI-CS and age ≥18. SNHs were defined as hospitals with the highest number of inpatient stays that were paid by Medicaid or were uninsured (the top quartile). A total of 23,229 STEMI-CS of which 3,639 (15.7%) were treated at SNHs. Admissions to SNHs were younger (mean age 66.0 vs 67.2, p0.001), more likely men (64.0% vs 62.2%, p = 0.04), more frequently ethnic minorities (Black; 11.0% vs 6.0%, Hispanic 20.4% vs 5.8%, p0.001), and had higher Elixhauser ≥4 (25.8% vs 21.9%, respectively, p0.001). Percutaneous coronary interventions were less performed (60.4% vs 65.8%, p0.001) whereas administrations of thrombolysis (2.9% vs 2.1%, p = 0.001) were more frequent at SNHs. Coronary artery bypass and the use of mechanical circulatory support was similar. In-hospital mortality was significantly elevated at SNHs (36.6% vs 32.7%, adjusted odds ratio 1.24, 95% confidence interval 1.10 to 1.39) whereas new dialysis, stroke, and fatal arrhythmias were similar. The median length of stay was similar (6 vs 7 days, p = 0.58) but the median cost was higher (40,175 vs 38,012 US dollars, p = 0.01) at SNHs. SNHs had lower utilization of percutaneous coronary intervention and higher in-hospital mortality compared with non-SNHs in STEMI-CS. Further cause analysis is warranted to improve outcomes of STEMI-CS admitted at SNHs.

Background: As the frequency of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States (US) community, more patients are hospitalized with NAFLD. However, data on the prevalence and outcomes of hospitalizations with NAFLD are lacking. We investigated the prevalence, trends and outcomes of NAFLD hospitalizations in the US. Methods: Hospitalizations with NAFLD were identified in the National Inpatient Sample (2007-2014) by their ICD-9-CM codes, and the prevalence and trends over an 8-year period were calculated among different demographic groups. After excluding other causes of liver disease among the NAFLD cohorts (n=210,660), the impact of sex, race and region on outcomes (mortality, discharge disposition, length of stay [LOS], and cost) were computed using generalized estimating equations (SAS 9.4). Results: Admissions with NAFLD tripled from 2007-2014 at an average rate of 79/100,000 hospitalizations/year (P

In the setting of cardiogenic shock (CS), impaired biventricular function can cause acute decrease in renal function via reduced renal perfusion and increased renal venous pressure. We sought to analyze the characteristics and outcomes of patients hospitalized with CS who utilized renal replacement therapy (hemodialysis) for acute kidney injury (AKI-HD). We utilized data from the National Inpatient Sample to calculate national rates of in-hospital mortality, use of temporary mechanical support, vascular injury requiring surgery, length of stay (LOS) and hospitalization cost from 2010 to September 2015. We compared the in-hospital outcomes between CS with AKI-HD and a propensity score-matched group without AKI-HD. We identified 6,076 hospitalizations (weighted n = 24,272) with CS and AKI-HD and 76,878 (weighted n = 378,553) with CS not AKI-HD. Among these cases 48.1% (n = 39,403, weighted n = 193,746) had ST elevation myocardial infarction as the cause of CS. Patients with CS and AKI-HD had higher comorbidity burden and they were also more likely to receive mechanical circulatory support device (absolute standardized difference10% for all comparisons) compared with CS patients without AKI-HD. After matching 4,457 cases for patient-level and hospital-level characteristics, CS with AKI-HD was associated with significantly higher in-hospital mortality (75.74% vs 51.58%, p0.001), use of temporary mechanical support (24.0% vs 19.3%, p0.001), LOS (21.4 vs14.4 days, p0.001) and cost ($80,406 vs $52,833, p0.0001). AKI-HD occurred in approximately 6% of patients with CS in years 2010 to 2015 and was associated with significantly increased in-hospital morbidity and mortality, LOS, and cost.

OBJECTIVES: The aim of this study was to determine the prevalence of peripheral artery disease (PAD) and its association with in-hospital outcomes after endovascular transcatheter aortic valve replacement (EV-TAVR). BACKGROUND: TAVR is an established treatment for patients at prohibitive, high, or intermediate surgical risk. PAD is a significant comorbidity in the determination of surgical risk. However, data on association of PAD with outcomes after EV-TAVR are limited. Methods: Patients in the National Inpatient Sample who underwent EV-TAVR between January 1, 2012 and September 30, 2015 were evaluated. The primary outcome was in-hospital mortality. RESULTS: A total of 51,685 patients underwent EV-TAVR during the study period. Of these, 12,740 (24.6%) had a coexisting diagnosis of PAD. The adjusted odds for in-hospital mortality [OR 1.08 (95% CI 0.83–1.41)], permanent pacemaker implantation [OR 0.98 (0.85–1.14)], conversion to open aortic valve replacement [OR 1.05 (0.49–2.26)], or acute myocardial infarction [OR 1.31(0.99–1.71)] were not different in patients with versus without PAD. However, patients with PAD had greater adjusted odds of vascular complications [OR 1.80 (1.50–2.16)], major bleeding [OR 1.20 (1.09–1.34)], acute kidney injury (AKI) [OR 1.19 (1.05–1.36)], cardiac complications [aOR 1.21 (1.01–1.44)], and stroke [OR 1.39(1.10–1.75)] compared with patients without PAD. Length of stay (LOS) was significantly longer for patients with PAD [7.23 (0.14) days vs. 7.11 (0.1) days, p < 0.001]. CONCLUSION: Of patients undergoing EV-TAVR, ~25% have coexisting PAD. PAD was not associated with increased risk of in-hospital mortality but was associated with higher risk of vascular complications, major bleeding, AKI, stroke, cardiac complications, and longer LOS.

