Regional variation across the United States in management and outcomes of ST-elevation myocardial infarction: analysis of the 2003 to 2010 nationwide inpatient sample database

BACKGROUND

Regional differences in the treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI) within the United States remain poorly understood.

HYPOTHESIS

Treatment choice and outcomes in patients with STEMI differ between regions within the United States.

METHODS

We used the 2003 to 2010 Nationwide Inpatient Sample databases to identify all patients age ≥ 40 years hospitalized with STEMI. Patients were divided into 4 groups according to region: Northeast, Midwest, South, and West. Multivariable logistic regression was used to identify differences in treatment choice and outcomes (in-hospital mortality, acute stroke, and cardiogenic shock) among the 4 regions.

RESULTS

Of 1,990,486 patients age ≥ 40 years with STEMI, 350,073 (17.6%) were hospitalized in the Northeast, 483,323 (24.3%) in the Midwest, 784,869 (39.4%) in the South, and 372,222 (18.7%) in the West. Compared with the Northeast, patients in the Midwest, South, and West were less likely to receive medical therapy alone and more likely to receive percutaneous coronary intervention and coronary artery bypass grafting. Risk-adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.05-1.09, P <0.001), South (OR: 1.03, 95% CI: 1.01-1.05, P = 0.001), and West (OR: 1.06, 95% CI: 1.04-1.08, P <0.001), as compared with the Northeast. When adjusted further for regional variation in treatment selection, risk-adjusted in-hospital mortality was even higher in the Midwest, West, and South.

CONCLUSIONS

Despite higher reperfusion and revascularization rates, STEMI patients in the Midwest, West, and South have paradoxically higher risk-adjusted in-hospital mortality as compared with patients in the Northeast.

Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States

BACKGROUND

Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group.

CONCLUSIONS

The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.

Association of corrected QT interval with long-term mortality in patients with syncope

INTRODUCTION

The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation.

MATERIAL AND METHODS

We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis.

RESULTS

Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality.

CONCLUSIONS

A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Trends in acute kidney injury and outcomes after early percutaneous coronary intervention in patients ≥75 years of age with acute myocardial infarction

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

Predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura

BACKGROUND

Despite the widespread availability of plasmapheresis as a therapy, thrombotic thrombocytopenic purpura is associated with significant morbidity and mortality. There is a paucity of data on the predictors of poor clinical outcome in this population. Acute myocardial infarction is a recognized complication of thrombotic thrombocytopenic purpura. Little is known about the magnitude of this problem, its risk factors, and its influence on mortality in patients hospitalized with thrombotic thrombocytopenic purpura.

METHODS

We used the 2001-2010 Nationwide Inpatient Sample database to identify patients aged ≥18 years with the diagnosis of thrombotic thrombocytopenic purpura (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 446.6) who also received therapeutic plasmapheresis (ICD-9-CM code 99.71) during the hospitalization. Patients with acute myocardial infarction were identified using the Healthcare Cost and Utilization Project Clinical Classification Software code 100. Stepwise logistic regression was used to determine independent predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura patients.

RESULTS

Among the 4032 patients (mean age 47.5 years, 67.7% women, and 36.9% white) with thrombotic thrombocytopenic purpura who also underwent plasmapheresis, in-hospital mortality was 11.1%. Independent predictors of increased in-hospital mortality were older age (odds ratio [OR] 1.03; 95% confidence interval [CI], 1.02-1.04; P <.001), acute myocardial infarction (OR 1.89; 95% CI, 1.24-2.88; P = .003), acute renal failure (OR 2.75; 95% CI, 2.11-3.58; P <.001), congestive heart failure (OR 1.66; 95% CI, 1.17-2.34; P = .004), acute cerebrovascular disease (OR 2.68; 95% CI, 1.87-3.85; P <.001), cancer (OR 2.49; 95% CI, 1.83-3.40; P <.001), and sepsis (OR 2.59; 95% CI, 1.88-3.59; P <.001). Independent predictors of acute myocardial infarction were older age (OR 1.03; 95% CI, 1.02-1.04; P <.001), smoking (OR 1.60; 95% CI, 1.14-2.24; P = .007), known coronary artery disease (OR 2.59; 95% CI, 1.76-3.81; P <.001), and congestive heart failure (OR 2.40; 95% CI, 1.71-3.37; P <.001).

CONCLUSION

In this large national database, patients with thrombotic thrombocytopenic purpura had an in-hospital mortality rate of 11.1% and an acute myocardial infarction rate of 5.7%. Predictors of in-hospital mortality were older age, acute myocardial infarction, acute renal failure, congestive heart failure, acute cerebrovascular disease, cancer, and sepsis. Predictors of acute myocardial infarction were older age, smoking, known coronary artery disease, and congestive heart failure.

