Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Fibrinolysis vs. primary percutaneous coronary intervention for ST-segment elevation myocardial infarction cardiogenic shock

AIMS

There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI).

METHODS

Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status.

RESULTS

During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs.

CONCLUSIONS

The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.

Sex differences in acute cardiovascular care: a review and needs assessment

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Ten-year trends, predictors and outcomes of mechanical circulatory support in percutaneous coronary intervention for acute myocardial infarction with cardiogenic shock

AIMS

There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS.

METHODS AND RESULTS

Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p<0.001) and greater resource utilisation. IABP-assisted PCI had lower in-hospital mortality and lesser resource utilisation compared to pLVAD/ECMO.

CONCLUSIONS

MCS-assisted PCI identified a sicker AMI-CS cohort. There was a decrease in IABP and an increase in pLVAD/ECMO.

Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock

Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.

Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States

Background

There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI).

Objective

To assess the influence of insurance status on STEMI outcomes.

Methods

Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition.

Results

Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home.

Conclusions

Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Facilitating supportive care in cardiac intensive care units

PURPOSE OF REVIEW

The number of patients who die in the hospital in the Western world is high, and 20-30% of them are admitted to an ICU in the last month of life, including those in cardiac ICUs (CICUs) where invasive procedures are performed and mortality is high. Palliative consultation is provided in only a few cases. The ethical and decisional aspects associated with the advanced stages of illness are very rarely discussed.

RECENT FINDINGS

The epidemiological and clinical landscape of CICUs has changed in the last decade; the incidence of acute coronary syndromes has decreased, whereas noncardiovascular diseases, comorbidities, the patients' age and clinical and therapeutic complexity have increased. The use of advanced and invasive treatments, such as mechanical ventilation, mechanical circulatory support and renal replacement therapies, has increased. This evolution increases the possibility of developing a life-threatening clinical event.

SUMMARY

This review aimed to analyze the main epidemiological, clinical, ethical and training aspects that can facilitate the introduction of supportive/palliative care programs in the CICU to improve symptom management during the advanced/terminal stages of illness, and address such issues as advance care planning, withdrawing/withholding life-sustaining treatments, deactivation of implantable defibrillators and palliative sedation.

Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease

Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005–2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD–38.5%, 2.6%; CKD-III–79.1%, 6.5%; CKD-IV–84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21–1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69–0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77–0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.

Long-Term Outcomes of Acute Myocardial Infarction With Concomitant Cardiogenic Shock and Cardiac Arrest

This study sought to evaluate long-term mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients with cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI). This was a retrospective cohort study using an administrative claims database. AMI patients from January 1, 2010 to May 31, 2018 were stratified into CA + CS, CA only, CS only, and AMI alone cohorts. Outcomes of interest were long-term mortality and MACCE (death, AMI, cerebrovascular accident, unplanned revascularization) in AMI survivors. A total 163,071 AMI patients were included with CA + CS, CA only, and CS only in 2.4%, 5.0%, and 4.0%, respectively. The CA + CS cohort had higher rates of multiorgan failure, mechanical circulatory support use and less frequent coronary angiography use. In-hospital mortality was noted in 10,686 (6.6%) patients - CA + CS (48.8%), CA only (35.9%), CS only (24.1%), and AMI alone (2.9%; p < 0.001). Over 23.5 ± 21.7 months follow-up after hospital discharge, patients with CA + CS (hazard ratio [HR] 1.36 [95% confidence interval {CI} 1.19 to 1.55]), CA only (HR 1.16 [95% CI 1.08 to 1.25]), CS only (HR 1.39 [95% CI 1.29 to 1.50]) had higher all-cause mortality compared with AMI alone (all p < 0.001). Presence of CS, either alone (HR 1.22 [95% CI 1.16 to 1.29]; p < 0.001) or with CA (HR 1.18 [95% CI 1.07 to 1.29]; p < 0.001), was associated with higher MACCE compared with AMI alone. In conclusion, CA + CS, CA, and CS were associated with worse long-term survival. CA and CS continue to influence outcomes beyond the index hospitalization in AMI survivors.

Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young

BACKGROUND

There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults.

METHODS

A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay.

