scholarly journals National trends in coronary intensive care unit admissions, resource utilization, and outcomes

2019 ◽  
Vol 9 (8) ◽  
pp. 923-930
Author(s):  
Sarah Woolridge ◽  
Wendimagegn Alemayehu ◽  
Padma Kaul ◽  
Christopher B Fordyce ◽  
Patrick R Lawler ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Mortality Rates ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment

Background: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. Methods: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005–2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. Results: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p<0.001) and non-cardiac diagnoses (11.8% to 13.1%; p<0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, p<0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, p<0.001), heart failure (7.3% to 8.4%, p<0.001), shock (4.9% to 5.7%, p<0.001), and decline in unstable angina (4.9% to 4.0%, p<0.001) and stable coronary diseases (21.3% to 12.4%, p<0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, p<0.001) including mechanical ventilation (9.6% to 13.1%, p<0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63–0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73–0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention. Conclusion: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

scholarly journals Temporal Trends, Predictors, and Outcomes of Acute Ischemic Stroke in Acute Myocardial Infarction in the United States

2021 ◽  
Author(s):  
Gaurav Aggarwal ◽  
Sri Harsha Patlolla ◽  
Saurabh Aggarwal ◽  
Wisit Cheungpasitporn ◽  
Rajkumar Doshi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Temporal Trends ◽  
St Segment Elevation ◽  
Endoscopic Gastrostomy ◽  
St Segment ◽  
Hospitalization Costs

Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000–2017) were evaluated for in‐hospital AIS. Outcomes of interest included in‐hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST‐segment–elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04–1.15]) and decreased in non–ST‐segment–elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46–0.49]) admissions ( P <0.001). Compared with those without, the AIS cohort was on average older, female, of non‐White race, with greater comorbidities, and higher rates of arrhythmias. The AMI‐AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) ( P <0.001). The AIS cohort had higher in‐hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72–1.78]; P <0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P <0.001). Among AMI‐AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in‐hospital mortality and poor functional outcomes in AMI admissions.

Acquired organ system derangements and hospital mortality: are all organ systems created equally?

1999 ◽  
Vol 8 (3) ◽  
pp. 180-188 ◽  
Author(s):  
MH Kollef ◽  
G Sherman
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Organ System ◽  
Neurological Dysfunction ◽  
Relative Importance ◽  
Surgical Intensive Care ◽  
Organ Systems

BACKGROUND: Acquired organ system derangements are common among patients who require intensive care, but the relative importance of different derangements as determinants of patients' outcomes is unclear. OBJECTIVES: To determine organ system derangements that occur in patients who require intensive care and the relative importance of different derangements to hospital mortality. METHODS: A prospective cohort study design was used to evaluate the occurrence of organ system derangements and hospital mortality in 617 adults admitted to the medical and surgical intensive care units of a university-affiliated teaching hospital. RESULTS: Eighty-three patients (13.5%) died while hospitalized. Patients who died had significantly more derangements than did patients who survived (3.3 +/- 1.2 vs 0.9 +/- 0.9; P &lt; .001). The crude hospital mortality rate varied with the specific organ system involved (pulmonary, 23.6%; gastrointestinal, 25.0%; hepatic, 42.4%; hematological, 47.9%; cardiac, 54.0%; renal, 54.8%; neurological, 65.9%). Derangements of neurological function (adjusted odds ratio, 3.20; 95% CI, 2.0-5.3; P = .019) and cardiac function (adjusted odds ratio, 3.96; 95% CI, 2.63-5.99; P &lt; .001) were independently associated with hospital mortality. Additionally, derangements occurred later during the stay in the intensive care unit in patients who died in the hospital than in patients who survived, especially for derangements of pulmonary, neurological, and renal function. CONCLUSION: Among critically ill patients, neurological and cardiac dysfunction are the acquired organ system derangements most closely associated with hospital mortality. These data suggest that hospital mortality depends on both the specific types of derangements that occur and the total number of such derangements. Interventions to prevent cardiac and neurological dysfunction have the greatest potential for improving outcomes for patients in the intensive care unit.

