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Liu J, Zhou Y, Huang H, Liu R, Kang Y, Zhu T, Wu J, Gao Y, Li Y, Wang C, Chen S, Xie N, Zheng X, Meng R, Liu Y, Tan N, Gao F. Impact of stress hyperglycemia ratio on mortality in patients with critical acute myocardial infarction: insight from american MIMIC-IV and the chinese CIN-II study. Cardiovasc Diabetol 2023; 22:281. [PMID: 37865764 PMCID: PMC10589959 DOI: 10.1186/s12933-023-02012-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/04/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Among patients with acute coronary syndrome and percutaneous coronary intervention, stress hyperglycemia ratio (SHR) is primarily associated with short-term unfavorable outcomes. However, the relationship between SHR and long-term worsen prognosis in acute myocardial infarction (AMI) patients admitted in intensive care unit (ICU) are not fully investigated, especially in those with different ethnicity. This study aimed to clarify the association of SHR with all-cause mortality in critical AMI patients from American and Chinese cohorts. METHODS Overall 4,337 AMI patients with their first ICU admission from the American Medical Information Mart for Intensive Care (MIMIC)-IV database (n = 2,166) and Chinese multicenter registry cohort Cardiorenal ImprovemeNt II (CIN-II, n = 2,171) were included in this study. The patients were divided into 4 groups based on quantiles of SHR in both two cohorts. RESULTS The total mortality was 23.8% (maximum follow-up time: 12.1 years) in American MIMIC-IV and 29.1% (maximum follow-up time: 14.1 years) in Chinese CIN-II. In MIMIC-IV cohort, patients with SHR of quartile 4 had higher risk of 1-year (adjusted hazard radio [aHR] = 1.87; 95% CI: 1.40-2.50) and long-term (aHR = 1.63; 95% CI: 1.27-2.09) all-cause mortality than quartile 2 (as reference). Similar results were observed in CIN-II cohort (1-year mortality: aHR = 1.44; 95%CI: 1.03-2.02; long-term mortality: aHR = 1.32; 95%CI: 1.05-1.66). In both two group, restricted cubic splines indicated a J-shaped correlation between SHR and all-cause mortality. In subgroup analysis, SHR was significantly associated with higher 1-year and long-term all-cause mortality among patients without diabetes in both MIMIC-IV and CIN-II cohort. CONCLUSION Among critical AMI patients, elevated SHR is significantly associated with and 1-year and long-term all-cause mortality, especially in those without diabetes, and the results are consistently in both American and Chinese cohorts.
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Affiliation(s)
- Jin Liu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yang Zhou
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haozhang Huang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rui Liu
- School of Mathematics, South China University of Technology, Guangzhou, China
| | - Yu Kang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tingting Zhu
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Jielan Wu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yuwei Gao
- Jinan university, Zhuhai People's Hospital, Zhuhai, China
| | - Yuqi Li
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Zhongshan City People's Hospital, Zhongshan, China
| | - Chenyang Wang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shiqun Chen
- Global Health Research Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Nianjin Xie
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xueyan Zheng
- Institute of Control and Prevention for Chronic Non-infective Disease, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Ruilin Meng
- Institute of Control and Prevention for Chronic Non-infective Disease, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Ning Tan
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Southern Medical University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Fei Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Jian L, Zhang Z, Zhou Q, Duan X, Xu H, Ge L. Association between albumin corrected anion gap and 30-day all-cause mortality of critically ill patients with acute myocardial infarction: a retrospective analysis based on the MIMIC-IV database. BMC Cardiovasc Disord 2023; 23:211. [PMID: 37118662 PMCID: PMC10148465 DOI: 10.1186/s12872-023-03200-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/22/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The anion gap (AG) has been linked to the prognosis of many cardiovascular disorders. However, the correlation between albumin-corrected anion gap (ACAG) and 30 d all-cause mortality of intensive care patients with acute myocardial infarction (AMI) is unclear. Furthermore, owing to the lack of studies, it is also unknown whether ACAG is more accurate than AG in predicting the mortality of AMI. METHODS The Medical Information Mart for Intensive Care IV (MIMIC IV) dataset was used to provide patient data in this retrospective cohort study. ACAG is computed using the formulae: [4.4-{albumin (g/dl)}] × 2.5 + AG. The