RESULTS

A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P<0.001). Compared with men, women with AMI-CS were more frequently of Black race, from a lower socioeconomic status, with higher comorbidity, and admitted to rural and small hospitals (all P<0.001). Women had lower rates of ST-segment elevation presentation (73.0% versus 78.7%), acute noncardiac organ failure, cardiac arrest (34.3% versus 35.7%), and received less-frequent coronary angiography (78.3% versus 81.4%), early coronary angiography (49.2% versus 54.1%), percutaneous coronary intervention (59.2% versus 64.0%), and mechanical circulatory support (50.3% versus 59.2%; all P<0.001). Female sex was an independent predictor of in-hospital mortality (23.0% versus 21.7%; adjusted odds ratio, 1.11 [95% CI, 1.07-1.16]; P<0.001). Women had lower hospitalization costs ($156 372±$198 452 versus $167 669±$208 577; P<0.001) but comparable lengths of stay compared with men.

CONCLUSIONS

In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.

Complications from percutaneous-left ventricular assist devices versus intra-aortic balloon pump in acute myocardial infarction-cardiogenic shock

BACKGROUND

There are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS).

OBJECTIVE

To assess the trends, rates and predictors of complications.

METHODS

Using a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied.

RESULTS

Of 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all p<0.001 except for amputation). Non-White race, higher comorbidity, organ failure, and extracorporeal membrane oxygen use were predictors of complications for both cohorts. The pLVAD cohort with complications had higher in-hospital mortality (45.5% vs. 33.1%; adjusted odds ratio 1.65 [95% confidence interval 1.55-1.75]), shorter duration of hospital stay, and higher hospitalization costs compared to the IABP cohort with complications (all p<0.001). These results were consistent in propensity-matched pairs.

CONCLUSIONS

AMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.

Management and outcomes of uncomplicated ST-segment elevation myocardial infarction patients transferred after fibrinolytic therapy

BACKGROUND

This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy ('drip-and-ship') for ST-segment elevation myocardial infarction (STEMI) in the United States.

METHODS

During 2009-2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition.

RESULTS

A total of 27,454 STEMI admissions receiving a 'drip-and-ship strategy', 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11-0.27]; p < .001) but not CA without revascularization (OR 0.72 [95% CI 0.42-1.21]; p = .21) was associated with lower in-hospital mortality. The fibrinolysis alone cohort had higher use of do-not-resuscitate status (12.8%) and fewer discharges to home (56.6%) compared to cohorts undergoing CA without (1.7%; 86.9%) and with (0.3% and 91.2%) revascularization, respectively. Presence of complications, do-not-resuscitate status, and higher comorbidity were predictive of lower CA and revascularization use.

CONCLUSION

Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes.

Inpatient Palliative Care Use in Patients With Pulmonary Arterial Hypertension: Temporal Trends, Predictors, and Outcomes

BACKGROUND

Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce.

RESEARCH QUESTION

We sought to evaluate the inpatient use of PCS in patients with PAH.

STUDY DESIGN AND METHODS

Using the National (Nationwide) Inpatient Sample, 30,495 admissions with a primary diagnosis of PAH were identified from 2001 through 2017. The primary outcome of interest was temporal trends and predictors of inpatient PCS use in patients with PAH.

RESULTS

The inpatient use of PCS was low (2.2%), but increased during the study period from 0.5% in 2001 to 7.6% in 2017, with a significant increase starting in 2009. White race, private insurance, higher socioeconomic status, hospital-specific factors, higher comorbidity burden (Charlson Comorbidity Index), cardiac and noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation were independent predictors of increased PCS use. PCS use was associated with a higher prevalence of do-not-resuscitate status, a longer length of stay, higher hospitalization costs, and increased in-hospital mortality with less frequent discharges to home, likely because these patients were also sicker (higher comorbidity index and illness acuity).

INTERPRETATION

The inpatient use of PCS in patients with PAH is low, but has been increasing over recent years. Despite increased PCS use over time, patient- and hospital-specific disparities in PCS use continue. Further studies evaluating these disparities and the role of PCS in the comprehensive care of PAH patients are warranted.

Influence of seasons on the management and outcomes acute myocardial infarction: An 18-year US study

Background

There are limited data on the seasonal variation in acute myocardial infarction (AMI) in the contemporary literature.

Hypothesis

There would be decrease in the seasonal variation in the management and outcomes of AMI.

