Factors influencing the indication of coronary angiography in patients presenting with chest pain unspecified: an analysis of two decades (1994-2014)

Guidelines for cardiac catheterization in patients with non-specific chest pain (NSCP) provide significant room for provider discretion, which has resulted in variability in the utilization of invasive coronary angiograms (CAs) and a high rate of normal angiograms. The overutilization of CAs in patients with NSCP and discharged without a diagnosis of coronary artery disease is an important issue in medical care quality. As a result, we sought to identify patient demographic, socioeconomic, and geographic factors that influenced the performance of a CA in patients with NSCP who were discharged without a diagnosis of coronary artery disease. We intended to establish reference data points for gauging the success of new initiatives for the evaluation of this patient population. In this 20-year retrospective cohort study (1994-2014), we examined 107 796 patients with NSCP from the Myocardial Infarction Data Acquisition System, a large statewide validated database that contains discharge data for all patients with cardiovascular disease admitted to every non-federal hospital in NJ. Patients were partitioned into two groups: those offered a CA (CA group; n = 12 541) and those that were not (No-CA group; n = 95 255). Geographic, demographic, and socioeconomic variables were compared between the two groups using multivariable logistic regression, which determined the predictive value of each categorical variable on the odds of receiving a CA. Whites were more likely than Blacks and other racial counterparts (19.7% vs. 5.6% and 16.5%, respectively; P < .001) to receive a CA. Geographically, patients who received a CA were more likely admitted to a large hospital compared to small- or medium-sized ones (12.5% vs. 8.9% and 9.7%, respectively; P < .05), a primary teaching institution rather than a teaching affiliate or community center (16.1 % vs. 14.3% and 9.1%, respectively; P < .001), and at a non-rural facility compared to a rural one (12.1% vs. 6.5%; P < .001). Lastly from a socioeconomic standpoint, patients with commercial insurance more often received a CA compared to those having Medicare or Medicaid/self-pay (13.7% vs. 9.5% and 6.0%, respectively; P < .001). The utilization of CA in patients with NSCP discharged without a diagnosis of coronary artery disease in NJ during the study period may be explained by differences in geographic, demographic, and socioeconomic factors. Patients with NSCP should be well scrutinized for CA eligibility, and reliable strategies are needed to reduce discretionary medical decisions and improve quality of care.

Evidence of Reduced Virulence and Increased Colonization among Pneumococcal Isolates of Serotype 3 Clade II Lineage in Mice

Recent phylogenetic profiling of pneumococcal serotype 3 (Pn3) isolates revealed a dynamic interplay among major lineages with the emergence and global spread of a variant termed Clade II. The cause of Pn3 clade II dissemination along with epidemiological and clinical ramifications are currently unknown. Here, we sought to explore biological characteristics of dominant Pn3 clades in a mouse model of pneumococcal invasive disease and carriage. Carriage and virulence potential were strain dependent with marked differences among clades. We found that clinical isolates from Pn3 clade II are less virulent and less invasive in mice compared to clade I isolates. We also observed that clade II isolates are carried for longer and at higher bacterial densities in mice compared to clade I isolates. Taken together, our data suggest that the epidemiological success of Pn3 clade II could be related to alterations in the pathogen's ability to cause invasive disease and to establish a robust carriage episode.

US Initiative to Eliminate Racial and Ethnic Disparities in Health: The Impact on the Outcomes of ST-Segment-Elevation Myocardial Infarction in New Jersey

Background In 1998, President Clinton launched a federal initiative to eliminate racial and ethnic health disparities. The impact on the outcomes of ST-segment-elevation myocardial infarction has not been well studied. Methods and Results ST-segment-elevation myocardial infarction outcomes from 1994 to 2015 were studied in 7942 Black, 27 665 Hispanic, and 88 727 White patients with first admission of ST-segment-elevation myocardial infarction using the Myocardial Infarction Data Acquisition System. Logistic regressions were used to assess mortality adjusting for demographics, comorbidities, and interventional procedures. There was an overall rise from 1994 to 2015 in the use of percutaneous coronary interventions in all 3 groups. Before 1998, White patients received more percutaneous coronary interventions compared with Black and Hispanic patients (P<0.05). After 1998, the disparity in use of percutaneous coronary interventions in Black and Hispanic patients was greatly reduced compared with White patients, and the difference reversed in favor of Hispanic patients after 2005 (P<0.05). There was an overall downward trend of in-hospital mortality without evidence of disparity among Black, Hispanic, and White patients. A linear regression model was used with a change point in 1998. Before 1998, the slope of 1-year all-cause and cardiovascular mortality was not statistically significant. After 1998, the mortality showed negative slopes for all 3 groups, however, with lower overall crude mortality for Hispanic patients compared with Black and White patients (P<0.0001). Conclusions The initiative launched in 1998 may have contributed to a reduction in percutaneous coronary intervention usage disparity in patients with ST-segment-elevation myocardial infarction. Short- and long-term mortality decreased in all 3 groups, but more in the Hispanic population.

