Incidence and impact of venous thromboembolism in hospitalized patients with Crohn-disease

Background

Prevalence of Crohn's disease (CD) is high in North America and in Europe ranging between 100 and 350 patient-cases per 100,000 citizens. CD is characterized by chronic inflammation with a progressive course and is often associated with different intestinal as well as extra-intestinal complications. CD is associated with both, other inflammatory diseases such as ankylosing spondylitis and psoriasis as well as venous thromboembolism (VTE). CD causes an activation of coagulation system, which might be the main reason for an increased risk of thromboembolic complications. Beside previous study results regarding higher VTE risk of patients with CD in comparison to the general population, particularly, data on impact of VTE on survival and risk factors for the occurrence of VTE in CD are sparse.

Purpose

The objectives of our study were to provide evidence about the current and past prevalence of VTE events in hospitalized patients with CD and to investigate the impact of VTE on outcomes of CD patients.

Methods

The German nationwide inpatient sample was screened for patients admitted due to CD (ICD-code K50) (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, own calculations). CD hospitalizations were stratified for VTE and risk factors for VTE and impact of VTE on in-hospital case-fatality rate were investigated.

Results

Overall, 333,975 patients-cases with hospital admissions due to CD were counted in Germany (median age 38.0 [IQR 24.0–52.0] years, 56.0% females) during the observational period between 2005 and 2018. VTE rate increased slightly from 0.6% to 0.7% (β 0.000097 [95% CI 0.000027 to 0.000167], P=0.007) from 2005 to 2018 and with age-decade of life (β 0.0017 [95% CI 0.0016 to 0.0019], P<0.001). In total, 0.7% (n=2,295) of the CD inpatients had an event of VTE. Patients with VTE were in median 12 years older (49.0 [34.0–62.0] vs. 37.0 [24.0–52.0] years, P<0.001) and CD colon-manifestations were more prevalent in those patients (32.0% vs. 27.7%, P<0.001). Age ≥70 years, obesity, colon-involvement, cancer, surgery, thrombophilia, and heart failure were strongly associated with higher risk of VTE in CD patients.

In-hospital death occurred 15-times more often in CD with VTE than without (4.5% vs. 0.3%, P<0.001). VTE was independently associated with substantially increased in-hospital case-fatality rate (OR 9.31 [95% CI 7.54–11.50], P<0.001).

Conclusions

VTE is a life-threatening event in hospitalized CD patients associated with 9.3-fold increased case-fatality rate. Older age, obesity, colon involvement, cancer, surgery, thrombophilia and heart failure were strong risk factors for VTE in patients with CD.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis

Background

Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse.

Purpose

We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries.

Methods

We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies.

Results

We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era.

Conclusion

PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Mortality related to pulmonary embolism in the United States before and during the COVID-19 pandemic: an analysis of the CDC Multiple Cause of Death database

Background

The COVID-19 pandemic caused a large number of excess deaths. COVID-19 emerged as a prothrombotic disease often complicated by pulmonary embolism (PE). In light of this, we hypothesized that PE-related mortality rates (stable before the pandemic) would be characterized by an increasing trend following the COVID-19 outbreak.

Purpose

To investigate the mortality rates associated with PE among deaths with or without COVID-19 during the 2020 pandemic in the United States (US).

Methods

For this retrospective epidemiological study, we analyzed public medically certified vital registration data (death certificates encompassing underlying and multiple causes of death) from the Mortality Multiple Cause-of-Death database provided by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2018–20). We investigated the time trends in monthly PE-related crude mortality rates for 2018–2019 and for 2020 (the latter associated vs. not associated with COVID-19), utilizing annual national population totals from the US Census Bureau. Second, we calculated the PE-related proportionate mortality among COVID-19 deaths (overall and limited to autopsy-based diagnosis). We performed subgroup analyses based on age groups, sex and race.

Results

During 2020, 49,423 deaths in association with PE were reported, vs. 39,450 in 2019 and 38,215 in 2018. The crude PE-related mortality rate without COVID-19 was 13.3 per 100,000 population in 2020 compared to 11.7 in 2018 and 12.0 in 2019 (Figure 1A). The PE-related mortality rate with COVID-19 was 1.6 per 100,000 population in 2020. Among non-COVID-19-related deaths, the crude PE-related mortality rate was higher in women; among COVID-19-related deaths, it was higher in men. PE-related mortality rates were approximately two-fold higher among black (vs. white) general population irrespective of COVID-19 status (Figures 1B and 1C). Among COVID-19 deaths, PE-related deaths corresponded to 1.4% of total; the value rose to 6.0% when an autopsy was performed. This figure was higher in men and its time evolution is depicted in Figure 2A. The proportionate mortality of PE in COVID-19 deaths was higher for younger age groups (15–44 years) compared to non-COVID-19-related deaths (Figure 2B).

