Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective

Recurrent Non-Variceal Upper Gastrointestinal Bleeding among Patients Receiving Dual Antiplatelet Therapy

BACKGROUND

Patients undergoing dual antiplatelet therapy (DAPT) may experience recurrent gastrointestinal bleeding (GIB). We investigated the clinical characteristics and risk factors for recurrent non-variceal upper gastrointestinal bleeding (NVUGIB) in patients who had experienced NVUGIB while receiving DAPT.

METHODS

We enrolled patients diagnosed with NVUGIB while receiving DAPT between 2006 and 2020. Definite bleeding was confirmed by esophagogastroduodenoscopy in all NVUGIB patients.

RESULTS

A total of 124 patients were diagnosed with NVUGIB while receiving DAPT. They were predominantly male (n = 103, 83.1%), bleeding mostly from the stomach (n = 94, 75.8%) and had peptic ulcers (n = 72, 58.1%). After the successful hemostasis of NVUGIB, 36 patients (29.0%) experienced at least one episode of recurrent upper GIB, 19 patients (15.3%) died, and 7 (5.6%) patients had a bleeding-related death. Multivariate analysis showed that age was a significant factor for re-bleeding (odds ratio [OR], 1.050; 95% confidence interval [CI]: 1.001-1.102; p-value: 0.047), all-cause mortality (OR, 1.096; 95% CI: 1.020-1.178, p = 0.013), and re-bleeding-related mortality (OR, 1.187; 95% CI: 1.032-1.364, p-value: 0.016). In Kaplan-Meier analysis, the cumulative probabilities of re-bleeding, death, and bleeding-related death were significantly higher in patients aged 70 and older (p = 0.008, <0.001, and 0.009, respectively).

CONCLUSIONS

Clinicians should be cautious about re-bleeding and mortality in elderly patients who experience NVUGIB while receiving DAPT.

A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States

BACKGROUND

Palliative care (PC) has been shown to be beneficial in end stage liver disease (ESLD), yet the hospitalization data for PC utilization is unknown.

AIM

To identify the trend of PC utilization for the special population of alcohol-associated ESLD patients, factors affecting its use and ascertain its impact on healthcare utilization.

METHODS

We analyzed around 78 million discharges from the 2007-2014 national inpatient sample and 2010-2014 national readmission database including adult patients admitted for decompensated alcohol-associated cirrhosis. We identified patients with PC consultation as a secondary diagnosis. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

RESULTS

Out of the total 1421849 hospitalizations for decompensated liver cirrhosis, 62782 (4.4%) hospitalizations had a PC consult, which increased from 0.8% (1258) of all alcohol-associated ESLD hospitalizations in 2007 to 6.6% in 2014 (P < 0.01). Patient and hospital characteristics associated with increased odds of PC utilization were advanced age, lower income, Medicaid coverage, teaching institution, urban location, length of stay > 3 d, prolonged ventilation, and administration of total parenteral nutrition (all P < 0.01). Palliative encounters in alcohol-associated ESLD and acute-on-chronic liver failure (ACLF) score were associated with increased odds of discharge to a rehabilitation facility, but significantly lower odds of 30-d readmissions (aOR: 0.35, 95%CI: 0.31-0.41), lower total hospitalization charges and lower mean hospitalization days (all P < 0.01).

CONCLUSION

Inpatient PC is sparingly used for patients with decompensated alcohol related liver disease, however it has increased over the past decade. PC consultation is associated with lower 30-d readmission rates on multivariate analysis, and lower hospitalization cost and length of stay in patients with ACLF score ≥ 2.

Clinical characteristics and risk factors of in-hospital gastrointestinal bleeding in patients with acute myocardial infarction

Background

Gastrointestinal bleeding (GIB) is one of the most serious complications of acute myocardial infarction (AMI) and is correlated with poor outcomes.

Objective

To evaluate the prevalence, risk factors and in-hospital mortality of GIB in patients with AMI.

Methods

This observational case-control study retrospectively enrolled consecutive patients with AMI from the Department of Cardiovascular Medicine and Cardiovascular Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2015 to December 2020. GIB after AMI was identified by International Classification of Diseases (ICD) codes from inpatient medical settings and validated by medical record review. AMI patients without GIB were accordingly classified as the control group. Propensity score matching (PSM) was used to match with the GIB group and the control group. All anonymized clinical data were provided by the Biobank of the First Affiliated Hospital of Xi'an Jiaotong University.