primary outcome was 30 d all-cause mortality intensive care patients with AMI. To explore the prognostic worthiness of ACAG, the receiver operating characteristic curve, smooth curve fitting, Cox regression model, and Kaplan survival analysis was performed. RESULTS We enrolled 2,160 patients in this study. ACAG had a better predictive value for 30 d all-cause mortality than AG, with an area under the curve of 0.66. The association between ACAG levels and overall mortality was nonlinear. In our model, after correcting for confounding factors, the ACAG was the independent predictor for 30 d all-cause mortality (HR 1.75, 95%CI 1.24, 2.47). ACAG K-M estimator curve analyses revealed that the group with ACAG ≥ 21.75 mmol/l had poor survival rate than the other group. CONCLUSIONS High serum ACAG levels were a significant risk factor for 30 d all-cause mortality in critically ill patients with AMI. ACAG concentration and 30 d all-cause mortality had a nonlinear relationship. ACAG had better predictive value in identifying 30 d all-cause mortality of patients with AMI in ICU than the AG.
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Affiliation(s)
- Linhao Jian
- Department of the First Clinical College, Jinan University, 601 Huangpu Avenue West, Guangzhou, 510632, China
- Department of Cardiology, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China
| | - Zhixiang Zhang
- Department of Cardiology, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China
| | - Quan Zhou
- Department of Science and Education, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China
| | - Xiangjie Duan
- Department of Infectious Diseases, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China
| | - Haiqin Xu
- Department of Cardiac Electrophysiology, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China
| | - Liangqing Ge
- Department of Cardiology, The First People's Hospital of Changde, 818 Renmin Avenue, Changde City, 415003, China.
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Song J, Yu T, Yan Q, Wu L, Li S, Wang L. A simple APACHE IV risk dynamic nomogram that incorporates early admitted lactate for the initial assessment of 28-day mortality in critically ill patients with acute myocardial infarction. BMC Cardiovasc Disord 2022; 22:502. [PMID: 36434509 PMCID: PMC9700900 DOI: 10.1186/s12872-022-02960-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Early risk stratification is important for patients with acute myocardial infarction (AMI). We aimed to develop a simple APACHE IV dynamic nomogram, combined with easily available clinical parameters within 24 h of admission, thus improving its predictive power to assess the risk of mortality at 28 days. METHODS Clinical information on AMI patients was extracted from the eICU database v2.0. A preliminary XGBoost examination of the degree of association between all variables in the database and 28-day mortality was conducted. Univariate and multivariate logistic regression analysis were used to perform screening of variables. Based on the multifactorial analysis, a dynamic nomogram predicting 28-day mortality in these patients was developed. To cope with missing data in records with missing variables, we applied the multiple imputation method. Predictive models are evaluated in three main areas, namely discrimination, calibration, and clinical validity. The discrimination is mainly represented by the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Calibration is represented by the calibration plot. Clinical validity is represented by the decision curve analysis (DCA) curve. RESULTS A total of 504 people were included in the study. All 504 people were used to build the predictive model, and the internal validation model used a 500-bootstrap method. Multivariate analysis showed that four variables, APACHE IV, the first sample of admission lactate, prior atrial fibrillation (AF), and gender, were included in the nomogram as independent predictors of 28-day mortality in AMI. The prediction model had an AUC of 0.819 (95%CI 0.770-0.868) whereas the internal validation model had an AUC of 0.814 (95%CI 0.765-0.860). Calibration and DCA curves indicated that the dynamic nomogram in this study were reflective of real-world conditions and could be applied clinically. The predictive model composed of these four variables outperformed a single APACHE IV in terms of NRI and IDI. The NRI was 16.4% (95% CI: 6.1-26.8%; p = 0.0019) and the IDI was 16.4% (95% CI: 6.0-26.8%; p = 0.0020). Lactate accounted for nearly half of the total NRI, which showed that lactate was the most important of the other three variables. CONCLUSION The prediction model constructed by APACHE IV in combination with the first sample of admission lactate, prior AF, and gender outperformed the APACHE IV scoring system alone in predicting 28-day mortality in AMI. The prediction dynamic nomogram model was published via a website app, allowing clinicians to improve the predictive efficacy of the APACHE IV score by 16.4% in less than 1 min.