Conclusion

In 2020, an overall 20%-increase in PE-related mortality was reported, not being limited to patients with COVID-19. Our findings could be interpreted in the context of undiagnosed COVID-19 cases, uncounted late sequelae, and possibly sedentary lifestyle and avoidance of healthcare facilities during the pandemic that may have prevented timely diagnosis and treatment of other diseases. Whether vaccination programs had an impact on PE-associated mortality in the year 2021, remains to be determined.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends regarding clinical impact of diabetes mellitus on peripheral artery disease

Introduction

Patients with peripheral artery disease (PAD) and Diabetes mellitus (DM) suffer from higher morbidity and mortality rates compared to non-diabetic PAD patients. Huge efforts are made to improve medical care of patients with DM including chronic disease programs.

Purpose

To investigate temporal trends of the clinical burden of DM on PAD patients between the years 2005 and 2019.

Methods

All patients hospitalized due to PAD between 2005 and 2019 in Germany based on the diagnosis related groups [DRG] system were stratified according to presence or absence of DM (source: Federal Statistical Offices of Germany, DRG statistics 2005–2019 and own calculations). Morbidity and mortality of both groups were compared in time trend.

Results

The number of hospitalisations due to PAD increased from 142,778 in the year 2005 to 190,135 in 2019 (β 3956 per year [95% CI 3034–4878], P<0.001). In the same period also the amount of PAD patients with additional diagnosis of DM inclined (2005: 41,609 patients corresponding 29.1% of all PAD patients vs. 2019: 65,302 patients corresponding 34.3% of all PAD patients; β 2019 per year [95% CI 1593–2446], P<0.001). While the portion of patients with type 1 DM decreased during the observational period (β −1.43 [95% CI −1.49 to −1.37]; P<0.001), type 2 DM was progressive (β 2.27 [95% CI 2.23–2.32]; P<0.001). PAD patients with DM suffered from lower rates of pulmonary embolism (β −0.64 [95% CI −0.89 to −0.40]; P<0.001) and intracerebral bleeding (β −0.45 [95% CI −0.94 to 0.04]; P=0.072) in the last years of the investigation period, whereas the amount of patient-cases with pneumonia (β 0.29 [95% CI 0.23–0.35]; P<0.001), shock (β 0.75 [95% CI 0.66–0.84]; P<0.001) and gastrointestinal bleeding (β 0.33 [95% CI 0.20–0.46]; P<0.001) increased. Fortunately, less amputations had to be performed in diabetics over time (amputations regardless of minor or major amputations: β −0.42 [95% CI −0.44 to −0.40]; P<0.001; minor amputations: β −0.03 [95% CI −0.06 to −0.01]; P=0.015; major amputations: β −1.24 [95% CI −1.28 to −11.20]; P<0.001) and in-hospital mortality decreased during the observational-time (2005: 4.7%, 2019: 2.8%; β −0.64 [95% CI −0.69 to −0.59]; P<0.001). Despite the improvement in morbidity and mortality within the investigated time period, diabetics with DM were still associated with increased risk for morbidity and mortality compared to PAD patients without DM.

Conclusions

We observed an improvement regarding morbidity and mortality in hospitalized PAD patients with DM in Germany within the investigation period between 2005 and 2019. However, DM remained to be associated with increased morbidity and mortality compared to non-diabetics. Hence, despite the achieved improvements within the period 2005 to 2019, DM still represents an outstanding risk factor for morbidity and mortality in patients with PAD.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 infection and its impact on case-fatality in patients with pulmonary embolism

Background

Although a high prevalence of pulmonary embolism (PE) has been reported as a complication during severe COVID-19 infections in critical ill patients, nationwide data of hospitalized patients with COVID-19 with PE is still limited. Thus, we sought to analyze seasonal trends and predictors of in-hospital case-fatality in patients with COVID-19 and PE in Germany.

Methods

We used the German nationwide inpatient sample to analyze all data on hospitalizations for COVID-19 patients with and without PE in Germany during the year 2020 and to compare changes of PE prevalence to 2019.

Results

We analyzed data of 176,137 hospitalizations because of COVID-19 in 2020. Among those, PE was recorded in 1.9% (n=3,362) of discharge or death certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%). The case-fatality rate increased with patients' age peaking in the 9th life-decade. Regardless of COVID-19, 196,203 inpatients were diagnosed with PE in Germany between 2019 and 2020. The number of PE hospitalizations were widely equally distributed between both years (98,485 vs. 97,718), while the case-fatality rate of all patients with PE was slightly lower in 2019 compared to 2020 (12.7% vs. 13.1%, P<0.001). In contrast, considerable differences in prevalence and case-fatality were demonstrated in 2020 regarding PE patients with and without COVID-19 infection (28.7% vs. 13.1%, P<0.001) (Figure 1). A COVID-19-infection was associated with a 2.8-fold increased risk of case-fatality in patients with PE (OR 2.81, 95% CI 1.66–2.12, P<0.001).

Conclusions

In Germany, the prevalence of PE events complicating hospitalizations was similar in 2019 and 2020. However, the fatality rate among patients with COVID-19-associated PE was substantially higher than that in those without either COVID-19 or PE, indicating an additive prognostic effect of these two conditions.

Funding Acknowledgement

Type of funding sources: None.