Methods

Adult (>18 years) AMI admissions were identified using the National Inpatient Sample (2000‐2017). Seasons were classified as spring, summer, fall, and winter. Outcomes of interest included prevalence, in‐hospital mortality, use of coronary angiography, and percutaneous coronary intervention (PCI). Subgroup analyses for type of AMI and patient characteristics were performed.

Results

Of the 10 880 856 AMI admissions, 24.3%, 22.9%, 22.2%, and 24.2% were admitted in spring, summer, fall, and winter, respectively. The four cohorts had comparable age, sex, race, and comorbidities distribution. Rates of coronary angiography and PCI were slightly but significantly lower in winter (62.6% and 40.7%) in comparison to the other seasons (64‐65% and 42‐43%, respectively) (P < .001). Compared to spring, winter admissions had higher in‐hospital mortality (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.06‐1.08), whereas summer (aOR 0.97; 95% CI 0.96‐0.98) and fall (aOR 0.98; 95% CI 0.97‐0.99) had slightly lower in‐hospital mortality (P < .001). ST‐segment elevation (10.0% vs 9.1%; aOR 1.07; 95% CI 1.06‐1.08) and non‐ST‐segment elevation (4.7% vs 4.2%; aOR 1.07; 95% CI 1.06‐1.09) AMI admissions in winter had higher in‐hospital mortality compared to spring (P < .001). The primary results were consistent when stratified by age, sex, race, geographic region, and admission year.

Conclusions

Compared to other seasons, winter admission was associated with higher in‐hospital mortality in AMI in the United States.

Cardiogenic shock and cardiac arrest complicating ST-segment elevation myocardial infarction in the United States, 2000-2017

BACKGROUND

There are limited data on the outcomes of cardiogenic shock (CS) and cardiac arrest (CA) complicating ST-segment-elevation myocardial infarction (STEMI).

METHODS

Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample (2000-2017) and classified as CS + CA, CS only, CA only and no CS/CA. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, use of do-not-resuscitate (DNR) status and palliative care referrals across the four cohorts.

RESULTS

Of the 4,320,117 STEMI admissions, CS, CA and both were noted in 5.8%, 6.2% and 2.7%, respectively. In 2017, compared to 2000, there was an increase in CA (adjusted odds ratio [aOR] 1.83 [95% confidence interval {CI} 1.79-1.86]), CS (aOR 3.92 [95% CI 3.84-4.01]) and both (aOR 4.09 [95% CI 3.94-4.24]) (all p < 0.001). The CS+CA (77.2%) cohort had higher rates of multiorgan failure than CS only (59.7%) and CA only (26.3%), p < 0.001. The CA only cohort had lower rates (64%) of coronary angiography compared to the other groups (>70%), p < 0.001. In-hospital mortality was higher in CS+CA compared to CS alone (adjusted OR 1.87 [95% CI 1.83-1.91]), CA alone (adjusted OR 1.99 [95% CI 1.95-2.03]) or neither (aOR 18.37 [95% CI 18.02-18.71]). The CS+CA cohort had higher use of palliative care and DNR status. The presence of CS, either alone or in combination with CA, was associated with higher hospitalization costs.

CONCLUSIONS

The combination of CS and CA was associated with higher rates of non-cardiac organ failure and in-hospital mortality in STEMI compared to those with either CS or CA alone.

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Introduction

Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.

Methods

This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.

Results

We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.

Conclusion

The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Epidemiological Trends in the Timing of In-Hospital Death in Acute Myocardial Infarction-Cardiogenic Shock in the United States

BACKGROUND

There are limited data on the epidemiology and timing of in-hospital death (IHD) in patients with acute myocardial infarction-cardiogenic shock (AMI-CS).

METHODS

Adult admissions with AMI-CS with IHDs were identified using the National Inpatient Sample (2000-2016) and were classified as early (≤2 days), mid-term (3-7 days), and late (>7 days). Inter-hospital transfers and those with do-not-resuscitate statuses were excluded. The outcomes of interest included the epidemiology, temporal trends and predictors for IHD timing.