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Affiliation(s)
- Jikai Song
- grid.410645.20000 0001 0455 0905Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province China
| | - Tianhang Yu
- grid.440734.00000 0001 0707 0296North China University of Science and Technology, Tangshan, Hebei Province China
| | - Qiqi Yan
- grid.410645.20000 0001 0455 0905Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province China
| | - Liuyang Wu
- grid.410645.20000 0001 0455 0905Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province China
| | - Sujing Li
- grid.410645.20000 0001 0455 0905Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province China
| | - Lihong Wang
- grid.410645.20000 0001 0455 0905Zhejiang Provincial People’s Hospital, Qingdao University, Hangzhou, Zhejiang Province China
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Tan L, Xu Q, Shi R. A Nomogram for Predicting Hospital Mortality in Intensive Care Unit Patients with Acute Myocardial Infarction. Int J Gen Med 2021; 14:5863-5877. [PMID: 34566426 PMCID: PMC8457867 DOI: 10.2147/ijgm.s326898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Background This study aims to construct and validate an early-stage nomogram for predicting hospital mortality of ICU patients with acute myocardial infarction (AMI), to help clinicians determine the appropriate intervention. Methods The primary cohort of 2704 patients diagnosed with acute myocardial infarction in admission records from eICU-Collaborative Research Database (eICU-CRD) v2.0. Univariate logistic regression analysis and multivariate logistic regression analysis were enrolled for the construction of the predictive nomogram. Demographic factors, history of clinical cardiovascular disease, vital signs, the use of vasopressors, urine output, and serum variables in the first 24 hours were included in this analysis. The nomogram was evaluated by performance traits including Harrell's concordance index (C-index) and area under the receiver operating characteristic (AUC) analysis, calibration curve, and decision curve analysis (DCA). The nomogram was validated in a different cohort containing 1026 subjects collected from MIMIC-III Database v1.4. Finally, in order to compare the performance with other classic prediction models, AUC analysis, calibration curve, DCA and accuracy analysis (net reclassification improvement (NRI)) were conducted for three ICU scores in validated cohort. Results The nomogram revealed 14 predictors of the first 24 hours derived from univariate and multivariable analyses, including age, history of peripheral vascular disease, atrial fibrillation, cardiogenic shock and cardiac arrest, the use of norepinephrine, urine output, white blood cell (WBC), hemoglobin (Hb), red blood cell (RBC), red cell distribution width (RDW), glucose, bicarbonate and magnesium. The C-index of this nomogram was 0.834 (95% CI 0.812 to 0.856). Then, the result of AUC analysis, the DCA and calibration curve indicated that our nomogram was feasible for clinical prediction. The predictive ability and clinical use of the nomogram were verified in the validated cohort. The AUC analysis of ICU scores showed that the AUC of these score systems was ranged from 0.811 to 0.860 (the AUC of nomogram: 0.885). Moreover, our nomogram also showed a better performance in calibration curve and DCA NRI. Conclusion The study presents a prediction nomogram incorporating 14 variables that could help identify AMI patients admitted in ICU who might have a high risk of hospital mortality in the first hospitalized 24 hours. This nomogram showed a better performance than normal ICU score systems.