Abstract 327: Electronic Health Record Integration of Predictive Analytics to Select High-risk Stable Patients With Non-st-segment Elevation Myocardial Infarction for Intensive Care Unit Admission

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Aman D Kansal ◽  
Alexander Fanaroff ◽  
Cynthia Green ◽  
Manesh R Patel ◽  
Tracy Y Wang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Risk Score ◽  
Predictive Analytics ◽  
Health Record ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Risk Patients

Background: Nationwide, intensive care unit (ICU) utilization for initially stable patients with non-ST-segment elevation myocardial infarction (NSTEMI) is not associated with patient risk. Use of the ACTION ICU risk score, which predicts clinical deterioration requiring ICU care in initially stable NSTEMI patients, could guide admission of high-risk patients to the ICU and low-risk patients to a lower acuity unit. Methods: We created a modified best practice advisory (BPA) within the electronic health record (EHR) at a single institution. The BPA semi-automatically calculates the ACTION ICU score (5 elements automatically populate from the EHR and 4 are entered manually) and recommends a location for admission based on a 10% risk threshold for clinical deterioration over the course of admission. The BPA was triggered for all ED patients with serum 4 th generation troponin T above the local upper limit of normal. Physicians could temporarily hide the BPA, permanently cancel it if they felt the patient’s presentation was not primarily due to NSTEMI, or generate the ACTION ICU score. We measured how ED physicians used the BPA, and clinical and utilization outcomes for patients admitted through the ED with a discharge diagnosis of NSTEMI in the 12 months before and after BPA roll-out. Results: Between August 14, 2017 and August 13, 2018, the BPA triggered 972 times. It was hidden until the patient left the ED 230 times (23.7%) and canceled 561 times (57.7%). Providers opted to calculate a risk score 181 times (18.6%), and a score was successfully calculated 146 times. Among 135 patients for whom the BPA triggered that had a final hospital diagnosis of NSTEMI, the BPA was inappropriately canceled in 62 (45.9%) and hidden in 16 (11.9%). Overall, there were 190 NSTEMI admissions through the ED in the year after BPA integration into the EHR and 253 in the year prior. In the year after BPA integration 32.6% of the NSTEMI patients were admitted directly to the ICU compared with 37.5% admitted to ICU prior to BPA (p=0.32). No change was found in the distribution of ACTION ICU scores of NSTEMI patients admitted to the ICU prior to vs after BPA integration, as well as no differences in ICU length of stay (p=0.96), hospital length of stay (p=0.27), the proportion of patients transferred from the ward to the ICU (p=0.78), or in-hospital mortality (p=0.18). Conclusions: Embedding the ACTION ICU risk score into the EHR did not affect clinical or utilization outcomes for patients presenting to the ED with NSTEMI, but was limited by inappropriate cancellation of the risk score calculator. Better EHR mapping to enable risk calculation without the need for user input may be needed for successful deployment of predictive analytics in this patient population.

Early Invasive Versus Ischemia-Guided Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome With Chronic Obstructive Pulmonary Disease: A National Inpatient Sample Analysis

Angiology ◽  
2019 ◽  
Vol 71 (4) ◽  
pp. 372-379 ◽  
Author(s):  
Tomo Ando ◽  
Oluwole Adegbala ◽  
Hisato Takagi ◽  
Luis Afonso ◽  
Alexandros Briasoulis
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Invasive Strategy ◽  
St Segment Elevation ◽  
St Segment ◽  
Early Invasive Strategy

Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation–acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients ( P interaction = .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.

Prehospital study of survival outcomes from out-of-hospital cardiac arrest in ST-elevation myocardial infarction in Queensland, Australia (the PRAISE study)

2020 ◽  
pp. 204887262090752
Author(s):  
Brendan V Schultz ◽  
Tan N Doan ◽  
Emma Bosley ◽  
Brett Rogers ◽  
Stephen Rashford
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Arrest ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Univariate Analysis ◽  
Survival Outcomes ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Hospital Cardiac Arrest

