Sachin Sule

Background: Early mechanical revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with improved survival. The current guidelines also recommend (Class IIa) the use of intra-aortic balloon pump (IABP) in patients with cardiogenic shock. However, the evidence supporting this recommendation is controversial. Objectives: To examine the trends (2001-2010) in mechanical revascularization, IABP use and in-hospital mortality in patients with cardiogenic shock complicating AMI and to determine if IABP use is associated with improved in-hospital survival among these patients. Methods: We conducted a retrospective trend analysis of the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2001-2010. All patients ≥ 40 years of age with AMI and cardiogenic shock were identified using ICD-9-CM diagnosis codes. Tr...

The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized. We queried the 2007-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% vers...

Background: Cardiac conduction abnormalities are relatively common in acute ST-elevation myocardial infarction (STEMI). However there are limited data on the temporal trends in the incidence and outcomes of complete heart block (CHB) in patients with STEMI.Methods: We used the 2003-2011 Nationwide Inpatient Sample databases to identify all patients >20 years of age hospitalized with a primary diagnosis of STEMI. Patients with prior history of pacemaker implantation, implantable cardioverter defibrillator, cardiac arrest or non-ischemic cardiomyopathy were excluded. Temporal trends were analyzed after adjusting for demographics, hospital characteristics and co-morbidities, using multivariable logistic regression.Results: Of the 2,077,081 patients with STEMI from 2003-2011, 45,413 (2.2%) patients had CHB documented (mean age 68±13 years, 58.3% men, and 76% with inferior wall STEMI). In the cohort with CHB, 66.1% underwent percutaneous coronary intervention (PCI), 8.8% coronary arte...

Background: Limited data are available on the contemporary and potentially changing trends in the incidence and outcomes of cardiogenic shock complicating non-ST-elevation myocardial infarction (NSTEMI).Objectives: To examine temporal trends in the incidence of cardiogenic shock in patients with NSTEMI, as well as trends in coronary angiography, revascularization (PCI or CABG), and outcomes (in-hospital mortality and length of stay) in these patients.Methods: We used the 2003-2011 Nationwide Inpatient Sample databases to identify all patients ≥18 years of age with a primary diagnosis of NSTEMI (ICD-9-CM code 410.71). Patients with a concomitant diagnosis of cardiogenic shock were identified using ICD-9-CM code 785.51. Temporal trends in incidence of cardiogenic shock, coronary angiography and revascularization rates, and outcomes were analyzed using logistic regression.Results: From 2003 to 2011, among 3,628,071 patients with NSTEMI, 85,176 (2.3%) had cardiogenic shock. The proporti...

Background: Regional disparities in outcomes after out-of-hospital cardiac arrest have been described. However, whether such differences exist in outcomes after in-hospital cardiac arrest (IHCA) has not been well studied.Objectives: To determine if outcomes after cardiopulmonary resuscitation (CPR) for IHCA differ across geographic regions in the United States.Methods: We used the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent CPR (ICD-9-CM procedure codes 99.60 and 99.63) for IHCA. Patients were divided into 4 groups according to hospital region [[Unable to Display Character: –]] Northeast, Midwest, South, and West. Multivariable logistic regression analysis was used to identify differences in outcomes (survival to hospital discharge, neurological status, and total hospital cost) among the 4 regions.Results: Of 838,951 patients who received CPR for IHCA, 162,290 (19.3%) were in the Northeast, 159,777 (19%) in Midwest, 316,363 (...

The prevalence and contemporary trends of pre-heart transplantation (HT) coagulopathy and associated clinical outcomes have not been studied from a national database. Pre-HT coagulopathy is associated with increased in-hospital mortality. Among 2454 adult HT recipients from the 2003 to 2010 Nationwide Inpatient Sample databases, 707 (29%) had pre-HT coagulopathy (defined as a comorbidity variable, based on International Classification of Diseases, Ninthe Revision, Clinical Modification and Diagnosis Related Group codes). We used propensity scores for coagulopathy to assemble a matched cohort of 664 pairs of patients with and without coagulopathy balanced in 54 baseline characteristics. The prevalence of pre-HT coagulopathy increased from 17% in 2003 to 44% in 2010 (P for trend <0.001). In-hospital mortality occurred in 8.6% and 4.7% of matched HT recipients with and without coagulopathy, respectively (hazard ratio: 1.81; 95% confidence interval [CI]: 1.17-2.80; P = 0.008). Coagulopathy was not significantly associated with post-HT graft complications (odds ratio [OR]: 1.20; 95% CI: 0.95-1.52; P = 0.131) but was associated with increased blood transfusions (OR: 1.92; 95% CI, 1.54-2.41; P < 0.001). Coagulopathy and no-coagulopathy groups had no difference in median length of stay (22 days in each group, P = 0.746), but median total hospital charges were higher among patients with coagulopathy compared to…

Nebivolol is a beta-blocker under U.S. Food and Drug Administration review for the treatment of hypertension. The unique pharmacologic properties of nebivolol include high specificity for the beta-1 receptor and a nitric oxide-mediated vasodilatory effect. The agent provides significant blood pressure reduction from baseline values as compared with placebo. Clinical trials have demonstrated that nebivolol reduces blood pressure similarly to atenolol, bisoprolol, amlodipine, nifedipine, lisinopril, and hydrochlorothiazide. The tolerability of nebivolol is similar to or better than that of these agents. In elderly patients (> or = 70 years of age) with clinically stable congestive heart failure, the addition of nebivolol to the treatment regimen improved the time to all-cause mortality and cardiovascular hospital admissions over that of placebo. If approved, nebivolol would likely be a viable alternative therapy for hypertension and heart failure; however, additional studies are needed in patients having coronary artery disease.

Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year...

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p<0.001) and ventricular tachycardia or ventricular fibrillat...