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.

Background We evaluated the effects of hospital ownership, classified into three tiers (nonfederal government, not-for-profit, and for-profit hospitals), on in-hospital outcomes after implantation of continuous-flow left ventricular assist devices (LVADs) in the United States from 2009 to 2014. Methods Data from the National Inpatient Sample were used to calculate annual national estimates in utilization, in-hospital mortality, major complications, lengths of stay, cost of hospitalization, and disposition at discharge for years 2009 to 2014. Complications were calculated using patient safety indicators and International Classification of Diseases, Ninth Revision, Clinical Modification codes. Results Of the 3,571 patients (weighted, 17,547) with LVAD implants in the United States between 2009 and 2014, 82.1% were in not-for-profit hospitals, 15.6% in nonfederal government hospitals, and 2.3% in for-profit hospitals. In-hospital mortality significantly decreased over time only in not-for-profit hospitals by average annual change of –7.4% (p = 0.001) and was higher in for-profit hospitals than other tiers of hospital ownership. Our analysis did not suggest any differences in postoperative complications among different hospital ownership types. LVAD implantation in nonfederal government hospitals was associated with the highest cost ($227,930; interquartile range [IQR], $173,259 to $301,566) and implantation in for-profit hospitals was associated with lower cost ($148,406; IQR, $133,149 to $199,317; p = 0.03). The length of stay was similar across the three tiers of hospital ownership. Nonroutine discharge was significantly more frequent in not-for-profit hospitals (73.6%; IQR 69.5% to 77.7%) compared with nonfederal government (48.8%; IQR, 42.4% to 55.1%) and for-profit (59.8%; IQR, 43.0% to 76.6%) hospitals (p Conclusions Disparities in in-hospital mortality, cost, and disposition exist between various hospital ownerships during admission for LVAD implant.

One of the major causes of mortality in systemic lupus erythematosus (SLE) is acute myocardial infarction. Whether in-hospital outcomes and management of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are different in SLE patients compared with those without SLE from large, recent dataset is unclear. We queried the Nationwide Inpatient Database from 2005 to 2014 and identified STEMI and NSTEMI admissions with and without SLE. The primary outcome was in-hospital mortality. Secondary outcomes were revascularization strategy (percutaneous coronary intervention, coronary artery bypass surgery, or thrombolytics), medical therapy rates (no reperfusion), and major adverse clinical events. A propensity-matched cohort was created to compare these outcomes. Odds ratio (OR) was calculated from the propensity-matched cohort. A total of 321,048 STEMI admissions, of which 1,001 (0.31%) and 572,971 NSTEMI admissions, of which 2,134 (0.37%) were SLE, were identified. In those with STEMI, 882 SLE and non-SLE admissions were propensity-matched. In-hospital mortality (9.1% vs 11.8%, OR 0.75, p = 0.07), revascularization strategy, medical therapy rates, and major adverse events were similar. Similarly, in those with NSTEMI, 1,770 SLE and 1,775 non-SLE were matched. In-hospital mortality (4.1% vs 4.50%, OR 0.90, p = 0.51), coronary artery bypass surgery, medical therapy rates, and major adverse events were mostly similar but the rate of percutaneous coronary intervention was higher in SLE (32.9% vs 29.6%, OR 1.16, p = 0.04). For both STEMI and NSTEMI, hospital cost and length of stay were similar between SLE and non-SLE cohorts. From a large administrative database in the United States, revascularization strategies and in-hospital outcomes of acute coronary syndrome were mostly similar between SLE and non-SLE.