Trends and risk factors of in-hospital mortality of patients with COVID-19 in Germany

Background

Unselected data of nationwide studies of hospitalized patients with COVID-19 is still sparse, but these data are of outstanding interest not to exceed hospital capacities and to avoid overloading of national health-care systems.

Purpose

Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality and mechanical ventilation (MV) in patients with COVID-19 in Germany.

Methods

We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st in 2020 (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Covid-19-inpatients with MV vs. without MV and survivors vs. non-survivors were compared. Logistic regression models were calculated to investigate associations between patients' characteristics as well as adverse events and i) necessity of MV and ii) in-hospital death.

Results

We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Cardiovascular comorbidities were common in hospitalized patients with confirmed COVID-19-infections: Overall, almost half of the patients (46.8%; n=82,480) had arterial hypertension and 25,574 (14.4%) had a diagnosis of coronary artery disease. In 60.7% (n=106,913) of the hospitalizations, pneumonia was reported, 8.6% (n=15,061) had an acute infection of the upper or lower airways other than pneumonia, and 6.6% (n=11,594) suffered from an acute respiratory distress syndrome (ARDS) during hospitalization

Age ≥70 years (OR 5.91, 95% CI 5.70–6.13, P<0.001), pneumonia (OR 4.58, 95% CI 4.42–4.74, P<0.001) and acute respiratory distress syndrome (OR 8.51, 95% CI 8.12–8.92, P<0.001) were strong predictors of in-hospital death. Most COVID-19-patients were treated in hospitals in urban areas (n=92,971) associated with lowest case-fatality (17.5%) as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between 6th and 8th age-decade. In the first age-decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV and five of them died (0.3%).

Conclusion

The results of our study indicate seasonal and regional variations concerning number of COVID-19-patients, necessity of MV and case-fatality in Germany. These findings may help to ensure flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional health-care systems.

Funding Acknowledgement

Type of funding sources: None.

Causes of death and predictors of long-term mortality after pulmonary embolism

Background

While a large number of studies has investigated short-term outcome after pulmonary embolism (PE), the effects of PE on long-term mortality are insufficiently studied.

Purpose

To investigate long-term outcomes in an unselected real-world cohort of patients with acute PE.

Methods

Consecutive patients with acute PE enrolled in a prospective single-centre registry between 05/2005 and 12/2017 were followed for up to 14 years. The primary study outcome was all-cause mortality during follow-up. Kaplan-Meier analyses were used to evaluate the probability of long-term survival. The prognostic relevance of baseline characteristics was assessed using Cox proportional hazards models. Standardised mortality rates (SMR) were calculated to estimate relative rates of mortality in the study cohort compared to the expected mortality in the general population adjusted for sex, age and year of birth.

Results

We analysed data from 882 patients (age 69 [interquartile range (IQR) 56–77] years), followed for a total of 3,904 patient years (median follow-up 3.2 [IQR 1.3–7.2] years). Overall, 40.9% of patients died during follow-up. One- and five-year mortality rates were 19.8% and 33.7%, respectively. While most early deaths could be attributed to PE or associated complications, cancer was the predominant cause of death between 30 days and 3 years after PE, whereas cardiovascular events and infections were the most frequent causes of death after more than 3 years (Figure 1).

In patients who survived the first 30 days after PE, the observed number of deaths was higher than the expected mortality in the general population throughout the follow-up period (Figure 2; 5-year SMR 2.77 [95% CI 2.42–3.15]). The strongest predictor of late mortality was active cancer at the time of PE, that was associated with a Hazard Ratio [HR] of 4.03 [95% CI 3.07–5.28]) for death after &gt;30 days. Of note, active cancer was only associated with an increased mortality risk during the first three years of follow-up, but did not predict death after more than three years. In non-cancer patients, mortality was also elevated compared to the general population (5-year SMR 1.80 [95% CI 1.51–2.14]) and late mortality was predicted by chronic pulmonary disease (HR 2.22 [95% CI 1.51–3.27]), chronic heart failure (HR 1.90 [95% CI 1.36–2.66]), age per decade (HR 1.79 [95% CI 1.54–2.09]) and anaemia (HR 1.59 [95% CI 1.16–2.17]).

Conclusion

Even after survival of the acute phase, the mortality risk of PE patients remained elevated compared to the general population throughout the 14 year follow-up period. The main driver of late mortality is cancer. However, elevated mortality was also observed in in PE patients without cancer, in whom late mortality was predicted by chronic cardiopulmonary comorbidities, age and anaemia.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Psoriasis and its impact on the clinical outcome of patients with pulmonary embolism

Background

Venous thromboembolism (VTE) is common and associated with high morbidity and mortality. Although chronic inflammation was not categorized as a traditional risk factor for VTE, chronic inflammation might increase the risk to develop VTE events.

While studies confirmed an increased cardiovascular morbidity and mortality in psoriatic patients, data regarding the influence of psoriasis on patients' cardiovascular profile and on prognosis of patients with pulmonary embolism (PE) are sparse.

Purpose

We aimed to investigate the impact of psoriasis on prognosis of PE patients.

Methods

Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005–2017 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2017, own calculations).