RESULTS

IHD was noted in 113,349 AMI-CS admissions (median time to IHD 3 (interquartile range 1-7) days), with early, mid-term and late IHD in 44%, 32% and 24%, respectively. Compared to the mid-term and late groups, the early IHD group had higher rates of ST-segment-elevation AMI-CS (74%, 63%, 60%) and cardiac arrest (37%, 33%, 29%), but lower rates of acute organ failure (68%, 79%, 89%), use of coronary angiography (45%, 56%, 67%), percutaneous coronary intervention (33%, 36%, 42%), and mechanical circulatory support (31%, 39%, 50%) (all p < 0.001). There was a temporal increase in the early (adjusted odds ratio (aOR) for 2016 vs. 2000 2.50 (95% confidence interval (CI) 2.22-2.78)) and a decrease in mid-term (aOR 0.75 (95% CI 0.71-0.79)) and late (aOR 0.34 (95% CI 0.31-0.37)) IHD. ST-segment-elevation AMI-CS and cardiac arrest were associated with the increased risk of early IHD, whereas advanced comorbidity and acute organ failure were associated with late IHD.

CONCLUSIONS

Early IHD after AMI-CS has increased between 2000 and 2016. The populations with early vs. late IHD were systematically different.

Reporting of sex as a variable in cardiovascular studies using cultured cells: A systematic review

Reporting the sex of biological material is critical for transparency and reproducibility in science. This study examined the reporting of the sex of cells used in cardiovascular studies. Articles from 16 cardiovascular journals that publish peer-reviewed studies in cardiovascular physiology and pharmacology in the year 2018 were systematically reviewed using terms "cultured" and "cells." Data were collected on the sex of cells, the species from which the cells were isolated, and the type of cells, and summarized as a systematic review. Sex was reported in 88 (38.6%) of the 228 studies meeting inclusion criteria. Reporting rates varied with Circulation, Cardiovascular Research and American Journal of Physiology: Heart and Circulatory Physiology having the highest rates of sex reporting (>50%). A majority of the studies used cells from male (54.5%) or both male and female animals (32.9%). Humans (31.8%), rats (20.4%), and mice (43.8%) were the most common sources for cells. Cardiac myocytes were the most commonly used cell type (37.0%). Overall reporting of sex of experimental material remains below 50% and is inconsistent among journals. Sex chromosomes in cells have the potential to affect protein expression and molecular signaling pathways and should be consistently reported.

Burden of Arrhythmias in Acute Myocardial Infarction Complicated by Cardiogenic Shock

There are limited data on arrhythmias in acute myocardial infarction with cardiogenic shock (AMI-CS). Using a 17-year AMI-CS population from the National Inpatient Sample, we identified common arrhythmias - atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrioventricular blocks (AVB). Admissions with concomitant cardiac surgery were excluded. Outcomes of interest included temporal trends, predictors, in-hospital mortality, and resource utilization in cohorts with and without arrhythmias. Of the 420,319 admissions with AMI-CS during 2000 to 2016, arrhythmias were noted in 213,718 (51%). AF (45%), ventricular tachycardia (35%) and ventricular fibrillation (30%) were the most common arrhythmias. Compared with those without, the cohort w`ith arrhythmias was more often male, of white race, with ST-segment elevation AMI-CS presentation, and had higher rates of cardiac arrest and acute organ failure (all p <0.001). Temporal trends of prevalence revealed a stable trend of atrial and ventricular arrhythmias and declining trend in AVB. The cohort with arrhythmias had higher unadjusted (42% vs 41%; odds ratio [OR] 1.03 [95% confidence interval 1.02 to 1.05]; p <0.001), but not adjusted (OR 1.01 [95% CI 0.99 to 1.03]; p = 0.22) in-hospital mortality compared with those without. The cohort with arrhythmias had longer hospital stay (9 ± 10 vs 7 ± 9 days; p <0.001) and higher hospitalization costs ($124,000 ± 146,000 vs $91,000 ± 115,000; p <0.001). In the cohort with arrhythmias, older age, female sex, non-white race, higher co-morbidity, presence of acute organ failure, and cardiac arrest, predicted higher in-hospital mortality. In conclusion, cardiac arrhythmias in AMI-CS are a marker of higher illness severity and are associated with greater resource utilization.

Weekend Effect in the Management and Outcomes of Acute Myocardial Infarction in the United States, 2000-2016

Objective

To assess the effects of weekend admission vs weekday admission on the management and outcomes of acute myocardial infarction (AMI).