Update on pharmacologic therapy for pulmonary embolism

Warfarin, unfractionated heparin (UFH), and low-molecular-weight heparins are anticoagulants that have been used for treatment of pulmonary embolism. Currently approved drugs for treatment of venous thromboembolism include UFH, enoxaparin, dalteparin, fondaparinux, warfarin, and rivaroxaban. The advent of newer oral anticoagulants such as rivaroxaban, dabigatran, and apixaban has provided us with alternative therapeutic options for long-term anticoagulation. This article will give an overview of the various anticoagulant drugs, use in various clinical scenarios, data supporting their clinical use, and recommendations regarding duration of anticoagulant therapy.

ST-elevation myocardial infarction in the elderly--temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States

BACKGROUND

Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥65 years with STEMI needed further investigation.

METHODS

We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and ≥80 years.

RESULTS

During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend<0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65 years of age who underwent PCI for STEMI.

CONCLUSIONS

In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.

Abstract 287: Association of Primary Payer Status and In-Hospital Mortality After Heart Transplant: A Nationwide Inpatient Sample Study

Background: Medicaid enrollment and expenditures are projected to increase sharply with the Affordable Care Act’s eligibility expansions. However, the impact of these changes on outcomes after heart transplant procedure has not been studied before. The aim of this study was to analyze the relationship between payment source and outcomes following heart transplant in a national database.

Methods: We used the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) to evaluate patients who obtained a heart transplant (ICD 9 procedure codes 37.51). Discharge weights were used to obtain nationwide estimates. A total of 2,329 heart transplant procedures were identified in the NIS database, corresponding to an estimated 11,536 nationwide heart transplant procedures between 2005 and 2010. Patients were stratified on the basis of payer status: Medicare (30%), Medicaid (17%), private insurance (52%), and uninsured (1.5%). Multivariable logistic regression models were used to assess the effect of primary payer status on in-hospital mortality.

Results: Patients had a mean age of 47 (±19) years, 26% were women and 55% were whites. Among insured patients, compared with private insurance, a higher unadjusted in-hospital mortality rate was found among patients with Medicare (4.3% vs. 6.4%; OR, 1.57; 95% CI, 1.31-1.89; P <0.001), and Medicaid (5.3%; OR, 1.30; 95% CI, 1.03-1.63; P=0.028). After controlling for patient demographics, comorbidities, income, hospital features and hospital region, Medicaid (OR, 1.41; 95% CI, 1.09-1.83; P=0.009) and Medicare (OR, 1.60; 95% CI, 1.31-1.96; P<0.0001) payer status were independently associated with higher in-hospital mortality. Length of stay was longest for Medicaid patients (48 ± 52 days) and shortest for Medicare patients (33 ± 38 days, P <0.001). Medicaid patients also accrued the highest unadjusted hospital charges (USD 518,233 ± 314,717, P <0.001).

Conclusion: In this national study of hospitalized patients undergoing heart transplant, uninsured payer status was rare. Medicaid or Medicare payer status was associated with increased risk adjusted in-hospital mortality, while Medicaid payer status was also associated with increased length of stay and increased hospital charges. Further prospective studies are needed to elucidate factors that are responsible for such disparities in outcomes by payer status.

Abstract 90: Ten-year Trends in Mechanical Revascularization, Intra-Aortic Balloon Pump Use and In-Hospital Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Background: Early mechanical revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with improved survival. The current guidelines also recommend (Class IIa) the use of intra-aortic balloon pump (IABP) in patients with cardiogenic shock. However, the evidence supporting this recommendation is controversial.

Objectives: To examine the trends (2001-2010) in mechanical revascularization, IABP use and in-hospital mortality in patients with cardiogenic shock complicating AMI and to determine if IABP use is associated with improved in-hospital survival among these patients.

Methods: We conducted a retrospective trend analysis of the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2001-2010. All patients ≥ 40 years of age with AMI and cardiogenic shock were identified using ICD-9-CM diagnosis codes. Trends in mechanical revascularization (PCI or CABG), IABP use and in-hospital mortality were analyzed. We used logistic regression analysis to determine the association between IABP use and in-hospital mortality.