Does Ones Socioeconomic Status Predispose to the Development of Stress Induced Cardiomyopathy?

INTRODUCTION

Stress-induced cardiomyopathy (SIC), known as Takotsubo Cardiomyopathy, presents with chest pain and ECG changes suggestive of an acute myocardial infarction, triggered by physical or emotional stress. SIC has a higher incidence in Caucasians (CAUC) than in African Americans (AA). It is unclear whether this disparity is due to a racial predisposition, selection bias or a consequence of environmental factors.

HYPOTHESIS

We hypothesize that people from a lower socioeconomic strata (SES) have a lower incidence of SIC. Furthermore it is possible that the incidence of SIC could be similar among CAUC and AA at the same SES. Stress pre-conditioning maybe protective in preventing SIC among AA.

METHODS

Data of patients with discharge diagnosis of SIC were extracted from the Myocardial Infarction Data Acquisition System (MIDAS) spanning the period from 2006 through 2015. The incidence of SIC amongst CAUC and AA was compared per 100,000 NJ population. The incidence of SIC in CAUC and AA was examined across income brackets. Comparisons between CAUC and AA were performed with two-sample proportion tests.

RESULTS

During the study period CAUC had an overall higher incidence of SIC compared to AA, 0.017% vs 0.0084% per 100,000 population (p-value < 0.0001). This difference persisted after logistic regression adjustment (P=0.0064). CAUC in the income brackets 30-40k had lower incidence of SIC than those in 60-80k (P=0.0156) and those with income 60-80k had lower incidence of SIC than those with income 80-100k. AA with income between 30-60k had a lower incidence of SIC than CAUC (P=0.0330).

CONCLUSIONS

In this study only CAUC exhibited a trend towards less SIC as a function of lower income level. This was not observed amongst AA however, compared to previously published data AA had a lower incidence of SIC. Our study suggests that SES has a protective effect amongst CAUC, however AA may have other, yet to be defined, stress pre-conditioning factors that are protective.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions

OBJECTIVE

A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported.

DESIGN

This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs.

RESULTS

A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion.

CONCLUSION

Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Monotherapy treatment with chlorthalidone or amlodipine in the systolic blood pressure intervention trial (SPRINT)

This post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) examined the performance of chlorthalidone (C) versus amlodipine (A) monotherapies. ANOVA was used to analyze the differences in systolic blood pressure (SBP) response between C and A. Logistic regression was used to examine monotherapy failure (adding a second antihypertensive agent or switching to a different antihypertensive agent) rates. Four hundred ninety-one participants were treated with C monotherapy (n = 210, mean dose = 22 mg/day) or A monotherapy (n = 281, mean dose = 7 mg/day). There was a significant difference in mean SBP reduction between the C and A monotherapies at the third visit (higher reduction with A, adjusted p = .018). Unadjusted analysis showed a higher failure with C in the standard treatment group. Although the average SBP at failure was higher and above the 140 mm Hg cutoff that indicated monotherapy failure with A (142.60) compared with C (138.40), more participants on C failed despite having SBP below the 140 cutoff. This was probably due to decisions made by the investigative teams to change the antihypertensive regimen, because, in their opinion, the clinical picture required it. After adjusting for baseline characteristics, C had higher failure than A only in the standard treatment group (1.64 odds ratio [OR], 95% CI 1.06-2.56, p = .028). A sub-analysis including participants who had never used antihypertensive treatment before randomization had similar results (2.57 OR, 95% CI 1.34-5.02, p = .004). Overall, in SPRINT chlorthalidone was associated with higher monotherapy failure than amlodipine in the standard treatment group because of decisions of the investigative teams.