Methods

Adult ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) hospital admissions were identified using the National (Nationwide) Inpatient Sample (2000-2016). Interhospital transfers were excluded. Timing of coronary angiography (CA) and percutaneous coronary intervention (PCI) relative to the day of admission was identified. Outcomes of interest included in-hospital mortality, receipt of early CA, timing of CA and PCI, resource utilization, and discharge disposition for weekend vs weekday admissions.

Results

Of the 9,041,819 AMI admissions, 2,406,876 (26.6%) occurred on weekends. Compared with 2000, in 2016 there was an increase in weekend STEMI (adjusted odds ratio [aOR], 1.12; 95% CI, 1.08-1.16; P<.001) but not NSTEMI (aOR, 1.01; 95% CI, 0.98-1.02; P=.21) admissions. Compared with weekday admissions, weekend admissions received comparable CA (59.9% vs 58.8%) and PCI (38.4% vs 37.6%) and specifically lower rates of early CA (hospital day 0) (26.0% vs 20.8%; P<.001). There was a steady increase in CA and PCI use during the 17-year period. Mean ± SD time to CA was higher in the weekend group vs the weekday group (1.2±1.8 vs 1.0±1.8 days; P<.001). Weekend admission did not influence in-hospital mortality (aOR, 1.01; 95% CI, 1.00-1.01; P=.05) but had fewer discharges to home (58.7% vs 59.7%; P<.001).

Conclusion

Despite small differences in CA and PCI, there were no differences in in-hospital mortality of AMI admissions on weekdays vs weekends in the United States in the contemporary era.

Sex Disparities in the Use and Outcomes of Temporary Mechanical Circulatory Support for Acute Myocardial Infarction-Cardiogenic Shock

Background

There are limited sex-specific data on patients receiving temporary mechanical circulatory support (MCS) for acute myocardial infarction-cardiogenic shock (AMI-CS).

Methods

All admissions with AMI-CS with MCS use were identified using the National Inpatient Sample from 2005 to 2016. Outcomes of interest included in-hospital mortality, discharge disposition, use of palliative care and do-not-resuscitate (DNR) status, and receipt of durable left ventricular assist device (LVAD) and cardiac transplantation.

Results

In AMI-CS admissions during this 12-year period, MCS was used more frequently in men-50.4% vs 39.5%; P < 0.001. Of the 173,473 who received MCS (32% women), intra-aortic balloon pumps, percutaneous LVAD, extracorporeal membrane oxygenation, and ≥ 2 MCS devices were used in 92%, 4%, 1%, and 3%, respectively. Women were on average older (69 ± 12 vs 64 ± 13 years), of black race (10% vs 6%), and had more comorbidity (mean Charlson comorbidity index 5.0 ± 2.0 vs 4.5 ± 2.1). Women had higher in-hospital mortality than men (34% vs 29%, adjusted odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.16-1.23; P < 0.001) overall, in intra-aortic balloon pumps users (OR: 1.20 [95% CI: 1.16-1.23]; P < 0.001), and percutaneous LVAD users (OR: 1.75 [95% CI: 1.49-2.06]; P < 0.001), but not in extracorporeal membrane oxygenation or ≥ 2 MCS device users (P > 0.05). Women had higher use of palliative care, DNR status, and discharges to skilled nursing facilities.

Conclusions

There are persistent sex disparities in the outcomes of AMI-CS admissions receiving MCS support. Women have higher in-hospital mortality, palliative care consultation, and use of DNR status.

Epidemiology of in-hospital cardiac arrest complicating non-ST-segment elevation myocardial infarction receiving early coronary angiography

In the period between 2000 and 2014, 584,704 admissions with non-ST-segment elevation myocardial infarction that received early coronary angiography (day zero) were identified from the National Inpatient Sample. In-hospital cardiac arrest was noted in 4349 (0.8%), of which ~47% were from ventricular arrhythmias and ~90% of occurred within ≤4 days. Non-ST-segment elevation myocardial infarction admissions with in-hospital cardiac arrest had higher in-hospital mortality compared to those without (61% vs. 1.6%) with an unchanged temporal trend of in-hospital cardiac arrest rates (adjusted odds ratio 1.29 [95% confidence interval 0.73-2.28]) in 2014 compared to 2000).

Systems of Care in Cardiogenic Shock

Cardiogenic shock presents a significant challenge to the medical community, and there is much debate as to the best classification system and treatment mechanisms. As interventions and technologies improve, systems of care for patients with cardiogenic shock must evolve as well. This review describes the current treatment models for cardiogenic shock, including the "hub-and-spoke" model, and defines specific characteristics of the ideal system of care for this patient population.

