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JACC. Advances Oct 2023Heart failure (HF) is a leading cause of readmission after cardiac surgery, yet risk factors for HF readmission after cardiac surgery remain poorly characterized.
BACKGROUND
Heart failure (HF) is a leading cause of readmission after cardiac surgery, yet risk factors for HF readmission after cardiac surgery remain poorly characterized.
OBJECTIVES
This study aimed to identify risk factors associated with 30-day HF-specific readmissions after cardiac surgery using a national database.
METHODS
We queried the 2016 to 2018 National Readmissions Database to identify U.S. patients who underwent coronary artery bypass grafting (CABG), mitral valve repair/replacement, and/or aortic valve repair/replacement. Exclusion criteria included history of ventricular assist device or heart transplant, dialysis-dependent renal insufficiency, and death during index admission. Clinical variables were defined using International Classification of Diseases-10th Revision codes. The primary outcome was a 30-day readmission for HF following discharge. Multivariable logistic regression was used to account for relevant clinical and demographic covariates and identify independent risk factors for HF readmissions following cardiac surgery.
RESULTS
Our study included 394,050 patients who underwent cardiac surgery (mean age 66 ± 12 years, 63% isolated CABG, 27% isolated valve, 11% CABG + valve). Of these patients, 7,318 were readmitted within 30 days of discharge for a principal diagnosis of HF. Independent risk factors of HF-specific readmission included older age, female sex, prolonged length of stay, comorbid congestive HF, nondialysis dependent chronic kidney disease, chronic obstructive pulmonary disease, chronic liver disease, obesity, atrial fibrillation, and acute kidney injury. Prior CABG was marginally protective for HF-specific readmission.
CONCLUSIONS
Using a national registry, we identified risk factors associated with HF readmission after cardiac surgery. Further analysis of these risk factors and their association with HF readmission is warranted.
PubMed: 38938350
DOI: 10.1016/j.jacadv.2023.100599 -
Caught Between a Rock and a Hard Place: Anticoagulation in Atrial Fibrillation Patients With Cancer.JACC. Advances Oct 2023
PubMed: 38938346
DOI: 10.1016/j.jacadv.2023.100611 -
JACC. Advances Oct 2023
PubMed: 38938340
DOI: 10.1016/j.jacadv.2023.100621 -
JACC. Advances Oct 2023Lymphoma treatment may be associated with new-onset atrial fibrillation (AF), especially among patients treated with Bruton tyrosine kinase inhibitors (BTKi).
BACKGROUND
Lymphoma treatment may be associated with new-onset atrial fibrillation (AF), especially among patients treated with Bruton tyrosine kinase inhibitors (BTKi).
OBJECTIVES
The authors sought to assess the risk of new-onset AF, AF risk factors, and the impact of AF on mortality in patients with lymphoma and no history of AF.
METHODS
The University of Rochester Medical Center Lymphoma Database was used to identify patients. The primary outcome was any AF episode identified using the International Classification of Diseases-10th Revision codes. Multivariable Cox regression was used to assess the risk of AF through the use of a time-dependent covariate for treatment overall as well as separate time-varying measures of BTKi (mainly ibrutinib) and non-BTKi treatment. The relative risk of all-cause mortality was determined using Cox proportional hazards analysis.
RESULTS
Among 1,957 lymphoma patients, the rate of AF at 5-years following initiation of BTKi treatment was higher (25%) compared to those receiving non-BTKi therapy (8%), and those receiving no treatment (4%). Multivariable analysis showed that BTKi treatment was associated with pronounced increased risk for AF compared to no treatment (HR: 5.07 [95% CI: 2.88-8.90; < 0.001]). Non-BTKi treatment was associated with an increased risk of AF compared to no treatment (HR: 1.82 [95% CI: 1.14-2.89; = 0.012]). Risk factors for the development of AF included age ≥64 years, male sex, hypertension, and lymphoma treatment. New AF was associated with an increased risk for subsequent mortality (HR: 3.71 [95% CI: 2.59-5.31]).
CONCLUSIONS
Patients undergoing lymphoma treatment, especially those with high-risk features, may benefit from AF surveillance.
PubMed: 38938336
DOI: 10.1016/j.jacadv.2023.100602 -
JACC. Advances Oct 2023Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.
BACKGROUND
Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.
OBJECTIVES
The purpose of this study was to characterize patient and hospital factors associated with CR participation after transcatheter aortic valve replacement (TAVR) and determine which factors explain hospital-level variation in CR participation.
METHODS
We linked clinical and administrative claims data from patients who underwent TAVR at 24 Michigan hospitals between January 1, 2016 and June 30, 2020 and obtained rates of CR enrollment within 90 days of discharge. Sequential mixed models were fit to evaluate hospital variation in 90-day post-TAVR CR participation.
RESULTS
Among 3,372 patients, 30.6% participated in CR within 90-days after discharge. Several patient factors were negatively associated with CR participation after TAVR including older age, Medicaid insurance, atrial fibrillation/flutter, dialysis use, and slower baseline 5-m walk times. There was substantial hospital variation in CR participation after TAVR ranging from 5% to 60% across 24 hospitals. Patient case mix did not explain hospital variation in CR across hospitals with median OR numerically increasing from 2.11 (95% CI: 1.62-2.67) to 2.13 (95% CI: 1.61-2.68) after accounting for patient-level factors.