Results: From 2001-2010, among 6,670,347 patients aged ≥ 40 years admitted with AMI, 287,256 (4.3%) had cardiogenic shock. The proportion of patients with cardiogenic shock complicating AMI increased from 3.7% in 2001 to 5.1% in 2010 (P trend < 0.001). There was a significant increase in mechanical revascularization rates (49.7% in 2001 to 66.3% in 2010, P trend < 0.001) as well as IABP use (38.7% in 2001 to 47.8% in 2010, P trend < 0.001) in these patients over the 10-year period. The overall in-hospital mortality among patients with AMI and cardiogenic shock decreased from 48.6% in 2001 to 32.7% in 2010 (P trend < 0.001). When adjusted for demographics, cardiovascular risk factors and mechanical revascularization status, IABP use was associated with higher in-hospital mortality (adjusted OR 1.14, 95% CI 1.11-1.16, P<0.001). Similarly, in the subgroup of patients who underwent mechanical revascularization, in-hospital mortality was higher among those with IABP placement (adjusted OR 1.39, 95% CI 1.35-1.43, P <0.001).

Conclusion: Mechanical revascularization rates in patients with cardiogenic shock complicating AMI have increased during the past decade. This is also associated with a decrease in in-hospital mortality during this period. IABP use has also increased over the past 10 years; however, IABP use is associated with higher in-hospital mortality among patients with AMI and cardiogenic shock.

Abstract 201: Predictors of Stroke in Hospitalized Patients with Thrombotic Thrombocytopenic Purpura

Background: Stroke may be the presenting symptom of thrombotic thrombocytopenic purpura (TTP), but the predictors of stroke in patients with TTP are unknown. We sought to seek the differences in characteristics in TTP patients presenting with and without stroke.

Methods: The study examined data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality for the years 2001 to 2010. Patients aged ≥ 18 years with the diagnosis of TTP (ICD-9 code 446.6) who received therapeutic plasmapheresis (ICD-9 code 99.71) were included for analysis. Patients with stroke among the group were identified using the HCUP clinical classification Software code (109 for stroke). Data on baseline characteristics and mortality were analyzed.

Results: A total of 4032 patients were identified to have TTP. Among these patients, 329 (8.16%) had the diagnosis of stroke. The independent predictors of stroke in this population by logistic regression analysis were age (OR 1.017; 95% CI 1.008 -1.026 p<0.001), white race (OR 0.704; 95% CI 0.536-0.926 p=0.012), dyslipidemia (OR 1.876; 95% CI 1.309-2.689 p= 0.001) and acute myocardial infarction (AMI) (OR 3.108; 95% CI 2.090-4.621 p<0.001). Independent predictors of in-hospital mortality in patients with TTP who developed stroke were hypertension (OR 0.399; 95% CI 0.190-0.839 p= 0.015), acute renal failure (OR 2.178; 95% CI 1.063-4.461 p=0.033), atrial fibrillation (OR 17.170; 95% CI 3.349-88.030 p=0.001), and ventricular tachycardia/ ventricular fibrillation/cardiac arrest (OR 12.748; 95% CI 1.982-81.979 p=0.007).

Conclusion: Stroke develops in 8.16% of patients admitted with TTP. The independent predictors of stroke in this group of patients are age, white race, dyslipidemia, and AMI.

Abstract P171: Etiologies of Syncope in 325 Consecutive Patients Hospitalized for Syncope

Purpose: To investigate the etiologies of syncope in patients hospitalized for syncope.

Methods: We investigated the etiologies of syncope in 325 consecutive patients, mean age 66 ± 17 years, hospitalized for syncope. All patients had Doppler echocardiograms and electrocardiographic monitoring by telemetry for arrhythmias during hospitalization.

Results: Of the 325 patients, the causes of syncope were vasovagal syncope in 58 patients (18%), volume depletion including acute blood loss and dehydration in 39 patients (12%), orthostatic hypotension in 8 patients (3%), bradyarrhythmias in 28 patients (18 with sick sinus syndrome and 10 with advanced second-degree or third-degree atrioventricular block) (9%), 36 with tachyarrhythmias (20 with ventricular tachycardia or ventricular fibrillation, 15 with supraventricular tachyarrhythmias, and 1 with pacemaker-mediated tachycardia) (11%), cardiomyopathy requiring insertion of an implantable cardioverter-defibrillator in 7 patients (2%), acute coronary syndromes in 23 patients (7%), aortic stenosis in 8 patients (3%), hypertrophic obstructive cardiomyopathy in 4 patients (1%), hypersensitive carotid sinus in 7 patients (2%), cerebral hemorrhage, ischemic stroke, or brain tumor documented by computed tomographic brain scans in 5 patients (2%), anaphylaxis in 2 patients (1%), sedative overdose in 5 patients (2%), hypoglycemia in 3 patients (1%), pulmonary embolism documented by contrast-enhanced spiral computed tomographic scans in 2 patients (1%), primary pulmonary hypertension in 2 patients (1%), micturition syncope in 2 patients (1%), heat stroke in 1 patient (<1%), cardiac tamponade in 1 patient (<1%), and undetermined etiology in 84 patients (26%).