A Twenty-Year Analysis of Demographics, Surgical Management, and Outcomes of Aortic Stenosis in New Jersey

We investigated the incidence and characteristics of 14,996 patients with aortic stenosis (AS) who were hospitalized in New Jersey between the years 1995 to 2015. The average age was 72, the majority were Caucasian males and common co-morbidities were hypertension, coronary artery disease and hypercholesterolemia. Hospital admission for AS declined between 1995 to 2007, to 10/100,000 patients, and increased to 15/100,000 patients in 2015 (p for trend <0.001). During the study period, the percentage of patients who received aortic valve replacement (AVR) increased (p <0.001). All-cause and cardiovascular mortality were higher among patients who did not undergo AVR at 1-year (HR 1.98 CI 1.75 to 2.23, p <0.001 and HR 1.82 CI 1.57 to 2.11, p <0.001, respectively) and 3-years (HR 2.16 CI 1.96 to 2.38, p <0.001 and HR 2.16 CI 1.90 to 2.45, p <0.001, respectively). The probability for readmission for AS was higher in patients who did not receive AVR compared to patients who had AVR at 1 year (HR 92.95 CI 57.85 to 149.35, p <0.001) and 3 years (HR 70.36 CI 47.18 to 104.95, p <0.001). These data imply that earlier diagnosis of AS and AVR when indicated will improve outcomes.

Use of advanced statistical techniques to predict all-cause mortality in the Systolic Blood Pressure Intervention Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) was conducted in patients with hypertension and additional risk for cardiovascular disease who were randomized to the intensive blood pressure group targeting systolic blood pressure (SBP) less than 120 mm Hg and to the standard group where the target was less than 140 mm Hg. Analyses were done in the matched group of participants with the same gender, same age (±2 years) and same SBP (±3 mm Hg) at three months of treatment regardless of initial randomization to intensive or standard group (shaded area in Figure 1).

Methods and results

During 3.26 years of follow-up, intensive group participants had 14.8 mm Hg lower SBP and received on average one more (2.8 vs. 1.8) blood pressure lowering medications. This was associated with lower all-cause mortality in the intensive treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90, p = 0.003). The effect on SBP was achieved at 3 months and remained unchanged thereafter. This paper addresses two questions with respect to all-cause mortality in SPRINT in the matched set. 1) What is the effect of receiving more than one drug on all-cause mortality. Conditional logistic regression for all-cause mortality with respect to number of drugs indicated that during the 3.26 years of follow-up persons who received more than one drug were more likely to die (coefficient = 0.5039, OR = 1.6552, p = 0.0322) than patients who received one drug. 2) Was there a U curve relationship between on treatment SBP and all-cause mortality? A U curve fitting a quadratic equation (parabola) of SBP and all-cause death was observed. This was seen in the patients randomized to the standard target group in unadjusted analyses as well as in analyses adjusted for demographics or all covariates (p < 0.001 for all). The U curves in the combined group and the intensive treatment group were less pronounced.

Conclusion

SPRINT participants who were matched for gender, age, and SBP at 3 months, and received more than one drug had higher all-cause mortality during the 3.26 years of follow-up. Those who were randomized to standard treatment target had a U curve relationship between SBP at three months and all-cause mortality. The U curves in the combined group and the intensive treatment group were less pronounced.

Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study

BACKGROUND

Constrictive pericarditis is a rare complication of open heart surgery (OHS), but little is known regarding the etiologic determinants, and prognostic factors. The purpose of this study was to investigate clinical predictors and long term prognosis of post-operative constrictive pericarditis (CP).

METHODS

Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 142,837 patients who were admitted for OHS in New Jersey hospitals between 1995 and 2015. Ninety-one patients were hospitalized with CP 30 days or longer after discharge from OHS. Differences in proportions were analyzed using Chi square tests. Controls were matched to cases for demographics, surgical procedure type, history of OHS, and propensity score. Cox proportional hazard models were used to evaluate the risk of all-cause death. Log-rank tests and Cox models were used to assess differences in the Kaplan-Meier survival curves with and without adjustments for comorbidities.

RESULTS

Patients with CP were more likely to have history of valve disease (VD, p < 0.001), atrial fibrillation (AF, p = 0.024) renal disease (CKD, p = 0.028), hemodialysis (HD, p = 0.008), previous OHS (p < 0.001). Patients with CP compared to matched controls had a higher 7-year mortality (p < 0.001). This difference became statistically significant at 1-year after surgery.