Background Outcomes of redo aortic valve intervention (AVI) following transcatheter aortic valve replacement (TAVR) have not been well described. We thought to investigate the incidence, predictors, and outcomes of redo AVI after TAVR. Methods The Nationwide Readmission Database (from 2012 to 2017) was queried to identify admissions for TAVR. Redo AVI was defined as readmissions that required either TAVR or balloon aortic valvuloplasty (BAV) or surgical aortic valve replacement (SAVR). A multivariable regression model was used to identify independent predictors of redo AVI. In-hospital outcomes of redo TAVR or BAV and redo SAVR were compared in the unadjusted model. Results A total of weighted 148,200 (unweighted redo AVI 297, no redo AVI 73,804) index TAVRs were identified. A weighted 593 (435 TAVR or BAV and 158 SAVR) redo AVI was included with an incidence of 1.0 per 100 person-year during a median of 105 (interquartile range 41–195) days follow-up. Predictors of redo AVI were female, heart failure, obesity, atrial fibrillation, transapical approach, oral anticoagulant use, and acute kidney injury. In-hospital mortality of redo AVI was 7.6% (5.3% for redo TAVR or BAV vs. 13.8% for redo SAVR, unadjusted p = 0.10). Stroke, myocardial infarction, bleeding requiring transfusion, new pacemaker, and acute kidney injury rates were 4.7%, 2.6%, 9.3%, 10.0%, and 31.2%, respectively in redo AVI. Length of stay and hospital cost was 4.8 days and 55,826 U.S. dollars, respectively. Conclusions The incidence of redo AVI was low following TAVR but was associated with high mortality and morbidities.

Background Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI). Objective We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI. Methods We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. Results Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. Conclusions Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% ( P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.

We sought to evaluate the trends and outcomes of patients with left ventricular assist devices (LVADs) and inotropes at the time of listing for heart transplantation. Adults with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between 2010 and 2017. Patients were grouped according to the presence or absence of inotropes at the time of listing and transplantation. A total of 2714 patients were included in the study including 664 patients on inotropes at the time of listing, 235 at the time of transplantation, and 118 on inotropes both at listing and at the time of transplantation. Patients on LVAD and inotropes at the time of listing were more frequently supported with a right ventricular assist device (RVAD) (P < .001), had higher risk of death in the waiting list (sub-hazard ratio [SHR] = 1.48, 95% CI 1.14-1.90, P = .002), and were less likely to be transplanted (SHR = 0.70, 95% CI 0.63-0.78, P < .001) compared with those not on inotropes, after adjusting for described confounders. Approximately 1 in 10 LVAD recipients listed as status 1A are on inotropic therapy at the time of heart transplantation. Patients on LVAD and inotropes have worse outcomes in terms of survival and lower rates of transplantation.

Alcohol septal ablation (ASA) is indicated for symptomatic hypertrophic cardiomyopathy (HC) patients. We sought to analyze the incidence of the 30-day readmission rate, predictors, causes of readmission, and incremental healthcare resource (cost and length of stay) utilization after ASA. Nationwide Readmission Database from 2010 January to 2015 September was queried to identify 30-day unplanned readmission after ASA for HC by using the International Classification of Disease, 9th Revision, Clinical Modification. Those readmitted were similar in terms of age and sex but had higher burden of co-morbidities compared with those not readmitted within 30-days. The 30-day unplanned readmission rate was 10.4% (511/4,932) after ASA. Readmissions lead to an additional mean hospitalization cost of 8,433 US dollars and mean of 4.9 days of length of stay. Predictors of 30-day unplanned readmission were liver disease (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 1.22 to 5.59), renal failure (aOR 2.30, 95%CI 1.52 to 3.50), previous myocardial infarction (aOR 1.97, 95%CI 1.16 to 3.33), previous pacemaker (aOR 1.50, 95%CI 1.09 to 2.08), atrial fibrillation (aOR 1.43, 95%CI 1.08 to 1.89), Medicaid (aOR 1.74, 95%CI 1.12 to 2.68), and weekend admission (aOR 1.75, 95%CI 1.12 to 2.75). Common reasons for readmissions were atrial fibrillation (12.6%), acute on chronic systolic heart failure (12.6%), paroxysmal ventricular tachycardia (6.4%), atrioventricular block (4.9%), and HC (3.0%). Unplanned readmissions after ASA occur in patients with higher burden of co-morbidities and are mainly caused by cardiac etiologies.

Recent positive results of transcatheter aortic valve replacement (TAVI) in clinical trials have sparked debate on whether TAVI should be first line for all patients with aortic stenosis. However, limited evidence exists on the clinical impact of TAVI on a national level. Using the national inpatient sample (NIS) of hospital discharges in the United States from 2001 to 2016, we evaluated the rate of AVR and associated in-hospital outcomes in pre-TAVI and TAVI era. Hierarchical mixed effect modeling was used to assess for trend and calculate risk adjusted estimates. Annual volume of AVR increased from 49,357 in 2001 to 100,050 in 2016 (103% increase). Compared with the pre-TAVI era, mean annual change in volume of AVR was higher in the TAVI era (+2.9% vs +9.4%, respectively, p0.001). In contrast, rate of in-hospital mortality decreased from 5.4% in 2001 to 2.7% in 2016 (50% decrease). Compared with the pre-TAVI era, magnitude of mean annual change in mortality was higher in TAVI era (-4.0% vs -6.7%, respectively, p = 0.04). Unlike SAVR for which risk-adjusted rate for most outcomes seems to have plateaued, TAVI demonstrated significant improvement from 2012 to 2016 for mortality (4.6% to 1.8%), acute kidney injury (15.1% to 2.6%) and nonroutine home discharge (63.6% to 44.6%). However, no significant change in the rate of stroke (2.4% to 2.1%) and pacemaker implantation remained high (8.1% to 9.4%). Lastly, median length of stay was shorter for TAVI compared with isolated SAVR (3 vs 8 days, respectively). In conclusion, the adoption of TAVI has led to increase in volume of AVR for severe aortic stenosis in the United States with favorable short-term outcome.