Results

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0–80.0] years) were recorded in Germany 2005–2017. Among these, 3,145 patients were additionally coded with psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0–76.0] vs. 72.0 [60.0–80.0] years, P&lt;0.001) and more often male (64.1% vs. 46.3%, P&lt;0.001). The prevalence of VTE risk factors, traditional cardiovascular risk factors and cardiovascular comorbidities was higher in psoriatic than in non-psoriatic individuals: All investigated traditional cardiovascular risk factors such as essential arterial hypertension (49.8% vs. 43.1%, P&lt;0.001), diabetes mellitus (24.4% vs. 18.7%, P&lt;0.001), hyperlipidaemia (14.1% vs. 12.0%, P&lt;0.001), as well as obesity (19.6% vs. 9.6%, P&lt;0.001) and atherosclerotic comorbidities like coronary artery disease (15.2% vs. 13.8%, P=0.022) and peripheral artery disease (3.6% vs. 2.9%, P=0.010) were more prevalent in PE patients with psoriasis.

Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%, P&lt;0.001), confirmed by logistic regressions showing an independent association of psoriasis with reduced case-fatality rate (OR 0.73 [95% CI 0.65–0.82], P&lt;0.001), despite higher prevalence of pneumonia (24.8% vs. 23.2%, P=0.029). Psoriasis was an independent predictor for gastro-intestinal bleeding (OR 1.35 [95% CI 1.04–1.75], P=0.023) and transfusion of blood constituents (OR 1.23 [95% CI 1.11–1.36], P&lt;0.001).

Conclusions

Overall, only a minority (0.3%) of all PE cases were coded additionally with psoriasis. PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality rate in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis.

Funding Acknowledgement

Type of funding sources: None.

Case fatality rate and fatal bleeding complication in patients with pulmonary embolism and patent foramen ovale

Objectives

In patients with acute pulmonary embolism (PE), right atrial pressure is elevated, which increases risk for right-to-left shunt when patent foramen ovale (PFO) is present and thus potentially increases risk for paradoxical embolism. Little is known about the clinical outcome of patients with PE and concomitant PFO.

Methods

We analysed data on patient characteristics, treatments and in-hospital outcomes for all PE patients (ICD-code I26) with concomitant presence of PFO in Germany 2005–2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations).

Results

Between January 2005 and December 2018, 1,174,235 patients with acute PE (53.5% females) were included in this analysis; of those, 5,486 (0.5%) had a concomitant diagnosis of PFO. Trends analysis demonstrating an increasing frequency of diagnosed PE with additional PFO from 2005 (n=299) to 2018 (n=556; p&lt;0.001). While patients with PE and PFO presented more often with signs of haemodynamic compromise such RV dysfunction (37.6% vs. 28.5%) or shock (7.1% vs. 3.9%) as well as paradox arterial emboli (47.8% vs. 3.2%) or intracerebral bleeding (3.3% vs. 0.6%), PE patients with PFO died less often compared to PE patients without PFO (11.1% vs. 15.8%). Patients with PE and PFO were younger (65 [IQR 52–75] vs. 72 [60–80]; P&lt;0.001) and were more often treated invasively with a reperfusion treatment approach like embolectomy (10.2% vs. 4.2%) or systemic thrombolysis (5.0% vs 0.1%). A multivariate logistic regression analysis revealed a 27.6-fold increased risk for paradox arterial emboli (OR, 27.6 [95% CI 26.1–29.1]; p&lt;0.001) and a 3.9-fold increased risk for intracerebral bleeding events (OR, 3.9 [95% CI 3.3–4.54]; p&lt;0.001) for patients with PE and concomitant PFO. In normotensive patients with RVD and PFO, embolectomy were not associated to affect the rate of intracerebral bleeding events (OR, 0.8 [95% CI 0.2–2.6]; p=0.720) compared to conventional non-reperfusion treatment; instead of systemic thrombolysis, which is associated with a higher risk of intracerebral bleeding (OR, 3.5 [95% CI 1.8–6.59]; p&lt;0.001) compared to conventional non-reperfusion treatment.

Conclusion

Patients with acute PE and the concomitant presence of PFO are associated with a high risk for paradox arterial emboli and intracranial bleeding events. Especially in normotensive patients, the use of systemic thrombolysis should be considered with cautious. Thus, our findings may improve the clinical management of patients with PE and PFO.

Funding Acknowledgement

Type of funding sources: None.

Impact of cardiac amyloidosis on outcomes of patients hospitalized with heart failure in Germany

Background

Amyloidosis is a multi-systemic disease resulting from deposition of misfolded proteins as insoluble fibrils in the interstitium of affected organs including the heart, subsequently leading to organ failure. Cardiac involvement is predominantly observed in light chain (AL) amyloidosis and wild-type transthyretin (ATTRwt) amyloidosis.

Purpose

We aimed to investigate prevalence and prognostic implications of cardiac amyloidosis of any etiology on outcomes of hospitalized patients with heart failure (HF) in Germany.

Methods

We analyzed data of the German nationwide inpatient sample (2005–2018) of patients hospitalized for HF (including myocarditis with HF and heart transplantation with HF). HF patients with amyloidosis (defined as cardiac amyloidosis [CA]) were compared with those HF patients without amyloidosis and impact of CA on outcomes was assessed (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations).