Pulmonary artery catheter use in acute myocardial infarction-cardiogenic shock

Aims

The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction‐cardiogenic shock (AMI‐CS).

Methods and results

A retrospective cohort of AMI‐CS admissions using the National Inpatient Sample (2000–2014) was identified. Admissions with concomitant cardiac surgery or non‐AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in‐hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non‐PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000–2014, 364 001 admissions with AMI‐CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non‐teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in‐hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04–1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity‐matched pairs, in‐hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94–1.08]). Right heart catheterization was used in 12.5% of non‐PAC admissions and was a marker of greater severity but did not indicate worse outcomes.

Conclusions

In AMI‐CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Background: There are limited data on complications in acute myocardial infarction (AMI) admissions receiving extracorporeal membrane oxygenation (ECMO). Methods: Adult (>18 years) admissions with AMI receiving ECMO support were identified from the National Inpatient Sample database between 2000 and 2016. Complications were classified as vascular, lower limb amputation, hematologic, and neurologic. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, and length of stay. Results: In this 17-year period, in ~10 million AMI admissions, ECMO support was used in 4608 admissions (<0.01%)—mean age 59.5 ± 11.0 years, 75.7% men, 58.9% white race. Median time to ECMO placement was 1 (interquartile range [IQR] 0–3) day. Complications were noted in 2571 (55.8%) admissions—vascular 6.1%, lower limb amputations 1.1%, hematologic 49.3%, and neurologic 9.9%. There was a steady increase in overall complications during the study period (21.1% in 2000 vs. 70.5% in 2016). The cohort with complications, compared to those without complications, had comparable adjusted in-hospital mortality (60.7% vs. 54.0%; adjusted odds ratio 0.89 [95% confidence interval 0.77–1.02]; p = 0.10) but longer median hospital stay (12 [IQR 5–24] vs. 7 [IQR 3–21] days), higher median hospitalization costs ($458,954 [IQR 260,522–737,871] vs. 302,255 [IQR 173,033–623,660]), fewer discharges to home (14.7% vs. 17.9%), and higher discharges to skilled nursing facilities (44.1% vs. 33.9%) (all p < 0.001). Conclusions: Over half of all AMI admissions receiving ECMO support develop one or more severe complications. Complications were associated with higher resource utilization during and after the index hospitalization.

Regional Variation in the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock in the United States

BACKGROUND

There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS).

METHODS AND RESULTS

Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93-0.98]; P<0.001) and West (aOR, 0.96 [95% CI, 0.94-0.98]; P=0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01-1.06]; P=0.002). The Midwest (aOR, 1.68 [95% CI, 1.62-1.74]; P<0.001), South (aOR, 1.86 [95% CI, 1.80-1.92]; P<0.001), and West (aOR, 1.93 [95% CI, 1.86-2.00]; P<0.001) had higher discharges to home.

CONCLUSIONS

There remain significant regional disparities in the management and outcomes of AMI-CS.

Acute myocardial infarction-cardiogenic shock in patients with prior coronary artery bypass grafting: A 16-year national cohort analysis of temporal trends, management and outcomes

BACKGROUND

There are limited data on the outcomes of acute myocardial infarction with cardiogenic shock (AMI-CS) in patients with prior coronary artery bypass grafting (CABG).

METHODS

A retrospective cohort of AMI-CS admissions during 2000-2016 from the National Inpatient Sample was created and prior CABG status was identified. Outcomes of interest included in-hospital mortality and resource utilization in the two cohorts. Temporal trends of prevalence, in-hospital mortality, and cardiac procedures were evaluated.

RESULTS

In 513,288 AMI-CS admissions, prior CABG was performed in 22,832 (4.4%). Adjusted temporal trends showed a 2-fold increase in CS in both cohorts. There was a temporal increase in coronary angiography and percutaneous coronary intervention (PCI) across both cohorts. The cohort with prior CABG was on average older, of male sex, of white race, and with higher comorbidity. The cohort with prior CABG received coronary angiography (50% vs. 75%), PCI (32% vs. 49%), right heart catheterization/pulmonary artery catheterization (15% vs. 20%), mechanical circulatory support (26% vs. 46%) less frequently compared to those without (all p < 0.001). The cohort with CABG had higher in-hospital mortality (53% vs. 37%; adjusted odds ratio 1.41 [95% confidence interval 1.36-1.46]), greater use of do not resuscitate status (13% vs. 6%), shorter lengths of hospital stay (7 ± 8 vs. 10 ± 12 days), lower hospitalization costs ($92,346 ± 139,565 vs. 138,508 ± 172,895) and fewer discharges to home (39% vs. 43%) (all p < 0.001).