Supplement_1 for Palliative Care in Ruptured Aortic Aneurysm in the United States: A Retrospective Analysis of Nationwide Inpatient Sample Database by Tomo Ando, Oluwole Adegbala, Takeshi Uemura, Said Ashraf, Emmanuel Akintoye, Mohit Pahuja, Luis Afonso, Alexandros Briasoulis and Hisato Takagi in Angiology

Aim: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database. Materials and Methods: We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients. Results: A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 ( P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR ( P = .86). Age 80 to 89 (aOR: 1.93), age ≥90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR. Conclusions: There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.

Background Periprocedural outcomes of transcatheter mitral valve repair (TMVR) with Mitraclip in patients with pulmonary hypertension (PH) are not well studied. Methods Patients who underwent TMVR with Mitraclip between 2011 and 2015 were identified using the National Inpatient Sample (NIS). All missing variables were excluded from the analysis and therefore, complete case analysis was performed. Results A total of 1,037 patients underwent TMVR with Mitraclip between 2011 and 2015. The prevalence of PH in these patients was 32.6%. In-hospital outcomes were compared between PH group and non-PH group. Inpatient mortality after TMVR was similar between the two groups (3.2% vs. 2.1%, OR 1.57, P = 0.335). There was no statistical significance between the two groups in the rates of hemorrhage requiring transfusion (8.5% vs. 7.2%, OR 1.17, P = 0.587), cardiogenic shock (4.4% vs. 4.5%, OR 0.98, P = 0.951), acute respiratory failure (15.2% vs. 13.1%, OR 1.23, P = 0.460), postoperative sepsis (2.75% vs. 3.9%, OR 0.66, P = 0.340), postoperative deep vein thrombosis or pulmonary embolism (2.7% vs. 3.9%, OR 1.98, P = 0.348). In addition, non-routine home discharge, median hospital cost and length of stay were similar between the two groups. Conclusion Pre-existing PH in patients undergoing TMVR with Mitraclip does not adversely affect in-hospital outcomes in this cohort of patients. Therefore, PH does not carry a prohibitive risk in selecting patients for Mitraclip procedure.

Cardiac tamponade is a severe complication of cardiac resynchronization therapy (CRT) implantations. We provide a contemporary large-scale study evaluating the incident trends, predictors and impact of cardiac tamponade in patients undergoing CRT.Data were obtained from the Nationwide Inpatient Sample (NIS) of 2007 through 2014. Trends in the annual rates of tamponades in CRT implantation were assessed using negative binomial regressions. Hierarchical mixed-effects logistic regression models were built to determine the independent predictors of tamponade in CRT implantation and 1:1 propensity-matched analysis performed to examine the impact of tamponade on outcomes.An estimated 310,704 CRT implantations were performed in the United States between 2007 and 2014, out of which 536 patients (0.17%) developed procedure-related cardiac tamponade. A significant increasing trend in the tamponade incidence was observed over the 8-year study period [1.65 per 10,000 CRT implantation in 2007 to 38.16 in 2014 (p 0.001)]. After multivariable adjustment, female sex and coagulation disorder were found to be independently associated with higher odds of tamponade. Conversely, prior history of CABG procedure was associated with lower odds of tamponade. CRT complicated with tamponade had significantly increased in-hospital mortality, bleeding requiring transfusion, prolonged hospital stay and increased cost.We found an increasing trend in the incidence of post CRT tamponade among hospitalized patients between 2007 and 2014. Female gender and coagulation disorder were associated with the development of tamponade among recipients of CRT. Risk stratification of patients who are undergoing CRT is crucial to improving outcome in CRT implantation.