Results

During this fourteen-year observational period 5,478,835 hospitalizations of HF patients were analyzed. Amyloidosis was coded in 5,407 hospitalizations of HF patients (0.1%). Prevalence of CA was 1.87 hospitalizations per 100,000 German population. CA patients were younger (75.0 [IQR 67.0/80.0] vs. 79.0 [72.0–85.0] years, p&lt;0.001), predominantly male (68.9%) and had a higher prevalence of cancer (14.8% vs. 3.6%, P&lt;0.001) compared with HF without amyloidosis. Although patients without amyloidosis had a pronounced cardiovascular risk profile -especially arterial hypertension (45.4% vs. 35.6%; p&lt;0.001) and diabetes mellitus (38.9% vs. 18.5%; p&lt;0.001)- and a higher prevalence of concomitant coronary artery disease (40.5% vs. 34.5%; p&lt;0.001) and chronic obstructive pulmonary disease (17.1% vs. 9.4%; p&lt;0.001), adverse in-hospital events including necessity of transfusions of blood constituents (7.1% vs. 5.4%, p&lt;0.001) and cardio-pulmonary resuscitation (CPR, 2.7% vs. 1.4%; p&lt;0.001) were more frequent in CA. CA was independently associated with acute kidney failure (OR 1.40 [95% CI 1.28–1.52], p&lt;0.001), CPR (OR 1.58 [95% CI 1.34–1.86], p&lt;0.001), intracerebral bleeding (OR 3.13 [95% CI 1.68–5.83], p&lt;0.001) and in-hospital mortality in the 6th and 8th decade of life (6thdecade: OR 1.40 [95% CI 1.01–1.94], p=0.042; 8thdecade: OR 1.18 [95% CI 1.03–1.35], p=0.02).

Conclusions

CA was identified as an independent risk factor for complications and in-hospital mortality in HF patients. Physicians should be aware of this issue concerning treatments and monitoring of CA-patients.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends, sex-differences and outcomes of patients hospitalized for heart failure in Germany

Background

Despite remarkable improvements in treatment of cardiovascular disease, heart failure (HF) is still characterized by a high mortality rate. Sex-specific differences in HF have been described, but underlying reasons are widely unexplored. Thus, we aimed to investigate sex differences of patients hospitalized for HF in a nationwide cohort.

Methods

The nationwide German inpatient sample (2005–2016) was used for this sex-specific analyses. Temporal trends on hospitalizations, mortality, and treatments were analyzed and independent predictors of adverse outcomes identified.

Results

The present analysis comprises 4,538,977 hospitalizations due to HF (52.0%women) in Germany (2005–2016). Although women were older (median 82 (IQR75–87) vs. 76 (69–82), P&lt;0.001), coronary artery disease (CAD, 50.3% vs. 30.7%, P&lt;0.001) was more prevalent in men, who were more often treated with PCI (3.4% vs. 1.4%, P&lt;0.001) and implantable cardioverter-defibrillator (2.2% vs. 0.5%, P&lt;0.001). In-hospital mortality was significantly lower in men than in women (8.9% vs. 10.2, P=0.001) and was reduced in patients who received PCI or implantation of an ICD.

While total numbers of hospitalizations between 2005 and 2016 increased in both men (β-estimate 7185.71 (95% CI 6502.23 to 7869.18), P&lt;0.001) and women (β-estimate 5297.60 (95% CI 4557.37 to 6037.83), P&lt;0.001) as well as almost all comorbid co-conditions, in-hospital mortality rate decreased more distinctly in women (β-estimate −0.41 (95% CI: −0.42 to −0.39), P&lt;0.001) compared to men (β-estimate −0.29 (95% CI: −0.30 to −0.27), P&lt;0.001).

Conclusions

Interventional treatments of HF were associated with improved outcomes and equally beneficial for both sexes. However, they were more often used in male HF patients, in which CAD is significantly more frequent than in female HF patients. This may explain the higher case fatality rate of HF in females.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research (BMBF)

Venous thromboembolism in patients hospitalized for knee and hip joint replacement surgery

Background

Venous thromboembolism (VTE) is a frequent acute cardiovascular disease, leading to significant morbidity and mortality worldwide. Major trauma, surgery, immobilisation and joint replacements are major provoking factors for VTE. In particular, patients undergoing knee and hip joint replacement surgery are at high risk of developing VTE perioperatively, even in the era of established pharmacological thromboprophylaxis. Without thromboprophylaxis, as many as 20–60% of patients may develop perioperative VTE.

Purpose

As recent studies indicate an increasing number of total knee and hip replacement surgeries in European countries and the United States, aims of our study were to investigate a) total burden and temporal trends of VTE complications following knee (KJR) and hip joint replacement (HJR) in Germany 2005–2016 and to identify b) predictors of VTE during hospitalization.

Methods

In an analysis of the nationwide German inpatient sample, we included all hospitalized patients with elective primary KJR and HJR in Germany between 2005 and 2016 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2016, own calculations). We analyzed temporal trends of surgical procedure, mortality, and VTE, and identified predictors of VTE.