CONCLUSION

CP is a rare complication of OHS that occurs more frequently in patients with VD, AF, CKD, HD, multiple OHS, and it is associated with an unfavorable long-term prognosis. Given the large number of OHS performed every year, the results highlight the need for clinicians to recognize and properly manage this complication of OHS.

High rate of stroke and low rate of atrial fibrillation in low socioeconomic strata and blacks: the atrial fibrillation paradox

Background and introduction

Persons living in areas of low socioeconomic status (SES) usually have higher rates of adverse cardiovascular events (CVE) including stroke. Also, atrial fibrillation (AF) is associated with higher rate of CVEs. One would expect that both the rate of stroke and the occurrence of AF would be higher in areas of low SES.

Purpose and methods

Using MIDAS, a validated statewide data base of all hospitalizations for cardiovascular disease in NJ with follow up of more than 25 years, we examined the rate of hospitalization for AF by SES in patients with history of myocardial infarction for the years 1995 to 2015 (n=258,339). Zip codes in New Jersey were aggregated into 4 categories representing quarters of the distribution of SES areas.

Results

At one-year follow-up, patients in the lowest SES (lowest 25th percentile) and Blacks were more likely to suffer a stroke (p&lt;0.0001). During one-year follow-up, patients in the lowest 25th percentile (Figure) were significantly less likely (p&lt;0.0001) to be readmitted with a diagnosis of AF. Blacks had lower rate of admission with a diagnosis AF compared to Whites (p&lt;0.0001) (Figure). Cox proportional hazards regression adjusting for demographics and co-morbidities confirmed the validity of these differences. In this analysis patients in the lowest SES quartile and Blacks were less likely to be admitted with AF than those in the highest quartile (HR 0.95, 95% CI 0.92–0.99). Also, Blacks were less likely to be admitted with AF than Whites (HR 0.76, 95% CI 0.71–0.82). This phenomenon (AF paradox) of lower incidence of AF in low SES and in Blacks has been attributed to under-ascertainment of AF in these groups, that may lead to underuse of anticoagulation and result in the occurrence of stroke.

Conclusion

Atrial fibrillation is underdiagnosed in patients at low socioeconomic strata and in Blacks and may lead to underuse of anticoagulation and the occurrence of stroke. Special efforts are warranted in detecting AF in these groups.

Funding Acknowledgement

Type of funding source: None

Meta-Analysis of Usefulness of Treatment of Hypercholesterolemia With Statins for Primary Prevention in Patients Older Than 75 Years

Clinical guidelines from the United States and Europe do not recommend treatment with statins for primary prevention in patients with hypercholesterolemia who are older than 75 years. Data from 35 randomized controlled trials in this age group where statin therapy for primary prevention was compared with placebo or usual care were analyzed. Using all-cause death as the outcome, we performed 2 types of analyses: frequentist and Bayesian. Frequentist analysis indicated no significant difference in mortality between cases (on statins) and controls (on placebo or usual care, p = 0.16). However, in the Bayesian analysis, patients >75 years had lower mortality from treatment with statins (p = 0.03). In conclusion, Bayesian analysis indicates a definite, statistically significant and clinically relevant benefit of statin treatment for primary prevention in patients >75 years of age.

Uses and opportunities for machine learning in hypertension research

Background

Artificial intelligence (AI) promises to provide useful information to clinicians specializing in hypertension. Already, there are some significant AI applications on large validated data sets.

Methods and results

This review presents the use of AI to predict clinical outcomes in big data i.e. data with high volume, variety, veracity, velocity and value. Four examples are included in this review. In the first example, deep learning and support vector machine (SVM) predicted the occurrence of cardiovascular events with 56%–57% accuracy. In the second example, in a data base of 378,256 patients, a neural network algorithm predicted the occurrence of cardiovascular events during 10 year follow up with sensitivity (68%) and specificity (71%). In the third example, a machine learning algorithm classified 1,504,437 patients on the presence or absence of hypertension with 51% sensitivity, 99% specificity and area under the curve 87%. In example four, wearable biosensors and portable devices were used in assessing a person's risk of developing hypertension using photoplethysmography to separate persons who were at risk of developing hypertension with sensitivity higher than 80% and positive predictive value higher than 90%. The results of the above studies were adjusted for demographics and the traditional risk factors for atherosclerotic disease.