Background The concomitant presence of atrial fibrillation (AF) in the setting of Transcatheter Mitral Valve Repair (TMVR) represents a clinical challenge. Despite the high AF burden in patients presenting for the TMVR procedure, there are no studies that evaluate the impact of AF on in-hospital outcomes of TMVR in a nationally representative United States sample reflecting real practice. Therefore, we sought to study the outcomes of AF patients undergoing TMVR. Methods and results The study included 1026 patients from the National Inpatient Sample (NIS) registry. Patients (age ≥18 years) who had undergone TAVR as a primary procedure from 2011 to 2014 were included, using the ICD-9-CM diagnostic codes. We examined patient characteristics and in-hospital outcomes. To account for patient and hospital-level baseline differences, we performed propensity score-matched analysis. The prevalence of AF was approximately 56%. After adjusting for patient-level and hospital-level characteristics, there was no statistical difference regarding in-hospital mortality (odds ratio [OR] 0.72, 95%CI 0.29-1.80, P = 0.487), post-TMVR complications, length of stay (OR 1.15, 95%CI 0.97-1.38, P = 0.111), and cost of hospitalization (OR 1.04, 95%CI 0.94-1.14, P = 0.475) between the group with AF versus without AF. However, patients with AF were more likely to have non-routine hospital discharge (42.94% vs 35.48% P = 0.02). Conclusion AF is a frequently encountered arrhythmia among patients undergoing TMVR with MitraClip. However, TMVR can be performed safely in the vast majority of patients, irrespective of their baseline rhythm.

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without liver cirrhosis are scarce. This study aimed to assess the clinical outcomes and impact of liver cirrhosis on patients who underwent TAVI. Patient with liver cirrhosis who underwent TAVI 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of liver cirrhosis on inpatient mortality. Secondary outcomes were the impact of liver cirrhosis on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The cirrhotic patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.59 to 2.10, p = 0.734) or after procedural complications. Furthermore, cirrhotic patients were less likely to develop vascular complications requiring surgery (OR 0.47, 95% CI 0.23 to 0.98, p = 0.043), to develop after procedural deep vein thrombosis(OR0.00, 95% CI0.001 to0.0001, p0.0001), and to require pacemaker implantation. However, cirrhotic patients were more likely to undergo nonroutine hospital discharges (OR 1.50, 95% CI 1.15 to 1.96, p = 0.003). In conclusion, TAVI is a safe and reasonable therapeutic option for cirrhotic patients with severe aortic stenosis, requiring aortic valve replacement.

Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation (AF). The cardiovascular effects of cannabis have been characterized as biphasic on the autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample for patients admitted with a diagnosis of HF in 2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis use. We identified a cannabis user group and a 1:1 propensity-matched non-cannabis user group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to 0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers, which was not explained by co-morbid conditions, age, insurance type, and socioeconomic status.

The objective of this analysis was to provide evidence on regional differences in outcomes, cost and disposition among patients who undergo continuous-flow LVAD implantation. Using data from the National Inpatient Sample and US Census Bureau, annual national estimates in utilization, in-hospital mortality, major complications, cost, length of stay (LOS), and disposition were estimated for years 2009 to 2014. Main outcomes and complications were identified using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. We analyzed a total of 3,572 (weighted = 17,552) patients with LVAD implants among the 4 Census regions of the United States. The patient population in the Southern region was younger with higher percentage of African-Americans. Overall, the comorbidity burden was higher in the Midwest. The risk-adjusted rate of in-hospital mortality did not differ significantly among the geographical regions (p = 0.8). With the exception of cardiac tamponade rates which were higher in the Northeast and West, all other post-operative complications did not differ between regions. LOS was higher in the Northeast (median 32 days) and lower in the South (median 27 days). The cost analysis suggested higher median cost in the West (median $246,292) and lowest in the Northeast region (median $192,604). Finally, higher percentages of patients were transferred to an extended care facility in the Northeast, whereas more patients were discharged to home in the Western region. We identified region disparities in LOS, cost and disposition but not in-hospital mortality and complications, among patients who underwent LVAD implantation between 2009 and 2014.

Alcohol withdrawal syndrome (AWS) has been associated with significant medical complications and length of stay. Cardiovascular effects from AWS include a physiologic tachycardia and hypertensive response. Although atrial fibrillation (AF) is one of the most common arrhythmias, the impact of a known history of AF on AWS is unclear. The purpose of our study is to assess the impact of history of AF on clinical outcomes, cost, and length of stay on AWS. The Nationwide Inpatient Sample was used to identify patients aged 18 years or older who underwent AWS with or without AF using the International Classification of Disease 9 Clinical Modification codes from January 2010 to December 2014. Outcomes were compared between those with or without AF using propensity score method-stratified morbidity ratio weighing- to adjust for baseline patient and hospital characteristics. A total of 280,451 patients with AWS of which 14,459 (5.2%) had history of AF. Patients with AF was older, less likely female, and more had higher burden of co-morbidities. In an adjusted model, in-hospital mortality (odds ratio [OR] 1.98 95% confidence interval [CI] 1.61 to 2.45), ischemic stroke (OR 1.67 95% CI 1.42 to 1.95), acute kidney injury (OR 1.36 95% CI 1.24 to 1.49), acute kidney injury requiring dialysis (OR 1.89 95% CI 1.39 to 2.50), and cost (mean ratio 1.27 95% CI 1.21 to 1.33) were higher in the AF cohort. Length of stay was shorter in patients with AF (mean ratio 0.85 95% CI 0.81 to 0.90). In conclusion, a known history of AF increased the risk of in-hospital mortality, morbidity, and hospital expense in AWS.