Aim Patients that experience an out-of-hospital cardiac arrest in the context of a paramedic-identified ST-segment elevation myocardial infarction are a unique cohort. This study identifies the survival outcomes and determinants of survival in these patients. Methods A retrospective analysis was undertaken of all patients, attended between 1 January 2013 and 31 December 2017 by the Queensland Ambulance Service, who had a ST-segment elevation myocardial infarction identified by the attending paramedic prior to deterioration into out-of-hospital cardiac arrest. We described the ‘survived event’ and ‘survived to discharge’ outcomes of patients and performed univariate analysis and multivariate logistic regression to identify factors associated with survival. Results In total, 287 patients were included. Overall, high rates of survival were reported, with 77% of patients surviving the initial out-of-hospital cardiac arrest event and 75% surviving to discharge. Predictors of event survival were the presence of an initial shockable rhythm (adjusted odds ratio 8.60, 95% confidence interval (CI) 4.16–17.76; P < 0.001) and the administration of prehospital medication for subsequent primary percutaneous coronary intervention (adjusted odds ratio 2.54, 95% CI 1.17–5.50; P = 0.020). These factors were also found to be associated with survival to hospital discharge, increasing the odds of survival by 13.74 (95% CI 6.02–31.32; P < 0.001) and 6.96 (95% CI 2.50–19.41; P < 0.001) times, respectively. The administration of prehospital fibrinolytic medication was also associated with survival in a subgroup analysis. Conclusion This subset of out-of-hospital cardiac arrest patients was found to be highly salvageable and responsive to resuscitative measures, having arrested in the presence of paramedics and presented with an identified reversible cause.

Abstract P31: Long-Term Outcomes Among Nonagenarians with Non--ST-Segment Elevation Myocardial Infarction

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Renato D Lopes ◽  
DaJuanicia N Holmes ◽  
Tracy Y Wang ◽  
Matthew T Roe ◽  
Eric D Peterson ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hospital Mortality ◽  
Mortality Rates ◽  
P Value ◽  
Elderly Adults ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
Kaplan Meier ◽  
St Segment ◽  
Mortality Table

Background: Age is a key determinant of adverse acute events following non-ST-segment elevation myocardial infarction (NSTEMI), but the influence of age on longer-term outcomes in hospital survivors has yet to be explored. Methods: Our population included NSTEMI patients aged ≥65 years in the CRUSADE registry who were treated from 2/2003-12/2006 and linked to Medicare claims data for longitudinal follow-up. In-hospital and 1-year mortality rates (among hospital survivors calculated using the Kaplan-Meier method) are shown for nonagenarians and younger elderly-aged groups. Cox proportional hazard modeling was used to adjust for baseline characteristics, discharge medications, and procedures. Results: Of 36,711 NSTEMI hospital survivors aged ≥65 years, 58.8% (21586/36711) were 65-79 years old, and 7.6% (2794/36711) were ≥90 years old. Compared with younger elderly adults (ages 65-79), nonagenarians had lower prevalence of diabetes but higher prevalence of congestive heart failure, hypertension, prior stroke, and renal insufficiency (all p<0.0001). The qualifying NSTEMI was more likely to be a first cardiac event (no prior MI, PCI, or CABG) for nonagenarians than for younger elderly adults (59.7% [1669/2794] vs. 51.0% [11002/21586], p<0.0001). Nonagenarians were less likely to receive revascularization (10.3% [289/2794] vs. 56.7% [12238/21586], p<0.0001) and evidence-based discharge medicine, and had high mortality (Table). One-year mortality remained higher for nonagenarians after adjustment (HR 2.15, 95% CI 1.99-2.32, reference age 65-79). Conclusions: Nonagenarians with NSTEMI experience 2-fold higher mortality following discharge compared with younger elderly adults, with a mortality rate approaching 50% at 1 year. This hazard persists after adjustment, suggesting the role of unmeasured competing risks in this vulnerable population. Table. Discharge medication, in-hospital mortality, and 1-year mortality rates by age category Discharge medications (%) 65-79 Years 80-84 Years 85-89 Years ≥90 Years P-value Aspirin 94.9 19085/21586 93.2 6166/7324 92.6 4118/5007 91.2 2198/2794 <0.001 Clopidogrel 71.5 13677/21586 67.8 4205/7324 64.0 2643/5007 58.2 1220/2794 <0.001 Beta-blocker 92.1 18352/21586 91.7 6119/7324 92.3 4131/5007 92.2 2229/2794 0.942 Statin 80.9 16514/21586 74.2 5018/7324 67.1 2998/5007 56.0 1297/2794 <0.001 ACE inhibitor or ARBs 66.4 13624/21586 65.9 4493/7324 64.2 2891/5007 61.4 1477/2794 <0.001 In-hospital mortality 4.4 996/22582 7.1 560/7784 9.2 509/5516 11.1 348/3141 <0.001 1-year mortality 13.2 2853/21586 23.8 1740/7324 33.5 1676/5007 45.6 1275/2794 –

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