Conclusion

These examples describe the use of artificial intelligence methods in the field of hypertension.

P2778Geographic variability in the decline of the incidence of fatal and non-fatal stroke: a statewide study

Background/Introduction

There is scant information on the geographic variability in the rate of stroke incidence as it relates to the demographics, comorbidities, risk factors, and insurance type.

Purpose/Methods

County-level data on four modifiable groups of health factors including healthy behaviors, clinical care, physical environment, and socioeconomic conditions were obtained from the Robert Wood Johnson Foundation. The percentage of persons 65 years or older, smokers, physically inactive, obese, diabetics, heavy drinkers, college graduates, low income, unemployed, uninsured heads of single parent households, and residence in areas of violent crime was used in predicting fatal or non-fatal stroke. The counties were lumped into 5 categories based on similarities of the above characteristics. The incidence of fatal and non-fatal stroke was compared among the 5 county clusters using a mixed-effects regression model.

Results

The incidence of fatal and non-fatal stroke was significantly lower (p<0.0001) in cluster 3, where residents had higher income, were better educated, and were less likely to be unemployed, to live in single parent households, to have diabetes, to be obese, to smoke, to be physically inactive, or to live in communities with violent crime. The percentage of persons older than 65, violent crime rate, and obesity were identified as significant predictors of stroke using a mixed-effects regression model.

Conclusions

This study indicates that the incidence of stroke is higher in areas with older population, higher rate of obesity, and in regions with more violent crime. In order to improve health outcomes, preventive measures for stroke should address environmental factors in addition to the known cardiovascular risk factors.

Acknowledgement/Funding

Robert Wood Johnson Foundation

P4574Marked changes in the incidence of subendocardial and ST elevation myocardial infarctions: a twenty-one year study

Background/Introduction

The use of new biomarkers, pharmacologic and interventional therapies have resulted in marked changes of the type of myocardial infarction.

Purpose

The purpose of this study is to report on the changes in the incidence of subendocardial and ST elevation myocardial infarctions (STEMI) in the state of New Jersey from 1994 to 2015 and describe possible explanations for this secular change.

Methods

The rate of occurrence of ST elevation myocardial infarction (ICD9 410.00) and of subendocardial (NSTEMI, ICD9 410.70 to 410.72) myocardial infarction was studied using the Myocardial Infarction Data Acquisition System (MIDAS), a statewide database of all admissions for acute myocardial infarction in New Jersey with more than 30 years longitudinal follow up. Admissions for myocardial infarction and unstable angina as well as for conditions associated with troponemia (heart failure ICD9 418.XX, chronic kidney disease ICD9 584.XX, 585.XX, 403.XX, diabetes ICD9 250.XX) were also identified. Associations among variables were examined using logistic regression and linear error in variables (LEIV) models.

Results

During the time period under consideration, there was a decrease in the total number of MIs in New Jersey by 17.5%, the number of STEMIs decreased by 67.4%, while the rate of NSTEMIs increased by 85.8% (top panel). There was a complementary relationship between the annual number of admissions for unstable angina to the annual number of admissions for NSTEMIs (bottom panel). The effect was more pronounced between 1994 and 2002 and plateaued thereafter corresponding to widespread use of troponins in the diagnosis of acute coronary syndromes.

Conclusions

The marked change in the type of myocardial infarction was due in part to the use of troponins that resulted in the classification of patients with unstable angina as patients with subendocardial infarction. These data support regionalization of facilities specializing in immediate intervention in STEMI patients.

P1836Constrictive pericarditis after open heart surgery: a 20-year case controlled study

Background

Constrictive pericarditis (CoPe) after open-heart surgery (OHS) is a rare complication. Information on the incidence, determinants, and prognosis of this condition has been scarcely reported.

Purpose

To investigate the long term prognosis of CoPe after OHS.

Methods

Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 144,902 patients that had OHS in New Jersey hospitals between 1995 and 2015. CoPe was identified in 79 patients after discharge. Differences in proportions were analyzed using chi square. Cases and controls were matched for demographics and comorbidities. Cox proportional hazard models were used to evaluate outcome risks. Log-rank test was used to assess differences in the Kaplan-Meier survival curves.