Background There is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S. Hypothesis HF hospitalization outcomes exhibit significant seasonal variation in the U.S. Methods Using data from the National Inpatient Sample (2011-2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere–Spring, Summer, Fall, & Winter–and analysis was conducted via multivariable-adjusted mixed-effect model. Results An estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91-0.99) and Fall (OR: 0.94, 95% CI: 0.89-0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02-1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, compared with the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04-1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88-1.00) and Fall (OR: 0.92, 95% CI: 0.87-0.98). Conclusions Among HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.

The objective of the study was to provide contemporary evidence on regional variation in hospitalization outcomes in patients with heart failure (HF) in the United States. Using the National Inpatient Sample, we compared hospitalization outcomes among primary HF admissions (2013 to 2014) among the 4 Census regions of the United States. Overall, an estimated 1.9 million HF hospitalizations occurred in the United States over the study period. Mortality rate was 3%, the mean length of stay was 5.3 days, the median cost of hospitalization was US$7,248, and the rate of routine home discharge was 51%. There was a significant regional variation for all end points (p 0.001); for example, compared with other regions of the country, the risk-adjusted rate of in-hospital mortality was highest in the Northeast (3.2%) and lowest in the Midwest (2.7%); and within each region, these mortalities were higher in the rural locations (range: 3.0% to 3.8%) than in the urban locations (range: 2.7% to 3.1%). In addition, the Northeast region had the longest length of stay (mean: 5.9 days) and the lowest risk-adjusted rate of routine home discharge (42%). However, the cost of hospitalization was highest in the West (median: US$8,898) and lowest in the South (US$6,366). A similar pattern of variation was found in subgroup analysis except that the risk-adjusted rate of in-hospital mortality was highest in the West among patients65 years (1.7% vs 1.2% [lowest] in the Midwest), male gender (3.2% vs 2.8% in the Midwest), and rural location (3.8% vs 3% in the Midwest). In conclusion, HF hospitalization outcomes tend to be worse in the Northeast compared with other regions of the country. In addition, the in-hospital mortality rate was higher in rural locations than in urban locations.

Background Less intensive treatment for heart failure with reduced ejection fraction (HFrEF) may be appropriate for patients in long-term care settings because of limited life expectancy, frailty, comorbidities, and emphasis on quality of life. Methods We compared treatment patterns between REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants discharged to long-term care versus home following HFrEF hospitalizations. We examined medical records and Medicare pharmacy claims for 147 HFrEF hospitalizations among 80 participants to obtain information about discharge disposition and medication prescriptions and fills. Results Discharge to long-term care followed 22 of 147 HFrEF hospitalizations (15%). Participants discharged to long-term care were more likely to be prescribed beta-blockers and less likely to be prescribed aldosterone receptor antagonists and hydralazine/isosorbide dinitrate (96%, 14%, and 5%, respectively) compared to participants discharged home (81%, 22%, and 23%, respectively). The percentages of participants discharged to long-term care and home who had claims for filled prescriptions were similar for beta-blockers (68% versus 66%) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs) (45% versus 47%) after 1 year. Smaller percentages of participants discharged to long-term care had claims for filled prescriptions of other medications compared to participants discharged home (diuretics: long-term care-50%, home-72%; hydralazine/isosorbide dinitrate: long-term care-5%, home-23%; aldosterone receptor antagonists: long-term care-5%, home-23%). Conclusions Differences in medication prescriptions and fills among individuals with HFrEF discharged to long-term care versus home may reflect prioritization of some medical therapies over others for patients in long-term care.

Background There is scarce evidence reflecting the clinical outcomes in patients with Idiopathic Thrombocytopenic Purpura (ITP) and Acute Myocardial Infarction (AMI). The ITP patient population is at higher risk of bleeding complications due to low platelet counts and difficulty in managing their antiplatelet and anticoagulation therapy. In our study, we sought to assess clinical outcomes of ITP patients admitted with AMI using the US national inpatient sample (NIS) database. Purpose To determine difference in in-hospital mortality, clinical complications, and length of stay (LOS) in AMI patients with and without ITP. Methods We identified adults aged ≥18 years hospitalized from 2005 to 2014 with AMI as their primary diagnosis utilizing ICD-9 codes 410.0 to 410.92. Patients with ITP were identified using ICD-9 code 287.31. The primary outcome was in-hospital mortality. Secondary outcomes included coronary revascularization procedures (PCI and CABG), and in-hospital complications including bleeding (intracranial, epistaxis, GI, and GU bleeding, hematoma, and bleeding requiring transfusion), cardiac complications, transfusions, acute ischemic stroke (AIS), and LOS. A propensity-matched cohort accounting for demographic characteristics, comorbidities, and cardiovascular risk factors, was created to compare these outcomes. Patients with secondary causes of ITP such as HIV, pregnancy, sepsis, SLE, malignancy were excluded. Results A total of 1108034 AMI admissions, of which 1002 with ITP, were identified. In the unmatched group, patients with ITP were older, and had more comorbidities (diabetes mellitus; hypothyroidism; atrial fibrillation; previous history of cardiovascular, peripheral, and end stage renal disease; all p Conclusion In the large population of patients included in the NIS database, patients with ITP admitted with AMI, have a significantly higher rate of bleeding complications, undergo less PCI and have a longer LOS compared to AMI patients without ITP. There are no current guidelines by ACC/AHA/ESC regarding management of patients with AMI and thrombocytopenia. These results warrant further investigation through randomized controlled trials including patients with thrombocytopenia to assess long term outcomes and to define optimal management in this population.