Conclusions: Of 325 consecutive patients hospitalized for syncope, the cause of syncope was diagnosed in 241 patients (74%).

Abstract P349: Risk Factors for Rehospitalization for Syncope and for Long-Term Mortality in 325 Consecutive Patients Hospitalized for Syncope

Purpose: To investigate in patients hospitalized for syncope risk factors for rehospitalization for syncope and long-term mortality.

Methods: We investigated in 325 consecutive patients, mean age 66 ± 17 years, hospitalized for syncope risk factors for rehospitalization for syncope and long-term mortality. Mean follow-up was 27 ± 8 months.

Results: Of 325 patients, 13 (4%) were rehospitalized for syncope, and 38 (12%) died. Stepwise logistic regression analysis showed significant independent prognostic factors for rehospitalization for syncope were glomerular filtration rate (GFR) (odds ratio 0.97; 95% CI, 0.95-0.995) diabetes (odds ratio 5.7; 95% CI, 1.6-20.4), atrial fibrillation (odds ratio 4.0; 95% CI, 1.0-15.6), and smoking (odds ratio 4.6 ; 95% CI, 1.3-16.8). Stepwise Cox regression analysis showed significant independent prognostic factors for mortality were GFR (hazard ratio (HR) 0.98 (95% CI, 0.97-0.99), diabetes ( HR 2.7; 95% CI = 1.4-5.2), coronary artery surgery (HR 2.9; 95% CI, 1.3-6.5), malignancy history ( HR 2.5; 95% CI, 1.2-5.2), narcotics use (HR 4.0; 95% CI, 1.7-9.8), smoking (HR 2.8; 95% CI, 1.4-5.5), and atrial fibrillation (HR 2.4; 95% CI, 1.0-5.4).

Conclusions: In patients hospitalized for syncope, significant independent prognostic factors for rehospitalization for syncope were GFR, diabetes, atrial fibrillation, and smoking; significant independent prognostic factors for mortality were GFR, diabetes, coronary artery surgery, malignancy history, narcotics use, smoking, and atrial fibrillation.

Association of warfarin use with valvular and vascular calcification: a review

Vitamin K is required for the activity of various biologically active proteins in our body. Apart from clotting factors, vitamin K-dependent proteins include regulatory proteins like protein C, protein S, protein Z, osteocalcin, growth arrest-specific gene 6 protein, and matrix Gla protein. Glutamic acid residues in matrix Gla protein are γ-carboxylated by vitamin K-dependent γ-carboxylase, which enables it to inhibit calcification. Warfarin, being a vitamin K antagonist, inhibits this process, and has been associated with calcification in various animal and human studies. Though no specific guidelines are currently available to prevent or treat this less-recognized side effect, discontinuing warfarin and using an alternative anticoagulant seems to be a reasonable option. Newer anticoagulants such as dabigatran and rivaroxaban offer promise as future therapeutic options in such cases. Drugs including statins, alendronate, osteoprotegerin, and vitamin K are currently under study as therapies to prevent or treat warfarin-associated calcification. Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Etiology of syncope in patients hospitalized with syncope and predictors of mortality and rehospitalization for syncope at 27-month follow-up

The authors investigated the etiologies of syncope and risk factors for mortality and rehospitalization for syncope at 27-month follow-up in 325 consecutive patients, mean age 66 years, hospitalized for syncope. The causes of syncope were diagnosed in 241 patients (74%). Of 325 patients, 13 (4%) were rehospitalized for syncope and 38 (12%) died. Stepwise logistic regression analysis showed that significant independent prognostic factors for rehospitalization for syncope were diabetes (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.6-20.4), atrial fibrillation (OR, 4.0; 95% CI, 1.0-15.6), and smoking (OR, 4.6; 95% CI, 1.3-16.8). Stepwise Cox regression analysis showed that significant independent prognostic factors for time to mortality were diabetes (hazard ratio [HR], 2.7; 95% CI, 1.4-5.2), coronary artery bypass graft surgery (HR, 2.9; 95% CI, 1.3-6.5), malignancy history (HR, 2.5; 95% CI, 1.2-5.2), narcotics use (HR, 4.0; 95% CI, 1.7-9.8), smoking (HR, 2.8; 95% CI, 1.4-5.5), atrial fibrillation (HR, 2.4; 95% CI, 1.0-5.4), and volume depletion (HR, 2.8; 95% CI, 1.4-5.8). Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.