Temporal Changes in Clinical Practice with COVID-19 Hospitalized Patients: Potential Explanations for Better In-Hospital Outcomes

Background/Aims: We reviewed demographic and clinical profiles, along with measures of hospital-based clinical practice to identify temporal changes in clinical practice that may have affected in-hospital outcomes of patients with COVID-19. Methods: Data consisted of sociodemographic and clinical data captured in University of Pittsburgh Medical Center (UPMC) electronic medical record (EMR) systems, linked by common variables (deidentified). The analysis population included hospitalized patients (across 21 hospitals) with a primary diagnosis of COVID-19 infection during the period March 14-August 31, 2020. The primary outcome was a composite of in-hospital mechanical ventilation/mortality. We compared temporal trends in patient characteristics, clinical practice, and hospital outcomes using 4 time-defined epochs for calendar year 2020: March 14-March 31 (epoch 1); April 1-May 15, (epoch 2), May 16-June 28 (epoch 3); and June 29-August 31 (epoch 4). We report unadjusted survival estimates, followed by propensity score analyses to adjust for differences in patient characteristics, to compare in-hospital outcomes of epoch 4 patients (recently treated) to epoch 1-3 patients (earlier treated). Results: Mean number of hospital admissions was 9.9 per day during epoch 4, which was ~2- to 3-fold higher than the earlier epochs. Presenting characteristics of the 1,076 COVID-19 hospitalized patients were similar across the 4 epochs, including mean age. The crude rate of mechanical ventilation/mortality was lower in epoch 4 patients (17%) than in epoch 1-3 patients (23% to 35%). When censoring for incomplete patient follow-up, the rate of mechanical ventilation/mortality was lower in epoch 4 patients (p<0.0001), as was the individual component of mechanical ventilation (p=0.0002) and mortality (p=0.02). In propensity score adjusted analyses, the in-hospital relative risk (RR) of mechanical ventilation/mortality was lower in epoch 4 patients (RR=0.67, 95% CI: 0.48, 0.93). For the outcome being discharged alive within 3, 5, or 7 days of admission, adjusted odds ranged from 1.6- to 1.7-fold higher among epoch 4 patients compared to earlier treated patients. The better outcomes in epoch 4 patients were principally observed in patients under the age of 75 years. Patient level dexamethasone use was 55.6% in epoch 4 compared to 15% or less of patients in the earlier epochs. Most patients across epochs received anticoagulation drugs (principally heparin). Overall steroid (81.7% vs. 54.3%, p<0.0001) and anticoagulation use (90.4% vs. 80.7%, p=0.0001) was more frequent on the day or day after hospitalization in epoch 4 patients compared to earlier treated patients. Conclusions: In our large system, recently treated hospitalized COVID-19 patients had lower rates of in-hospital mechanical ventilation/mortality and shorter length of hospital stay. Alongside of this was a change to early initiation of glucocorticoid therapy and anticoagulation. The extent to which the improvement in patient outcomes was related to changes in clinical practice remains to be established.

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Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

Biomarker Research ◽

10.1186/s40364-021-00283-y ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Temporal trends in tolvaptan use after revision of national heart failure guidelines in Japan

Scientific Reports ◽

10.1038/s41598-021-98173-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Yusuke Yamazaki ◽

Yasuyuki Shiraishi ◽

Shun Kohsaka ◽

Yuji Nagatomo ◽

Keiichi Fukuda ◽

...