Background The comparative outcomes of transcatheter mitral valve repair with Mitraclip (TMVR) versus surgical mitral valve repair (SMVR) in pulmonary hypertension (PH) patients are underexplored. Methods The Nationwide Inpatient Sample (NIS) database was queried from 2009 to 2015 and those who underwent TMVR or SMVR with PH were identified. International Classification of Diseases (ICD) codes were used to identify the target population, primary and secondary outcomes. Propensity scores (PS) were calculated for each patient. A standardized morbidity ratio (SMR) weight was then calculated for each patient in both groups. Absolute standardized differences (ASD) were used to compare the baseline characteristics. Results We identified a total of 341 and 4,665 cases from NIS who underwent TMVR and SMVR, respectively, over the study period. The mean age of patients was 67 yrs. Patients who underwent TMVR were older (75 vs. 66, ASD =0.32). Women comprised 47.8% of TMVR admission while 42.16% of SMVR admissions were females. Patients who underwent TMVR had a significantly higher Elixhauser comorbidity score >4 (43.4% vs 34.2%, ASD =0.3). TMVR group had higher rates of previous myocardial infarctions (16.7% vs. 7.1%, ASD = 0.30), congestive heart failure (80% vs. 6.2%, ASD = 0.44), percutaneous intervention (PCI) (15.6% vs. 5.9%, ASD = 0.32), coronary artery bypass grafting (CABG) (22.8% vs. 2.7%, ASD = 0.63), cerebrovascular disease (13.5% vs. 5.5%, ASD = 0.27), chronic obstructive pulmonary disease (30.8% vs. 21.1%, ASD = 0.22)and chronic renal failure (43.1% vs. 18.9%, ASD = 0.54). Inpatient mortality was similar between the 2 groups (3.6% vs 6.2%, p=0.573). TMVR patients had less hemorrhage requiring transfusion (8.1% vs 21.1, p Conclusions While in-hospital mortality in PH patients after TMVR compared to SMVR, TMVR was associated with significantly lower periprocedural complications.

BACKGROUND Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown. METHODS We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge. RESULTS Across more than 1000 hospitals in NIS, we identified 125,082 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 60 [34, 99]. Compared to those in the 1 st quartile of case volume, hospitals in the 4th quartile tends to have younger patients (mean = 66 vs 68 yrs), higher comorbidities (median Elixhauser score = 4 vs 3), and in low income areas (37 vs 30%). Overall, 23% of the patients survived to hospital discharge. There was a non-linear association between CPR volume and survival: a non-significant trend towards better survival was observed with increasing annual CPR volume that reached a plateau at 51-55 cases per year, after which survival began to drop and became significantly lower after 75 cases per year (p for non-linearity

Background Percutaneous peripheral arterial intervention (PPAI) patients are at a high risk of developing heparin-induced thrombocytopenia due to the need for repeated and prolonged heparin exposure. We sought to investigate the incidence, outcomes, and economic impact of heparin-induced thrombocytopenia post-PPAI utilizing the National Inpatient Sample. Methods All patients who underwent PPAI (age ≥18 years) from 2007 to 2014 were identified by using ICD-9-CM codes. Patients were then classified into two groups based on the presence or absence of heparin-induced thrombocytopenia during hospitalization. In-hospital outcomes were compared between the two groups after propensity-score matching to account for differences in baseline characteristics. Results Heparin-induced thrombocytopenia was reported in 527 patients (0.23%). After adjusting for patient-level and hospital-level characteristics, in-hospital mortality differences were not significantly different between patients with heparin-induced thrombocytopenia vs. those without heparin-induced thrombocytopenia (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.67 to 1.57, p = 0.951). However, PPAI patients with heparin-induced thrombocytopenia were more likely to develop ischemic stroke (OR 3.84, 95%CI 1.26 to 11.75, p = 0.018), deep venous thrombosis/pulmonary embolism (OR 1.32, 95%CI 0.79 to 1.79, p = 0.078), and acute kidney injury requiring dialysis (OR 4.04, 95%CI 1.72 to 9.50, p = 0.001). Furthermore, post-PPAI patients who developed heparin-induced thrombocytopenia had longer hospitalizations (13.8 vs. 9.8 days, p Conclusion Among patients who underwent PPAI, heparin-induced thrombocytopenia was associated with a higher risk of venous thrombosis/pulmonary embolism, ischemic stroke, acute kidney injury requiring dialysis, prolonged hospital stay, and increased cost.