Results

A total of 1,804,496 hospitalized patients underwent KJR (65.1% women, 53.4% aged ≥70 years) and 1,885,839 received HJR (59.1% women, 51.4% ≥70 years). VTE was documented in 23,297 (1.3% of total) KJR patients and in 11,554 HJR patients (0.6%).

The number of primary KJR (129,832 in 2005 to 167,881 in 2016 [β-(slope)-estimate 1978 per year; 95% CI 1951 to 2004, P&lt;0.001]) and primary HJR (145,223 in 2005 to 171,421 in 2016 [β-estimate 1818 per year; 95% CI 1083 to 2553, P&lt;0.001]) increased during this twelve-year period.

In-hospital VTE decreased from 1.9% to 0.9% (β-estimate −0.77 [95% CI: −0.81 to −0.72], P&lt;0.001) after KJR and from 0.9% to 0.5% (β-estimate −0.71 (95% CI: −0.77 to −0.65), P&lt;0.001) after HJR. In parallel, in-hospital death rate dropped from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate −0.44 [95% CI: −0.59 to −0.30], P&lt;0.001) after KJR and from 0.33% to 0.29% (β-estimate −0.11 (95% CI: −0.20 to −0.02), P=0.018) after HJR.

Infections during hospitalization were associated with a higher VTE risk. VTE events were associated with in-hospital death in KJR (OR 20.86 [95% CI: 18.78–23.15], P&lt;0.001) and HJR (OR 15.19 [95% CI: 14.19–16.86], P&lt;0.001) independently from age, sex and comorbidities.

Conclusions

While total numbers of KJR and HJR interventions increased in Germany between 2005 and 2016, the rate of VTE decreased substantially. VTE complications were associated with 15-to 21-fold increase of in-hospital case-fatality rate. Perioperative infections increased the risk for VTE substantially.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503), institutional grant for the Center for Thrombosis and Hemostasis. The authors are responsible for the contents of this publication.

Home treatment of fragile patients with acute pulmonary embolism: a subgroup analysis of the multinational home treatment of pulmonary embolism (HoT-PE) trial

Background and aims

Subgroup analyses of randomized trials and cohort studies on direct oral anticoagulants (DOACs) suggested that single direct drug treatment may be effective and safe in elderly and “fragile” patients with acute pulmonary embolism (PE). In a post-hoc analysis of HoT-PE, a prospective multicenter management trial, we studied whether early discharge and home treatment of acute PE is effective and safe in these patients.

Methods

HoT-PE enrolled patients with acute PE classified as being at low risk based on the modified Hestia criteria and the absence of right ventricular dysfunction. The primary efficacy outcome was symptomatic recurrent VTE, or PE-related death within 3 months of enrolment. The safety outcome included major bleeding. Fragility was defined as age &gt;75 years, a creatinine clearance level &lt;50 ml/min, or a body mass index &lt;18.5 kg/cm2.

Results

A total of 524 patients were included; of these, 112 (21.4%) were fragile. Mean age was 77 (range 74–80) years. A total of 104 (92.9%) fragile and 372 (90.3%) non-fragile patients spent two nights or less in hospital corresponding to a median hospital stay of 42 (Q1-Q3: 25–47) and 32 (Q1-Q3: 23–46) hours, respectively. The primary efficacy outcome occurred in one (0.9%) fragile and one (0.5%) non-fragile patient (absolute risk difference [ARD] +0.4%; 95% CI: −1.1%; +4.4%). Major bleeding occurred in three (2.7%) fragile and three (0.7%) non-fragile patients; ARD +2.0% (+0.3%; +6.9%). All-cause 3-month mortality was low in both groups (0.9% vs. 0.2%; ARD +0.7%, −0.7%; +4.7%).

Conclusion

Early discharge and home treatment of fragile patients with acute PE appears to be feasible and acceptably safe. The HoT-PE trial supports the notion that these patients should not be a priori excluded from early discharge, but caution is warranted due to a possibly higher risk of major bleeding on DOAC treatment.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism

Background and purpose

Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated or has failed. We investigated baseline characteristics and in-hospital outcomes of patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort.

Methods

Data from hospitalizations with PE between 2005 and 2016 were collected by the Federal Office of Statistics (Statistisches Bundesamt) in Germany and included in this analysis. Patients with PE who underwent CDT were compared with patients receiving systemic thrombolysis, and those without thromboytic or other reperfusion treatment.

Results

We analyzed data from 978,094 hospitalized patients with PE. Of these, 41,903 (4.3%) patients received thrombolytic treatment (systemic thrombolysis in 4.2%, CDT in 0.1%). Among PE patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis (OR, 0.29, 95% CI 0.13–0.66, P=0.003). No intracranial bleeding occurred among PE patients with shock who received CDT. Among haemodynamically stable PE patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis (OR, 0.52 [95% CI 0.38–0.70]; P&lt;0.001) or no thrombolytic treatment (0.45 [95% CI 0.33–0.62]; P&lt;0.001).