Keyword(s):

Heart Failure ◽

Clinical Practice ◽

Mortality Rate ◽

Risk Score ◽

Temporal Trends ◽

National Guidelines ◽

Hospital Outcomes ◽

Trends Over Time ◽

Multicenter Registry ◽

Over Time

AbstractWithin no definite diuretic protocol for acute heart failure (AHF) patients and its variation in regional clinical guidelines, the latest national guidelines in Japan commends use of tolvaptan in diuretic-resistant patients. This study aimed to examine trends in tolvaptan usage and associated outcomes of AHF patients requiring hospitalization. Between April, 2018 and October, 2019, 1343 consecutive AHF patients (median 78 [69–85] year-old) were enrolled in a prospective, multicenter registry in Japan. Trends over time in tolvaptan usage, along with the severity of heart failure status based on the Get With The Guideline-Heart Failure [GWTG-HF] risk score, and in-hospital outcomes were investigated. During the study period, tolvaptan usage has increased from 13.0 to 28.7% over time (p for trend = 0.07), and 49.4% started tolvaptan within 3 days after admission. The GWTG-HF risk score in the tolvaptan group has significantly decreased over time, while that in the non-tolvaptan group has unchanged. There were no differences in the in-hospital mortality rate between the patients with and without tolvaptan (6.7% vs. 5.8%). After revision of the Japanese clinical practice guidelines for AHF in March 2018, tolvaptan usage for AHF patients has steadily increased. However, in-hospital outcomes including mortality do not seem to be affected.

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Patient Characteristics and Outcomes of 11 721 Patients With Coronavirus Disease 2019 (COVID-19) Hospitalized Across the United States

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1268 ◽

2020 ◽

Cited By ~ 9

Author(s):

Michael W Fried ◽

Julie M Crawford ◽

Andrea R Mospan ◽

Stephanie E Watkins ◽

Breda Munoz ◽

...

Keyword(s):

United States ◽

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Mechanical Ventilation ◽

Kidney Disease ◽

Clinical Course ◽

Patient Characteristics ◽

The United States ◽

Geographic Region ◽

Hospitalized Patients

Abstract Background As coronavirus disease 2019 (COVID-19) disseminates throughout the United States, a better understanding of the patient characteristics associated with hospitalization, morbidity, and mortality in diverse geographic regions is essential. Methods Hospital chargemaster data on adult patients with COVID-19 admitted to 245 hospitals across 38 states between 15 February and 20 April 2020 were assessed. The clinical course from admission, through hospitalization, and to discharge or death was analyzed. Results A total of 11 721 patients were included (majority were >60 years of age [59.9%] and male [53.4%]). Comorbidities included hypertension (46.7%), diabetes (27.8%), cardiovascular disease (18.6%), obesity (16.1%), and chronic kidney disease (12.2%). Mechanical ventilation was required by 1967 patients (16.8%). Mortality among hospitalized patients was 21.4% and increased to 70.5% among those on mechanical ventilation. Male sex, older age, obesity, geographic region, and the presence of chronic kidney disease or a preexisting cardiovascular disease were associated with increased odds of mechanical ventilation. All aforementioned risk factors, with the exception of obesity, were associated with increased odds of death (all P values < .001). Many patients received investigational medications for treatment of COVID-19, including 48 patients on remdesivir and 4232 on hydroxychloroquine. Conclusions This large observational cohort describes the clinical course and identifies factors associated with the outcomes of hospitalized patients with COVID-19 across the United States. These data can inform strategies to prioritize prevention and treatment for this disease.

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In-hospital outcomes of self-expanding and balloon-expandable transcatheter heart valves in Germany

Clinical Research in Cardiology ◽

10.1007/s00392-021-01928-6 ◽

2021 ◽

Author(s):

Peter Stachon ◽

Philip Hehn ◽

Dennis Wolf ◽

Timo Heidt ◽

Vera Oettinger ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Propensity Score ◽