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Affiliation(s)
- Liao Tan
- Department of Cardiology, The Third Xiangya Hospital, Central South University Changsha, Hunan, People's Republic of China.,Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Qian Xu
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Ruizheng Shi
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 17:589-595. [PMID: 31899652 DOI: 10.1513/annalsats.201911-854oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.
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Mathews KS, Goel NN, Vargas-Torres C, Olson AD, Zhou J, Powell CA, Mazumdar M, Stock GN, McDermott CM. A Cross-sectional Study of Hospital Performance on ICU Utilization Practices for Patients with Chronic Obstructive Pulmonary Disease. Lung 2020; 198:637-644. [PMID: 32495192 DOI: 10.1007/s00408-020-00364-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Intensive care unit (ICU) resources are a costly but effective commodity used in the management of critically ill patients with chronic obstructive pulmonary disease (COPD). ICU admission decisions are determined by patient diagnosis and severity of illness, but also may be affected by hospital differences in quality and performance. We investigate the variability in ICU utilization for patients with COPD and its association with hospital characteristics. METHODS Using a 3M administrative dataset spanning 2008-2013, we conducted a retrospective cohort study of adult patients discharged with COPD at hospitals in three state to determine variability in ICU utilization. Quality metrics were calculated for each hospital using observed-to-expected (O/E) ratios for overall mortality and length of stay. Logistic and multilevel multivariate regression models were constructed, estimating the association between hospital quality metrics on ICU utilization, after adjustment for available clinical factors and hospital characteristics. RESULTS In 434 hospitals with 570,517 COPD patient visits, overall ICU admission rate was 33.1% [range 0-89%; median (IQR) 24% (8, 54)]. The addition of patient, hospital, and quality characteristics decreased the overall variability attributable to individual hospital differences seen within our cohort from 40.9 to 33%. Odds of ICU utilization were increased for larger hospitals and those seeing lower pulmonary case volume. Hospitals with better overall O/E ratios for length of stay or mortality had lower ICU utilization. CONCLUSIONS Hospital characteristics, including quality metrics, are associated with variability in ICU utilization for COPD patients, with higher ICU utilization seen for lower performing hospitals.
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Affiliation(s)
- Kusum S Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neha N Goel
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA.
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley D Olson
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jing Zhou
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles A Powell
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory N Stock
- College of Business, University of Colorado at Colorado Springs, Colorado Springs, CO, USA
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Miki R, Takeuchi M, Imai T, Seki T, Tanaka S, Nakamura M, Kawakami K. Association of intensive care unit admission and mortality in patients with acute myocardial infarction. J Cardiol 2019; 74:109-115. [DOI: 10.1016/j.jjcc.2019.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/25/2018] [Accepted: 01/15/2019] [Indexed: 12/01/2022]
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Valley TS, Iwashyna TJ, Cooke CR, Sinha SS, Ryan AM, Yeh RW, Nallamothu BK. Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study. BMJ 2019; 365:l1927. [PMID: 31164326 PMCID: PMC6547840 DOI: 10.1136/bmj.l1927] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN Retrospective cohort study. SETTING 1727 acute care hospitals in the United States. PARTICIPANTS Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.
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Affiliation(s)
- Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Shashank S Sinha
- Cardiac Intensive Care Unit, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
- Cardiovascular Critical Care Research, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
| | - Andrew M Ryan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Brahmajee K Nallamothu
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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The Role of Palliative Care in the Cardiac Intensive Care Unit. Healthcare (Basel) 2019; 7:healthcare7010030. [PMID: 30791385 PMCID: PMC6473424 DOI: 10.3390/healthcare7010030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.
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Intensive Care Unit Admission and Survival among Older Patients with Chronic Obstructive Pulmonary Disease, Heart Failure, or Myocardial Infarction. Ann Am Thorac Soc 2018; 14:943-951. [PMID: 28208030 DOI: 10.1513/annalsats.201611-847oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
RATIONALE Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown. OBJECTIVES To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI). METHODS We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs. RESULTS Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD. CONCLUSIONS ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.
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