Conclusion

In the German nationwide inpatient cohort, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Time trends of pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension

Background and purpose

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered as a rare but severe complication after acute pulmonary embolism (PE) and is potentially curable by pulmonary endarterectomy (PEA). We aimed to evaluate, over an 11-year period, time trends of in-hospital outcomes of PEA in CTEPH patients in the German nationwide inpatient sample.

Methods and results

We analyzed data on the characteristics, comorbidities, treatments and in-hospital outcomes for all CTEPH patients treated with PEA in Germany between 2006 and 2016. Overall, 1,398 inpatients were included. The annual number of PEA increased from 67 in 2006 to 194 in 2016 (β 0.69 [95% CI 0.51 to 0.86]; p&lt;0.001) in parallel with a significant decrease of in-hospital mortality (10.9% in 2008 to 1.5% in 2016; β −1.85 [95% CI: −2.46 to −1.24]; p&lt;0.001). Patients' characteristics shifted slightly towards older age and higher prevalence of chronic renal insufficiency and obesity over time, whereas duration of hospital stay decreased over time. Independent predictors of in-hospital mortality were age and right heart failure, and in-hospital complications such as ischemic stroke and bleeding events.

Conclusions

The number of CTEPH patients treated with PEA increased markedly in Germany between 2006 and 2016, in parallel with a decrease of in-hospital mortality. Our findings may suggest that the perioperative management of PEA and the general patients' selection have improved over time and might draw more attention to predictors for in-hospital mortality for CTEPH patients hospitalized for PEA.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

P2653Seasonal variations of myocardial infarction and sex-specific differences in Germany

Background

Ischemic heart disease (IHD) is the most common cause of death with an increasing frequency worldwide. It accounts for approximately 20% of all deaths in Europe and the United States of America. Approximately 1/3 of the IHD patients present with sudden cardiac death. The acute presentation of IHD myocardial infarction (MI) is a life-threatening, serious health problem, which causes substantially morbidity and mortality. It is well established that the onset of MI follows a circadian and seasonal periodicity. Seasonal variation regarding the incidence and the short-term mortality of acute MI was frequently reported, but data about sex-specific differences are sparse.

Purpose

Thus, our objectives were to investigate seasonal variations of myocardial infarction.

Methods

We analyzed the impact of seasons on incidence and in-hospital mortality of patients with acute MI in Germany from 2005 to 2015. We included all MI patients (ICD code I21) with an acute MI (, but not those MI patients with a recurrent event in the first 28 days after a previous MI (ICD code I22)), who were hospitalized in Germany between 2005 and 2015, in this analysis (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2015, own calculations).

Results

The nationwide sample comprised 3,008,188 hospitalizations of patients with MI (2005–2015). The annual incidence was 334.7 per 100.000 population. Incidence inclined from 316.3 to 341.6 per 100.000 population per year (β 0.17 [0.10 to 0.24], P<0.001), while in-hospital mortality rate decreased from 14.1% to 11.3% (β −0.29 [−0.30 to −0.28, P<0.001). Overall, 377,028 (12.5%) patients died in-hospital.

Seasonal variation of both incidence and in-hospital mortality were of substantial magnitude. Seasonal incidence (86.1 vs. 79.0 per 100.000 population per year, P<0.001) and in-hospital mortality (13.2% vs. 12.1%, P<0.001) were higher in the winter than in the summer saeson. Risk to die in winter was elevated (OR 1.080 (95% CI 1.069–1.091), P<0.001) compared to summer season independently of sex, age and comorbidities. Reperfusion treatment with drug eluting stents and coronary artery bypass graft were more often used in summer.

We observed sex-specific differences regarding the seasonal variation of in-hospital mortality: males showed lowest mortality in summer, while females during fall. Low temperature dependency of mortality seems more pronounced in males.

Conclusions

Incidence of acute MI increased 2005–2015, while in-hospital mortality rate decreased. Seasonal variations of incidence and in-hospital mortality were of substantial magnitude with lowest incidence and lowest mortality in the summer season. Additionally, we observed sex-specific differences regarding the seasonal variation of the in-hospital mortality.

Acknowledgement/Funding

This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503)

P5021Hypoperfusion markers identify patients with acute pulmonary embolism at highest risk for an adverse outcome

Background/Introduction

According to the European Society of Cardiology (ESC) 2014 guideline, systemic hypotension (HT) is the critical variable defining high-risk in patients with pulmonary embolism (PE). However, signs of organ hypoperfusion might more adequately identify PE patients with cardiogenic shock due to right ventricular (RV) failure.

Purpose

We investigated whether hypoperfusion markers provide superior prognostic information for identifying PE patients at highest risk of early adverse outcomes.

Methods

Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were included. We analysed the predictive value of symptoms and findings suggesting hypoperfusion for in-hospital adverse outcome (catecholamine treatment, resuscitation or PE-related death) and in-hospital all-cause mortality.