Hospital Mortality ◽

Hospital Stay ◽

Major Bleeding ◽

Postoperative Delirium ◽

Kidney Injury ◽

Length Of Hospital Stay ◽

Hospital Outcomes

Abstract Introduction The effect of valve type on outcomes in transfemoral transcatheter aortic valve replacement (TF-TAVR) has recently been subject of debate. We investigate outcomes of patients treated with balloon-expanding (BE) vs. self-expanding (SE) valves in in a cohort of all these procedures performed in Germany in 2018. Methods All patients receiving TF-TAVR with either BE (N = 9,882) or SE (N = 7,413) valves in Germany in 2018 were identified. In-hospital outcomes were analyzed for the endpoints in-hospital mortality, major bleeding, stroke, acute kidney injury, postoperative delirium, permanent pacemaker implantation, mechanical ventilation > 48 h, length of hospital stay, and reimbursement. Since patients were not randomized to the two treatment options, logistic or linear regression models were used with 22 baseline patient characteristics and center-specific variables as potential confounders. As a sensitivity analysis, the same confounding factors were taken into account using the propensity score methods (inverse probability of treatment weighting). Results Baseline characteristics differed substantially, with higher EuroSCORE (p < 0.001), age (p < 0.001) and rate of female sex (p < 0.001) in SE treated patients. After risk adjustment, no marked differences in outcomes were found for in-hospital mortality [risk adjusted odds ratio (aOR) for SE instead of BE 0.94 (96% CI 0.76;1.17), p = 0.617] major bleeding [aOR 0.91 (0.73;1.14), p = 0.400], stroke [aOR 1.13 (0.88;1.46), p = 0.347], acute kidney injury [OR 0.97 (0.85;1.10), p = 0.621], postoperative delirium [aOR 1.09 (0.96;1.24), p = 0.184], mechanical ventilation > 48 h [aOR 0.98 (0.77;1.25), p = 0.893], length of hospital stay (risk adjusted difference in days of hospitalization (SE instead of BE): − 0.05 [− 0.34;0.25], p = 0.762) and reimbursement [risk adjusted difference in reimbursement (SE instead of BE): − €72 (− €291;€147), p = 0.519)] There is, however, an increased risk of PPI for SE valves (aOR 1.27 [1.15;1.41], p < 0.001). Similar results were found after application of propensity score adjustment. Conclusions We find broadly equivalent outcomes in contemporary TF-TAVR procedures, regardless of the valve type used. Incidence of major complications is very low for both types of valve.

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Association of Rising Violent Crime With Blood Pressure and Cardiovascular Risk: Longitudinal Evidence From Chicago, 2014–2016

American Journal of Hypertension ◽

10.1093/ajh/hpz134 ◽

2019 ◽

Vol 32 (12) ◽

pp. 1192-1198

Author(s):

Elizabeth L Tung ◽

Rhys F M Chua ◽

Stephanie A Besser ◽

Stacy Tessler Lindau ◽

Marynia Kolak ◽

...

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Violent Crime ◽

Hospital Admissions ◽

Medical Center ◽

Academic Medical Center ◽

Patient Characteristics ◽

Multilevel Regression ◽

Chicago Police ◽

Elevated Heart Rate

Abstract BACKGROUND The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP). METHODS We analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014–2016). Serial observations were abstracted from the electronic health record at an academic medical center and paired to the City of Chicago Police Data Portal. The violent crime rate (VCR) was calculated as the number of violent crimes per 1,000 population per year for each census tract. Longitudinal multilevel regression models were implemented to assess elevated BP (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg) as a function of the VCR, adjusting for patient characteristics, neighborhood characteristics, and time effects. Secondary dependent measures included elevated heart rate, obesity, missed outpatient appointments, all-cause hospital admissions, and cardiovascular hospital admissions. RESULTS At baseline, the median VCR was 41.3 (interquartile range: 15.2–66.8), with a maximum rise in VCR of 59.1 over the 3-year surge period. A 20-unit rise in the VCR was associated with 3% higher adjusted odds of having elevated BP (95% confidence interval [CI]: 1.01–1.06), 8% higher adjusted odds of missing an outpatient appointment (95% CI: 1.03–1.13), and 6% higher adjusted odds of having a cardiovascular-related hospital admission (95% CI: 1.01–1.12); associations were not significant for elevated heart rate and obesity. CONCLUSION Rising violent crime was associated with increased BP during a temporal crime surge.