Results

Patients with CoPe were more likely to have history of valve disease (HVD) (p<0.0001), atrial fibrillation (AF) (p=0.0006) and chronic kidney disease (CKD) (p=0.012). Significant predictors of CoPe were AF (HR 1.62, 95% CI 1.02–2.59), CKD (HR 2.70, 95% CI 1.53–4.76), diabetes (HR 1.73, 95% CI 1.08–2.80) and HVD (HR 3.11, 95% CI 1.88–5.15). Patients with CoPe compared to matched controls had a higher 10-year mortality (p<0.0001). This became a statistically significant difference at 6 years after surgery (Figure).

Survival Curve

Conclusion

Constrictive pericarditis is a rare complication of OHS and occurs more frequently in patients with AF, CKD, diabetes and HVD. It is associated with an unfavorable long-term prognosis. The data highlight the need for strategies to help prevent this complication.

Acknowledgement/Funding

Robert Wood Johnson Foundation

Preeclamptic Women Are at Significantly Higher Risk of Future Cardiovascular Outcomes Over a 15-Year Period

Background: Preeclampsia (PE) may lead to maternal and infant mortality and severe medical complications. Understanding future short- and long-term cardiovascular (CV) outcomes of PE is important to women's health. Materials and Methods: A retrospective matched case-control study assessed the risks of CV outcomes over a 15-year period (1999-2013) in pregnant case women, with gravidity and parity of one, diagnosed with PE, compared to pregnant primiparous control women who were not diagnosed with PE. The New Jersey Electronic Birth Certificate (EBC) database and the Myocardial Infarction Data Acquisition System (MIDAS), a database of all hospital admissions in New Jersey with longitudinal follow-up, were used to conduct the analysis. Participants were 18 years and older with demographics consistent with New Jersey, a state with a range of racial and ethnic diversity. Main outcome measures postpregnancy and over this 15-year period were myocardial infarction (MI), stroke, CV death, and all-cause death. Results: Women with PE (N = 6,360) were more likely to suffer MI, stroke, CV death, and all-cause death than controls (N = 325,347). After matching cases to controls for demographics and comorbidities, hazard ratios of PE cases for the outcomes of MI (p adjusted for comorbidities and demographics = 0.0196), CV death (adjusted p = 0.007), and all-cause death (adjusted p = 0.0026) were significantly higher than 1 compared to matched controls. Women with PE had 3.94 (95% CI: 1.25-12.4) times higher hazard for MI, 4.66 (95% CI: 1.52-14.26) times higher hazard of CV death, and 2.32 (95% CI: 1.34-4.02) times higher hazard for all-cause death than matched controls. Conclusions: This 15-year study indicates that women who have PE with their first pregnancy have a significantly higher risk of adverse CV outcomes compared to controls and suggest a heightened and continued CV monitoring after birth for this population of women.

Trends in Hospitalization for Infective Endocarditis as a Reason for Admission or a Secondary Diagnosis

We postulate that the trends for infective endocarditis (IE) are different for patients admitted for this condition compared with those admitted for a different reason with IE as a secondary diagnosis. Using the Myocardial Infarction Data Acquisition System (MIDAS) database, we analyzed 21,443 records of patients hospitalized with diagnosis of IE from 1994 to 2015. There were 9,191 patients hospitalized with IE as the primary diagnosis, and 12,252 patients with IE as a secondary diagnosis. Piecewise linear models were used to detect changes in trends. A bootstrap method was used to assess the statistical significance of the slopes and break point of each model. Differences in co-morbidities and microbiological patterns were analyzed. Trend analysis showed a significant decrease in IE as the primary diagnosis starting in the year 2004 (p <0.01). Hospitalizations with IE as a secondary diagnosis showed a linear increase in incidence (p <0.001), without any change points. In primary diagnosis IE, the proportion of streptococci as a causative microorganism was higher compared with staphylococci (p <0.001). On the contrary, in secondary diagnosis IE, the proportion of staphylococci was higher than streptococci (p <0.001). The proportion of gram-negative and other organism IE was similar in both groups. In conclusion, this study showed 2 divergent temporal trends in hospitalizations for IE as a primary or secondary diagnosis starting in 2004. The profile of the microorganisms reveals a steady higher proportion of staphylococcal infection in secondary diagnosis IE compared with streptococcal infection. Different strategies are needed for the prevention of IE.