Background ST-segment elevation myocardial infarction complicated with cardiogenic shock (STEMI-CS) is associated with high mortality but the trends of utilization and predictors of palliative care (PC) referral in this population have not been well described. Objectives To investigate the utilization trends and predictors of PC referral in STEMI-CS. Methods Nationwide inpatient sample from 2005–2014 was queried to identify patients with STEMI-CS of age ≥18. PC referral was identified International Classification of Diseases, Ninth Edition Clinical Modification, V66.7. Results A total of 33,294 admissions were identified and 1,878 (5.6%) had PC encounter. PC referral group were older and had higher comorbidities. PC consultation increased approximately 10 times over the study period in those who died (from 2.3% to 27.4%) and in those who survived (from 0.21% to 2.83%). In multivariable analysis, age, higher Exlixhauser score, no revascularization, teaching hospital, large bed hospital, mechanical circulatory support use, and lower income status were associated with increased PC referral whereas coronary artery bypass graft was associated with lower PC referral rates. Patients under PC group were more often discharged to an extended care facility and less likely discharged home. Conclusion PC utilization increased substantially during the 10-years study period in the United States in STEMI-CS. Several baseline, procedural, hospital, and socioeconomic factors were associated with PC referral in the setting STEMI-CS.

The endogenous cannabinoid system modulates many brain-gut and gut-brain physiologic pathways, which are postulated to be dysfunctional in irritable bowel syndrome (IBS). Herein, we examine the relationship between cannabis use disorder (CUD) and having IBS.After selecting patients aged 18 years and above from the 2014 Nationwide Inpatient Survey, we used the International Classification of Diseases, 9th ed. codes to identify individuals with CUD, IBS, and the established risk factors for IBS. We then estimated the crude and adjusted odds ratios of having a diagnosis of IBS with CUD and assessed for the interactions of CUD with other risk factors (SAS 9.4). We confirmed our findings in two ways: conducting a similar analysis on a previous Nationwide Inpatient Survey data (2012); and using a greedy algorithm to design a propensity-scored case-control (1 : 10) study, approximating a pseudorandomized clinical trial.Out of 4 709 043 patients evaluated, 0.03% had a primary admission for IBS and 1.32% had CUD. CUD was associated with increased odds of IBS [adjusted odds ratio: 2.03; 95% confidence interval (CI): 1.53-2.71]. CUD was related to higher odds for IBS among males compared with females (3.48; 1.98-6.12 vs. 1.48; 0.88-2.50), and Hispanics and Caucasians compared with Blacks (5.28; 1.77-15.76, 1.80; 1.02-3.18 vs. 1.80; 0.65-5.03). On propensity-matching, CUD was associated with 80% increased odds for IBS (1.82; 1.27-2.60).Our findings suggest that CUD is significantly associated with IBS among the general population. Males, Caucasians, and Hispanics might be more impacted by CUD associated IBS. Additional biomedical studies are required to elucidate this relationship.

Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients.We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged18 years with myocarditis in the United States.The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P.01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P.01).Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.

BACKGROUND: Atrial fibrillation (AF) is associated with increased all‐cause mortality in the general population. However, the impact of AF on the in‐hospital outcomes of acute myocarditis (AM) patients is not well characterized. METHODS: Patients (age ≥ 18 years) with a primary diagnosis of AM in the National Inpatient Sample from 2007 to 2014 were included, using the ICD‐9‐CM diagnostic codes. We compared the in‐hospital outcomes between the AF group and propensity score‐matched control group without AF. RESULTS: AF was reported in 602 (9%) of the AM patients. Compared to those without AF, AM patients with AF experienced higher in‐hospital mortality (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1‐2.7, P = 0.02). AF was associated with higher risk of cardiogenic shock (OR 1.9, 95% CI 1.3‐2.8, P < 0.001), cardiac tamponade (OR 5.6, 95% CI 1.2‐25.3, P = 0.002) and acute kidney injury (OR 1.6, 95% CI 1.1‐2.1, P = 0.02). Furthermore, patients with AF were more likely to have non‐routine hospital discharge (31.6% vs 38.4% P = 0.02), longer length of stay and higher cost of hospitalization. CONCLUSIONS: AF was associated with increased risk of in‐hospital mortality and complications in patients admitted to the hospital with acute myocarditis.

Supplemental Material for Clinical and economic burden of heparin-induced thrombocytopenia in hospitalized patients undergoing percutaneous peripheral arterial interventions by Ahmed Subahi, Mohammed Osman, Oluwole Adegbala, Hossam Abubakar, Babikir Kheiri, Ahmed S Yassin, Mowyad Khalid, Emmanuel Akintoye, Ammar Eljack, Khansa Osman and Mohamad Alkhouli in Vascular