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A Nationwide Study of the Impact of Dysphagia on Hospital Outcomes Among Patients With Dementia

American Journal of Alzheimer s Disease & Other Dementias® ◽

10.1177/1533317516673464 ◽

2016 ◽

Vol 32 (1) ◽

pp. 5-11 ◽

Cited By ~ 14

Author(s):

Suchitra Paranji ◽

Neethi Paranji ◽

Scott Wright ◽

Shalini Chandra

Keyword(s):

Mechanical Ventilation ◽

Patient Characteristics ◽

Hospitalized Patients ◽

Skilled Nursing ◽

Percutaneous Endoscopic Gastrostomy Placement ◽

Endoscopic Gastrostomy ◽

Diagnosis Of Dementia ◽

The Impact ◽

New Evidence ◽

Mean Charge

Objectives: To assess the impact of dysphagia on clinical and operational outcomes in hospitalized patients with dementia. Design: Retrospective cohort study. Setting: 2012 Nationwide Inpatient Sample. Participants: All patients discharged with a diagnosis of dementia (N = 234,006) from US hospitals in 2012. Measurements: Univariate and multivariate regression models, adjusting for stroke and patient characteristics, to assess the impact of dysphagia on the prevalence of comorbidities, including pneumonia, sepsis, and malnutrition; complications, including mechanical ventilation and death; and operational outcomes, including length of stay (LOS) and total charges for patients with dementia. Results: Patients having dementia with dysphagia (DWD) had significantly higher odds of having percutaneous endoscopic gastrostomy placement during the admission (odds ratio [OR]: 13.68, 95% confidence interval [CI]: 12.53-14.95, P < .001), aspiration pneumonia (OR: 6.27, 95% CI: 5.87-6.72, P < .001), pneumonia (OR: 2.84, 95% CI: 2.67-3.02, P < .001), malnutrition (OR: 2.5, 95% CI: 2.27-2.75, P < .001), mechanical ventilation (OR: 1.69, 95% CI: 1.51-1.9, P < .001), sepsis (OR: 1.52, 95% CI: 1.39-1.67, P < .001), and anorexia (OR: 1.29, 95% CI: 1.01-1.65, P = .04). Mean LOS was 2.16 days longer (95% CI: 1.98-2.35, P < .001), mean charge per case was US$10,703 higher (95% CI: US$9396-US$12,010, P < .001), and the odds of being discharged to a skilled nursing, rehabilitation, or long-term facility was 1.59 times higher (95% CI: 1.49-1.69, P < .001) in the DWD cohort compared to patients having dementia without dysphagia. Conclusion: Dysphagia is a significant predictor of worse clinical and operational outcomes including a 38% longer LOS and a 30% increase in charge per case among hospitalized patients with dementia. Although these findings may not be surprising, this new evidence might bring heightened awareness for the need to more thoughtfully support patients with dementia and dysphagia who are hospitalized.

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Corticosteroids for hospitalized patients with mild to critically-ill COVID-19: a multicenter, retrospective, propensity score-matched study

Scientific Reports ◽

10.1038/s41598-021-90246-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Satoshi Ikeda ◽

Toshihiro Misumi ◽

Shinyu Izumi ◽

Keita Sakamoto ◽

Naoki Nishimura ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Critically Ill ◽