CONCLUSIONS

In AMI-CS, admission with prior CABG was older and had lower use of cardiac procedures and higher in-hospital mortality compared to those without prior CABG.

Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000 to 2014

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data.

METHODS

Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization.

RESULTS

In ≈9 million AMI admissions, ECMO was used in 2962 (<0.01%) and implanted a median of 1 day after admission. ECMO was used in 0.5% and 0.3% AMI admissions complicated by cardiogenic shock and cardiac arrest, respectively. ECMO was used more commonly in admissions that were younger, nonwhite, and with less comorbidity. ECMO use was 11× higher in 2014 as compared with 2000 (odds ratio, 11.37 [95% CI, 7.20-17.97]). Same-day percutaneous coronary intervention was performed in 23.1%; intra-aortic balloon pump/percutaneous LVAD was used in 57.9%, of which 30.3% were placed concomitantly. In-hospital mortality with ECMO was 59.2% overall but decreased from 100% (2000) to 45.1% (2014). Durable LVAD and cardiac transplantation were performed in 11.7% as an exit strategy. Of the hospital survivors, 40.8% were discharged to skilled nursing facilities. Older age, male sex, nonwhite race, and lower socioeconomic status were independently associated with higher in-hospital mortality with ECMO use.

CONCLUSIONS

In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO.

Complications of Temporary Percutaneous Mechanical Circulatory Support for Cardiogenic Shock: An Appraisal of Contemporary Literature

Cardiogenic shock (CS) is associated with hemodynamic compromise and end-organ hypoperfusion due to a primary cardiac etiology. In addition to vasoactive medications, percutaneous mechanical circulatory support (MCS) devices offer the ability to support the hemodynamics and prevent acute organ failure. Despite the wide array of available MCS devices for CS, there are limited data on the complications from these devices. In this review, we seek to summarize the complications of MCS devices in the contemporary era. Using a systems-based approach, this review covers domains of hematological, neurological, vascular, infectious, mechanical, and miscellaneous complications. These data are intended to provide a balanced narrative and aid in risk-benefit decision-making in this acutely ill population.

Intravascular ultrasound, optical coherence tomography, and fractional flow reserve use in acute myocardial infarction

BACKGROUND

There are limited data on the use of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR) during acute myocardial infarction (AMI).

OBJECTIVES

To assess the temporal trends of IVUS, OCT, and FFR use in AMI.

METHODS

A retrospective cohort study from the National Inpatient Sample (2004-2014) was designed to include AMI admissions that received coronary angiography. Administrative codes were used to identify percutaneous coronary intervention (PCI), IVUS, OCT, and FFR. Outcomes included temporal trends, inhospital mortality and resource utilization stratified by IVUS, OCT, or FFR use.

RESULTS

In 4,419,973 AMI admissions, IVUS, OCT, and FFR were used in 2.6%, 0.1%, and 0.6%, respectively. There was a 22-fold, 118-fold, and 33-fold adjusted increase in IVUS, OCT, and FFR use, respectively, in 2014 compared to the first year of use. Non-ST-elevation AMI presentation, male sex, private insurance coverage, admission to a large urban hospital, and absence of cardiac arrest and cardiogenic shock were associated with higher IVUS, OCT, or FFR use. PCI was performed in 83.2% of the IVUS, OCT, or FFR cohort compared to 64.2% of the control group (p < .001). The cohort with IVUS/OCT/FFR use had lower inhospital mortality (adjusted odds ratio 0.53 [95% confidence interval 0.50-0.56]), more frequent discharges to home (83.7% vs. 76.8%), shorter hospital stays (4.3 ± 4.4 vs. 5.0 ± 5.5 days) and higher hospitalization costs ($90,683 ± 74,093 vs. $74,671 ± 75,841).

CONCLUSIONS

In AMI, the use of IVUS, OCT, and FFR has increased during 2004-2014. Significant patient and hospital-level disparities exist in the use of these technologies.

