Cardiovascular Complications and Their Association With Mortality in Patients With Thrombotic Thrombocytopenic Purpura

BACKGROUND

Despite widespread availability of plasmapheresis, the mortality in thrombotic thrombocytopenic purpura remains high. Cardiovascular complications have been reported as an important cause of morbidity in these patients. The burden and prognostic implications of these complications have not been well studied. We analyzed the rates of cardiovascular complications in thrombotic thrombocytopenic purpura, temporal trends, and studied its impact on in-hospital mortality.

METHODS

We analyzed the National Inpatient Sample (NIS) from January 2005 to September 2015 to identify adult patients with thrombotic thrombocytopenic purpura. This group was further refined by excluding patients who did not receive therapeutic plasmapheresis, and other conditions that can mimic thrombotic thrombocytopenic purpura. We identified the age- and sex-stratified rates of cardiac arrhythmias, cardiac conduction system disorders, heart failure, acute coronary syndrome, myocarditis, pericarditis, takotsubo cardiomyopathy, cardiogenic shock, cardiac arrest, and stroke. We also compared in-hospital mortality with and without cardiovascular complications.

RESULTS

Among 15,054 thrombotic thrombocytopenic purpura hospitalizations (mean age 46.4 years, 69% in the 18- to 54-age group, 66.2% women, and 42.9% white), a cardiovascular complication was observed in 3802 (25.3%) hospitalizations. The following cardiovascular complications were identified: stroke (10.4%), heart failure (8.3%), acute coronary syndrome (6.4%), atrial tachyarrhythmia (5.9%), ventricular tachyarrhythmia (2.0%), cardiogenic shock (0.5%), takotsubo cardiomyopathy (0.1%), atrioventricular block (0.2%), myocarditis or pericarditis (0.3), and cardiac arrest (1.9%). Rates of several cardiovascular complications were significantly higher in patients 55 years or older compared to a younger age group, whereas males had higher rates of acute coronary syndrome and tachyarrhythmias compared to females. Overall, the cardiovascular complication rate was stable during the study period. The presence of a major cardiovascular complication was associated with a significantly higher in-hospital mortality (19.7%) as compared with no major cardiovascular complication (4.1%) (adjusted odds ratio 2.09, 95% confidence interval 1.41-3.09, P <0.001). Results were generally consistent in age and sex subgroups.

CONCLUSION

Cardiovascular complications were frequently observed at a rate of 1 in 4 in patients hospitalized for thrombotic thrombocytopenic purpura and were associated with substantially higher in-hospital mortality. These findings underscore the need to promptly identify and treat these complications to improve outcomes.

Contained Rupture of Sinus of Valsalva Aneurysm in a 64-Year-Old Man

We report a contained rupture of a right coronary sinus of Valsalva aneurysm, in which repair resulted in symptomatic improvement. Patients often present with symptoms secondary to rupture of the sinus of Valsalva aneurysm into one of the cardiac chambers, or secondary to the compression of adjacent structures. Whereas sinus of Valsalva aneurysms and their rupture are well reported in the literature, contained ruptures have been described only rarely. In those cases, symptoms often arose from compression of adjacent structures. Although transesophageal echocardiography is considered to be the diagnostic method of choice, cardiac magnetic resonance imaging and computed tomography can be equally helpful in establishing the diagnosis and delineating the lesion. Diagnosis and prompt repair in our 64-year-old patient resulted in the rapid resolution of his symptoms.

Abstract 368: Association of Atrial Fibrillation with In-hospital Outcomes in ST-Elevation Myocardial Infarction - A Propensity Matched Study

Background: Atrial fibrillation is a relatively common comorbid condition in patients with coronary artery disease. However, there are limited data on the association of atrial fibrillation (AF) with outcomes in ST-elevation myocardial infarction (STEMI).

Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnosis codes, to identify all patients > 18 years admitted with a primary diagnosis of STEMI. We studied the association of AF with in-hospital outcomes in these patients both by regression analysis and propensity match to adjust for demographics, hospital characteristics and co-morbidities.

Results: Of the total 452,772 (64.5% men) STEMI hospitalizations, AF was documented in 58,273 (12.9%) cases. Patients with AF were older (mean age 75±12 vs 64±14 years; p<0.001) and had a higher proportion of women (42.5% vs 34.5%; p<0.001) than patients without AF. STEMI patients with AF had a higher risk-adjusted in-hospital mortality (OR 1.15, 95% CI 1.12-1.19, p<0.001), longer average length of stay (7 days vs 4 days, P<0.001) and higher average total hospital charges ($74,082 vs $57,331, P<0.001) than those without AF. Using propensity matching, 57,388 STEMI patients with AF were compared with the same number of patients without AF. Within these matched cohorts, STEMI patients with AF had higher in-hospital mortality (16.7% vs 15.1%, OR 1.13, 95% CI 1.09-1.16; p<0.001), longer average length of stay (7 days vs 6 days, P<0.001), and higher average total hospital charges ($73,832 vs $65,201, P<0.001) than patients without AF.

Conclusions: In patients hospitalized with STEMI, AF was independently associated with modestly higher in-hospital mortality, higher hospital charges, and longer length of stay.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

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

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