Noninvasive Ventilation ◽

Clinical Status ◽

Invasive Mechanical Ventilation ◽

Hospitalized Patients ◽

Radiological Findings ◽

Corticosteroid Administration ◽

Matched Study

AbstractCorticosteroids use in coronavirus disease 2019 (COVID-19) is controversial, especially in mild to severe patients who do not require invasive/noninvasive ventilation. Moreover, many factors remain unclear regarding the appropriate use of corticosteroids for COVID-19. In this context, this multicenter, retrospective, propensity score–matched study was launched to evaluate the efficacy of systemic corticosteroid administration for hospitalized patients with COVID-19 ranging in the degree of severity from mild to critically-ill disease. This multicenter, retrospective study enrolled consecutive hospitalized COVID-19 patients diagnosed January–April 2020 across 30 institutions in Japan. Clinical outcomes were compared for COVID-19 patients who received or did not receive corticosteroids, after adjusting for propensity scores. The primary endpoint was the odds ratio (OR) for improvement on a 7-point ordinal score on Day 15. Of 1092 COVID-19 patients analyzed, 118 patients were assigned to either the corticosteroid and non-corticosteroid group, after propensity score matching. At baseline, most patients did not require invasive/noninvasive ventilation (85.6% corticosteroid group vs. 89.8% non-corticosteroid group). The odds of improvement in a 7-point ordinal score on Day 15 was significantly lower for the corticosteroid versus non-corticosteroid group (OR, 0.611; 95% confidence interval [CI], 0.388–0.962; p = 0.034). The time to improvement in radiological findings was significantly shorter in the corticosteroid versus non-corticosteroid group (hazard ratio [HR], 1.758; 95% CI, 1.323–2.337; p < 0.001), regardless of baseline clinical status. The duration of invasive mechanical ventilation was shorter in corticosteroid versus non-corticosteroid group (HR, 1.466; 95% CI, 0.841–2.554; p = 0.177). Of the 106 patients who received methylprednisolone, the duration of invasive mechanical ventilation was significantly shorter in the pulse/semi-pulse versus standard dose group (HR, 2.831; 95% CI, 1.347–5.950; p = 0.006). In conclusion, corticosteroids for hospitalized patients with COVID-19 did not improve clinical status on Day 15, but reduced the time to improvement in radiological findings for all patients regardless of disease severity and also reduced the duration of invasive mechanical ventilation in patients who required intubation.Trial registration: This study was registered in the University hospital Medical Information Network Clinical Trials Registry on April 21, 2020 (ID: UMIN000040211).

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Patient characteristics and in-hospital outcomes of Takotsubo Cardiomyopathy in pregnancy: a retrospective analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.3300 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Joshi ◽

S.P Patil ◽

C Rojulpote ◽

K Gonuguntla

Keyword(s):