CONCLUSIONS
Less than 1 in 3 patients who underwent TAVR in Michigan participated in CR within 90-days of discharge. Although several patient factors are associated with CR participation, hospital-level variation in CR participation after TAVR is not explained by patient case mix. Identifying hospital processes of care that promote CR participation after TAVR will be critical to improving CR participation after TAVR.
PubMed: 38938330
DOI: 10.1016/j.jacadv.2023.100581 -
JACC. Advances Oct 2023Atrial fibrillation (AF) is highly prevalent among cancer patients. The role of traditional risk stratification scores in the context of different cancer types in these...
BACKGROUND
Atrial fibrillation (AF) is highly prevalent among cancer patients. The role of traditional risk stratification scores in the context of different cancer types in these patients remains unknown.
OBJECTIVES
The purpose of this study was to determine the discriminative accuracy of the CHADSVASc score for ischemic stroke using receiver operating characteristic and area under the curve.
METHODS
The National Readmission Database (2015-2019) was used to identify all AF patients stratified by the cancer diagnosis, type, and CHADSVASc category (low; moderate; high risk). Outcomes at 30-day readmission were compared between cancer and noncancer groups using hierarchical multivariable logistic regression to calculate adjusted odds ratios (aORs) and 95% CIs.
RESULTS
A total of 6,996,088 AF patients were identified at index admission. Of these, 4,242,630 (642,237 cancer, 3,600,393 noncancer) were readmitted at 30 days. Cancer patients (92.1%) had a higher proportion of high CHADSVASc scores compared with their noncancer counterparts (89.8%, < 0.001). The 30-day readmission rate and incidence of major bleeding in cancer patients were significantly higher compared with their corresponding noncancer group across all CHADSVASc categories. Among the different cancer types, hematological and lung cancer had a high propensity for major bleeding. The odds of ischemic stroke were lower in the cancer group across high (1.9% vs 2.4%; aOR: 0.78; 95% CI: 0.76-0.79; < 0.0001), moderate (0.8% vs 1.3%; aOR: 0.57; 95% CI: 0.50-0.64; < 0.0001), and low (0.4% vs 0.9%; aOR: 0.46; 95% CI: 0.34-0.62; < 0.0001) risk category relative to the noncancer group irrespective of type of cancer. CHADSVASc category had a statistically significant discriminatory accuracy for ischemic stroke in both cancer and noncancer patients.
CONCLUSIONS
Cancer patients with AF are at a higher risk of readmission and major bleeding. The risk of ischemic stroke during readmission appears to be lower than noncancer patients. These findings may have implications for anticoagulant therapy in cancer patients.
PubMed: 38938329
DOI: 10.1016/j.jacadv.2023.100609 -
JACC. Advances Jun 2023Symptoms associated with severe aortic stenosis (AS) are used to guide management.
BACKGROUND
Symptoms associated with severe aortic stenosis (AS) are used to guide management.
OBJECTIVES
The purpose of this study was to examine the pattern of symptoms, comorbidities, and cardiac damage in moderate and severe AS.
METHODS
A total of 846,198 echocardiographic investigations from 330,940 individuals aged >18 years were selected for the most recent echocardiogram, moderate or severe AS (mean gradient 20.0-39.9 mm Hg, aortic valve peak gradient 3.0-3.9 m/s and aortic valve area >1.0 cm; or 40.0 mm Hg, ≥4.0 m/s or ≤1.0 cm, respectively), and a cardiologist consultation. Natural Language Processing was applied to letters to extract comorbidities, dyspnea, chest pain, and syncope. Patients with prior aortic valve replacement were excluded.
RESULTS
2,213 patients (0.7% overall, 32.8% females) had moderate and 3,416 (1.0%, 47.3% females) had severe AS. Comorbidities were common, including hypertension, (56.6% moderate AS, 53.1% severe AS, = 0.01), coronary disease (46.0% and 46.8%, respectively, = 0.58) and atrial fibrillation (29.6% and 34.8%, respectively, < 0.001). Symptoms were also common in moderate (n = 915, 41.3%) and severe (n = 1,630, 47.7%) AS ( < 0.001). Comorbidities were more likely in symptomatic vs asymptomatic patients ( < 0.001). Dyspnea was more likely in severe AS, whereas angina and syncope were similar in moderate vs severe AS. In multivariable analysis, only dyspnea was associated with severe (vs moderate) AS (OR: 1.73, 95% CI: 1.41-2.13, < 0.001). In both adjusted and unadjusted models, the degree of cardiac damage did not relate to presence of any symptoms but was associated with AS severity.
CONCLUSIONS
Dyspnea is common in moderate and severe AS, is associated with comorbidities and is not related to the degree of cardiac damage. Symptom-guided management decisions in AS may need revision.
PubMed: 38938261
DOI: 10.1016/j.jacadv.2023.100356 -
JACC. Advances Jun 2023Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain...
BACKGROUND
Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied.
OBJECTIVES
The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined.
METHODS
All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization.
RESULTS
Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs.
CONCLUSIONS
CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.
PubMed: 38938260
DOI: 10.1016/j.jacadv.2023.100375 -
JACC. Advances Jun 2023
PubMed: 38938249
DOI: 10.1016/j.jacadv.2023.100398 -
JACC. Advances Jun 2023
PubMed: 38938235
DOI: 10.1016/j.jacadv.2023.100405