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock

Background

There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS.

Methods

This was a retrospective cohort study from 2000–2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition.

Results

During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001).

Conclusion

AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock

BACKGROUND

There are limited data on the prevalence and outcomes of chronic total occlusions (CTO) of the coronary artery in acute myocardial infarction with cardiogenic shock (AMI-CS) patients.

METHODS

Using the National Inpatient Sample, all admissions with AMI-CS that underwent diagnostic angiography between January 1, 2008, and December 31, 2014, were included. CTO, percutaneous coronary intervention (PCI), comorbidities and concomitant cardiac arrest was identified for all admissions. Outcomes of interest included temporal trends, in-hospital mortality, and resource utilization in cohorts with and without CTO.

RESULTS

In this 7-year period, 163,628 admissions with AMI-CS admissions met the inclusion criteria, with 68% being ST-elevation AMI-CS. CTO was noted in 27,343 (16.7%) admissions, with an increase in prevalence during the study period. The cohort with CTOs was more likely to be male and bearing private insurance. The CTO cohort had higher cardiovascular comorbidity, higher rates of cardiac arrest and higher use of PCI and mechanical circulatory support. The presence of a CTO was independently associated with higher in-hospital mortality (adjusted odds ratio 1.20 [95% confidence interval 1.16-1.23]; p < 0.001). The cohort with CTO had lower resource utilization (hospital stay and hospitalization costs) but was discharged more frequently to other hospitals. The presence of a CTO was associated with higher in-hospital mortality in the sub-groups of ST-elevation AMI-CS (31.5% vs. 28.7%; p < 0.001) and non-ST-elevation AMI-CS (24.8% vs. 23.2%; p < 0.001).

CONCLUSIONS

In this cohort of AMI-CS admissions that underwent diagnostic angiography, the presence of a CTO identified a higher risk cohort that had higher in-hospital mortality.

Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000-2014

Background

There are limited epidemiological data on acute respiratory failure (ARF) in cardiogenic shock complicating acute myocardial infarction (AMI-CS). This study sought to evaluate the prevalence and outcomes of ARF in AMI-CS.

Methods

This was a retrospective study of AMI-CS admissions during 2000–2014 from the National Inpatient Sample. Administrative codes for ARF and mechanical ventilation (MV) were used to define the cohorts of no ARF, ARF without MV and ARF with MV. Admissions with a secondary diagnosis of AMI and with chronic MV were excluded. Outcomes of interest included in-hospital mortality, temporal trends of ARF prevalence and resource utilization.

Measurements and main results

During 2000–2014, 439,436 admissions for AMI-CS met the inclusion criteria. ARF and MV were noted in 57% and 43%, respectively. Admissions with non-ST-elevation AMI-CS, of non-White race and with non-private insurance received MV more frequently. Noninvasive ventilation and invasive MV increased from 0.4% and 39.2% (2000) to 3.6% and 46.4% (2014), respectively (p < 0.001). Coronary angiography and percutaneous coronary intervention were used less frequently in admissions receiving ARF with MV. Compared to admissions with no ARF, ARF without MV (adjusted odds ratio (aOR) 1.56 [95% confidence interval (CI) 1.53–1.59]; p < 0.001) and ARF with MV (aOR 2.50 [95% CI 2.47–2.54]; p < 0.001) were associated with higher in-hospital mortality. Admissions with ARF without MV had greater resource utilization and lesser discharges to home as compared to no ARF.

Conclusions

In this contemporary AMI-CS cohort, the presence of ARF and MV use was noted in 57% and 43%, respectively, and was associated with higher in-hospital mortality.

Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Background

This study sought to evaluate the 15‐year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction.

Methods and Results

A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction–cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in‐hospital mortality and resources utilization. Multivariable regression and propensity‐matching analyses were used to control for confounding. In this 15‐year period, there were 444 253 acute myocardial infarction–cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in‐hospital mortality (odds ratio 6.59 [95% CI 6.37–6.83]; P<0.001). The cohort with PCS use had >2‐fold higher in‐hospital mortality, 12‐fold higher use of do‐not‐resuscitate status, lesser in‐hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity‐matched cohort.

Conclusions

PCS use in patients with acute myocardial infarction–cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital‐specific disparities in the utilization of PCS.