Mechanical Ventilation ◽

Ventricular Fibrillation ◽

Cardiogenic Shock ◽

Pregnant Women ◽

Takotsubo Cardiomyopathy ◽

Patient Characteristics ◽

Left Ventricular ◽

Skewed Distribution ◽

Hospital Outcomes ◽

In Pregnancy

Abstract Introduction Takotsubo Cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction and predominantly affects post-menopausal women. However, it is rarely identified as a cause of acute heart failure in pregnancy. Objective We aimed to determine patient characteristics and in-hospital outcomes of TCM occurring in pregnancy. Methods We retrospectively analyzed the United States - National Inpatient Sample (NIS) Database from 2010–2014 to assess TCM in pregnant women ≥18 years using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. We compared patient demographics, co-morbidities and in-hospital outcomes between pregnant and non-pregnant women with TCM aged 18–49 years. Patients with a diagnosis of peripartum cardiomyopathy were excluded. Chi-square test and Student-t test or Mann- Whitney U test were used for categorical and continuous variables with normal and skewed distribution, respectively. Results TCM occurred at a younger age in pregnant women compared to non-pregnant women (Age [Mean ±SD]: 31.2±7.2 years vs. 41.8±7.1 years; p<0.001). Rates of TCM were higher during pregnancy in African American (19% vs. 11.5%; p=0.008), Hispanic (27.3% vs. 9.6%; p<0.001) and Asian women (11.3% vs. 2.6%; p<0.001) compared to non-pregnant women of similar race. However, among Caucasian women rates of TCM were higher in non-pregnant women (42.4% vs. 72.7%; p<0.001). There were no in-hospital deaths among pregnant women with TCM (0% vs. 5.2%; p=0.005), however they had higher rates of cardiogenic shock (13.8% vs. 5.8; p<0.001) and respiratory failure requiring mechanical ventilation (51.7% vs. 20.9%; p<0.001). The average length of hospitalization was also longer among pregnant women with TCM (Days [Mean±SD]: 5.8±4 vs. 5.5±7.5; p<0.001). Pregnant women had lower rates of diagnostic angiography (24.1% vs. 55.6%; p<0.001). Pregnant women with TCM had higher rates of ventricular fibrillation (6.9% vs. 2.9%; p=0.02), but had no atrial fibrillation (0% vs. 2.6%; p=0.05), atrial flutter (0% vs. 0.4%; p=0.43), paroxysmal supraventricular tachycardia (0% vs. 0.5%; p=0.4) and ventricular tachycardia (0% vs. 4.8%; p=0.07). Pregnant women with TCM had lower rates of psychiatric and certain medical co-morbidities: anxiety (6.9% vs. 20.4%; p<0.001), depression (0% vs. 2.6%; p=0.05), bipolar disorder (0% vs. 0.8%; p=0.3), hypertension (27.6% vs. 40.3%; p=0.002), hyperlipidemia (3.4% vs. 25.7%; p<0.001) and smoking (6.9% vs. 40.2%; p<0.001). The rates of diabetes (13.8% vs. 15.9%; p=0.5) and obesity (10.3% vs. 8.2%; p=0.37) were similar between the two groups. Conclusion There was no in-hospital mortality observed in pregnant women who developed TCM, however, they had increased rates of cardiogenic shock, mechanical ventilation, ventricular fibrillation and had longer hospitalizations. Funding Acknowledgement Type of funding source: None

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Empiric use of Anticoagulation in Hospitalized Patients with COVID-19: A Propensity Score-Matched Study of Risks and Benefits

10.21203/rs.3.rs-242205/v1 ◽

2021 ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background: Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods: We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 15 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results: The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345-0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110-1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114-3.729, p = 0.016). Conclusion: Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Temporal Trends in Tolvaptan Use After Revision of National Heart Failure Guidelines in Japan

10.21203/rs.3.rs-689564/v1 ◽

2021 ◽

Author(s):

Yusuke Yamazaki ◽

Yasuyuki Shiraishi ◽

Shun Kohsaka ◽

Yuji Nagatomo ◽

Keiichi Fukuda ◽

...

Keyword(s):

Heart Failure ◽

Clinical Practice ◽

Mortality Rate ◽

Risk Score ◽

Temporal Trends ◽

National Guidelines ◽

Hospital Outcomes ◽

Trends Over Time ◽

Multicenter Registry ◽

Over Time

Abstract Within no definite diuretic protocol for acute heart failure (AHF) patients and its variation in regional clinical guidelines, the latest national guidelines in Japan commends use of tolvaptan in diuretic-resistant patients. This study aimed to examine trends in tolvaptan usage and associated outcomes of AHF patients requiring hospitalization. Between April, 2018 and October, 2019, 1343 consecutive AHF patients (median 78 [69–85] y/o) were enrolled in a prospective, multicenter registry in Japan. Trends over time in tolvaptan usage, along with the severity of heart failure status based on the Get With The Guideline-Heart Failure [GWTG-HF] risk score, and in-hospital outcomes were investigated. During the study period, tolvaptan usage has increased from 13.0% to 28.7% over time (p for trend=0.07), and 49.4% started tolvaptan within 3 days after admission. The GWTG-HF risk score in the tolvaptan group has significantly decreased over time, while that in the non-tolvaptan group has unchanged. There were no differences in the in-hospital mortality rate between the patients with and without tolvaptan (6.7% vs. 5.8%). After revision of the Japanese clinical practice guidelines for AHF in March 2018, tolvaptan usage for AHF patients has steadily increased. However, in-hospital outcomes including mortality do not seem to be affected.

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