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Alvarez Villela M, Fu D, Roslin K, Smoller R, Asemota D, Miklin DJ, Kodra A, Vullaganti S, Roswell RO, Rangasamy S, Saikus CE, Kon ZN, Pierce MJ, Husk G, Stevens GR, Maybaum S. Defining levels of care in cardiogenic shock. Front Cardiovasc Med 2023; 10:1206570. [PMID: 38028504 PMCID: PMC10644172 DOI: 10.3389/fcvm.2023.1206570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Background Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Methods Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Results Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. Conclusion This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.
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Affiliation(s)
- Miguel Alvarez Villela
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Danni Fu
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Kylie Roslin
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Rebecca Smoller
- Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Daniel Asemota
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Daniel J. Miklin
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Arber Kodra
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Sirish Vullaganti
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Robert O. Roswell
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Sabarivinoth Rangasamy
- Department of Cardiology, Northern Westchester Hospital, Northwell Health, Mount Kisco, NY, United States
| | - Christina E. Saikus
- Department of Cardiothoracic Surgery, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Zachary N. Kon
- Department of Cardiothoracic Surgery, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Matthew J. Pierce
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Gregg Husk
- Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Gerin R. Stevens
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Simon Maybaum
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
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Abstract
Benign proliferations of smooth muscle cells are known as leiomyomas; these proliferations can occur in the colon and are typically found incidentally. Colonic leiomyomas are very rare and are most commonly found in the descending or sigmoid colon. A 59-year-old Hispanic female presented to the gastroenterology clinic for surveillance colonoscopy. The biopsy showed a submucosal microscopic leiomyoma in the transverse colon. The treatment of choice for most colonic leiomyomas is surgical excision. This rare case favors the notion that endoscopic polypectomy may be superior to surgical excision, ultimately providing a less-invasive and less-costly procedure without complications or recurrence.
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Affiliation(s)
| | - Jose R Russe
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Rebecca Smoller
- Internal Medicine, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Glen Head, USA
| | - Nausheer Khan
- Gastroenterology, Nassau University Medical Center, East Meadow, USA
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Agarwal C, Rodriguez MR, Sabharwal B, Yue B, Wilson E, Fang S, Weiss A, Smoller R, Narula J, Fuster V, Badimon J, Sanz J. T1 MAPPING PREDICTS ADVERSE CLINICAL OUTCOME IN MYOCARDITIS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Weiss A, Ibanez JAR, Agarwal C, Smoller R, Contreras J, Narula J, Fuster V, Badimon J, Salvo AS, Santos-Gallego C, Sinai M. T1 MAPPING IN PATIENTS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION DETECTS INCREASED INTERSTITIAL MYOCARDIAL FIBROSIS AND ASSESSES THE SEVERITY OF HEART FAILURE. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)34867-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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