Results

A total of 5,868 AMI patients were enrolled, 0.87% (51/5,868) of whom developed GIB after AMI. On the univariate analysis, history of diabetes, chronic kidney disease, Killip IV, a lower hemoglobin concentration, a higher serum level of creatinine, blood urea nitrogen and D-dimer were closely associated with the risk of GIB (P < 0.05). On the multivariable analysis, a lower hemoglobin concentration (OR: 0.93, 95% CI: 0.89–0.96, P < 0.001) was independently associated with the risk of GIB. Patients with GIB had a much higher in-hospital mortality rate than those without GIB (14.3 vs. 2.1%, P = 0.047). In-hospital mortality among patients with GIB after AMI appeared to be associated with a decreased hemoglobin concentration (OR: 0.93, 95% CI: 0.86–0.99, P = 0.045) and Killip IV (OR: 51.59, 95% CI: 2.65–1,005.30, P = 0.009).

Conclusion

The history of diabetes, poor renal function and heart failure were associated with the high risk of GIB in patients experiencing AMI. The in-hospital mortality in patients with AMI complicating GIB was higher than that in patients without GIB and was associated with a decreased hemoglobin concentration and high Killip classification.

Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

BACKGROUND

Clinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding.

METHODS

Patients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment.

RESULTS

A total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01).

CONCLUSION

In the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.

Prevention of erosive and ulcerative gastroduodenal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia

The OBJECTIVE was to evaluate methods for the prevention of gastrointestinal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia.METHODS AND MATERIALS. The study included 188 patients treated in the vascular surgery department of A. A. Polyantsev General Surgery Clinic of Volgograd State Medical University for obliterating atherosclerosis of the arteries of the lower extremities in the period from 2017 through 2021.RESULTS. There was a relationship between the indicator that the patient indicated independently – the number of painkillers taken per day to reduce pain, and erosive and ulcerative lesions of the stomach and duodenum in both groups. The increasing number of operations with critical lower extremity ischemia (СLEI) and the expected decrease in the number of amputations indicates the increased capabilities of vascular and X-ray endovascular surgeons in preserving the extremity and ultimately the life of patients with decompensated forms of obliterating lesions of the extremities. This group of patients had a large number of perioperative complications from various organs and systems, including a high probability of gastrointestinal bleeding.CONCLUSION. An increased risk group for the occurrence of gastrointestinal bleeding (GIB): patients with repeated reconstructions, surgical corrections of complications or amputations at various levels, as well as taking anticoagulants in therapeutic dosage. Long-term routine prevention of acute erosive and ulcerative lesions of the stomach and duodenum, gastrointestinal bleeding with proton pump inhibitors is not acceptable for this group of patients. It is necessary to have a complex effect on the factors of aggression – the exclusion of the use of NSAIDs, total eradication.

Rehospitalization, Treatment, and Resource Use After Inpatient Admission for Achalasia in the USA

INTRODUCTION

Readmission for achalasia treatment is associated with significant morbidity and cost. Factors predictive of readmission would be useful in identifying patients at risk.

METHODS

We performed a retrospective study using the Nationwide Readmission Database for the year 2016 and 2017. We collected data on hospital readmissions of 17,848 adults who were hospitalized for achalasia and discharged. The 30-day readmission rate as well as the primary cause, mortality rate, in-hospital adverse events, and total hospitalization charges were examined. A cox multivariate regression model was used to identify independent risk factors for 30-day readmission, including the surgical or endoscopic treatment used during the index admission.

RESULTS

From 2016 to 2017, the 30-day readmission rate for index admission with achalasia was 15.2%. Of these 15.2%, 34% were readmitted with persistent symptoms of achalasia or treatment-related complications. Older age, higher comorbidity index, possessing private insurance, and those with either pneumatic balloon dilation or no endoscopic/surgical treatment showed higher odds of readmission on multivariate analysis. Those treated with laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) showed lower odds of readmission. There was no difference in rates of readmission between those undergoing POEM or LHM, but mortality rate for readmission was significantly higher for the LHM group. The in-hospital mortality rate and length of stay were significantly higher for readmissions (p < 0.01) than the index admissions.

CONCLUSION

Three in 20 patients admitted with achalasia are likely to be readmitted within 30 days of their initial hospitalization, a number which can be higher in untreated patients and in those with multiple comorbidities. Rehospitalizations bear a higher mortality rate than the initial admission and present a burden to the healthcare system.