Results

We analysed 814 patients, including 83 (10.2%) ESC 2014 high-risk patients. Patients presenting with cardiac arrest (CA, 4.5%) were a priori defined as high risk. Markers suggesting hypoperfusion of the brain (altered metal status, odds ratio [OR] 8.2 [95% CI, 4.2–16.0]), lung (respiratory insufficiency, 25.0 [9.4–66.7]) and tissue (venous lactate ≥2.2 mmol/l, 6.4 [3.2–12.9]) as well as HT (13.5 [6.7–27.2]) predicted an adverse outcome. The risk for an adverse outcome increased with the number of positive markers (AUC 0.86 [0.80–0.93]). Patients with ≥3 positive hypoperfusion markers had an OR of 42.9 (11.0–167.3) and patients defined as high-risk by the ESC 2014 an OR of 17.2 (8.8–33.3) with regard to an adverse outcome (Figure 1; Table 1).

A new definition of high-risk (CA or ≥3 hypoperfusion markers) was associated with an OR of 73.2 (31.3–171.1) for an in-hospital adverse outcome and 26.2 (12.1–56.7) for in-hospital mortality.

Table 1. Prognostic performance of hypoperfusion markers Adverse outcome (if negative) Adverse outcome (if positive) Sensitivity Specificity LR+ OR (95% CI) ≥1 hypoperfusion marker 1.1% 21.0% 91.9% 68.2% 2.9 24.4 (7.3–80.8) ≥2 hypoperfusion markers 4.7% 50.0% 48.6% 95.5% 10.9 20.3 (9.1–45.1) ≥3 hypoperfusion markers 6.5% 75.0% 24.3% 99.3% 32.7 42.9 (11.0–167.3) ESC 2014 high-risk 5.7% 51.1% 35.0% 96.9% 11.4 17.2 (8.8–33.3) Cardiac arrest 8.4% 86.5% 33.0% 99.3% 47.3 70.1 (26.4–186.1) Abbreviations: LR+, positive likelihood ratio; OR, odds ratio; CI, confidence interval.

Figure 1. Frequency of adverse outcome

Conclusions

Markers of organ hypoperfusion have high predictive value for early adverse outcomes in acute PE. Risk increases with the number of positive markers and is critically elevated in patients presenting with CA or ≥3 markers.

Acknowledgement/Funding

This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

P4369Direct comparison of prognostic value of echocardiographic parameters of right ventricular dysfunction in normotensive patients with acute pulmonary embolism

Background

Although various echocardiographic parameters of right ventricular dysfunction (RVD) were reported to be of prognostic value in normotensive patients with acute pulmonary embolism (APE), an optimal definition of RVD on echocardiography is missing.

Purpose

We performed a direct comparison of prognostic value of RV/LV ratio, TAPSE, and TRPG/TAPSE for complicated clinical course that included: in-hospital APE related mortality, hemodynamic collapse or rescue thrombolysis.

Methods

Prospective cohorts of APE patients normotensive at admission, managed according to the ESC Guidelines 2014 were merged in a collaborative database. Transthoracic echocardiography was performed at admission, as soon as possible. All studied parameters were available in each patient. AUC in ROC analysis were assessed for each parameter and were compared between them. Multivariable Cox regression analysis was performed to assess the combination of echo-parameters.

Results

Overall, 490 pts were included in the study (229F), aged 64±18 years. Clinical endpoint occurred in 31 pts including 8 APE related deaths. AUC for SAE of RV/LV, TAPSE and TRPG/TAPSE were similar (Figure 1). TAPSE <16mm compared to other echo-parameters showed the highest PPV and NPV (Table 1). Cox regression analysis including SBP, HR, age, elevated troponin and echo-parameters showed that only blood pressure, RV/LV >1 and TAPSE <16mm were identified as independent predictors of outcome (HR 0.98 (95% CI: 0.96–0.99), p=0.03; 2,53 (95% CI: 1.2–5.7), p<0.03 and 3,76 (95% CI: 1.74–8.11), p<0.001).

Table 1. Predictive values of proposed cut offs of echocardiographic parameters Parameter Sensitivity Specificity PPV NPV TAPSE <16mm 52% 85% 18% 96% RV/LV >1.0 74% 63% 12% 95% TAPSE<20 & TRPG/TAPSE >4.5 10% 94% 10% 94%

Figure 1

Conclusions

Although all TAPSE, RV/LV ratio and TRPG/TAPSE showed similar performance for prognosticating of in-hospital outcome in normotensive PE patients, TAPSE<16mm showed the highest predictive value for identification of patients at risk of complicated clinical course.

Acute episode of cyclic vomiting syndrome preceded by arterial hypertension &ndash; Case presentation and review

Cyclic vomiting syndrome (CVS) is a functional disorder with recurrent episodes of vomiting. Between these episodes patients recover to well-being. Lack of awareness often leads to a delay in making the diagnosis. The diagnosis is based on a typical medical history and exclusion of other causes. We present a case report of a middle-aged patient who had recurrent episodes of vomiting for 12 years coinciding with hypertension. After excluding other causes, CVS was diagnosed. The episodes of acute vomiting were stopped by administration of antiemetic and sedative drugs and urapidil reduced the hypertension. Treatment with sedatives stops vomiting caused by the emetic centre of the central nervous system.