Faculty Bibliography

Stroke is a serious complication of noncardiac surgery. Congenital defects of the interatrial septum may be a potent risk factor for perioperative stroke. The aim of the present study was to determine the association between atrial septal defect (ASD) or patent foramen ovale (PFO) and in-hospital perioperative ischemic stroke after non-cardiac surgery in a large nationwide cohort of patients hospitalized in the United States. Patients undergoing noncardiac surgery between 2004 and 2014 were identified using the Healthcare Cost and Utilization Project's National Inpatient Sample. Patients without an in-hospital echocardiogram were excluded. The presence of an ostium secundum-type ASD or PFO was identified by ICD-9 diagnosis code 745.5. The primary study outcome was perioperative acute ischemic stroke. Between 2004 and 2014, there were 639,985 admissions for noncardiac surgery with an in-hospital echocardiogram. An ASD or PFO was documented in 9,041 (1.4%) hospitalizations. Perioperative ischemic stroke occurred more frequently in patients with an ASD or PFO compared with those without an ASD or PFO (35.1% vs 6.0%, p <0.001). The association between ASD or PFO and ischemic stroke persisted after adjustment for demographics and clinical covariates (adjusted odds ratio 6.30, 95% confidence interval, 5.59 to 7.10) and in all non-cardiac surgery subtypes. In conclusion, in a large, nationwide analysis of patients undergoing noncardiac surgery, a diagnosis of ASD or PFO was associated with an increased risk of acute ischemic stroke overall and in all surgical subtypes. Additional measures are necessary to mitigate stroke risk in patients with septal defects who are planned for non-cardiac surgery.

Background/UNASSIGNED:Psoriasis is an inflammatory skin disease associated with atherosclerotic cardiovascular disease (ASCVD) risk factors and vascular disease. The relative impact of psoriasis on vascular disease is the strongest in young patients with psoriasis, yet data are lacking on how sex differences influence cardiovascular risk factors and vascular disease in these patients. Objective/UNASSIGNED:This observational study aimed to identify the burden of cardiovascular risk factors and vascular disease in patients with psoriasis and to explore whether this burden is different between men and women age < 35 years. Methods/UNASSIGNED:Young (age ≥ 20 and < 35 years) hospitalized patients with psoriasis from the United States National Inpatient Sample were compared with those matched patients without psoriasis. Vascular disease was defined as ASCVD and/or venous thromboembolic disease. Multivariable logistic regression was used to determine the associations between psoriasis, sex, ASCVD risk factors, and vascular disease. Results/UNASSIGNED:Overall, patients with psoriasis (n = 18,353) were more often obese (16% vs. 6%); smokers (31% vs. 17%); and diagnosed with diabetes mellitus (10% vs. 6%), hypertension (16% vs. 8%), hyperlipidemia (6% vs. 2%), ASCVD (2.2% vs. 1.6%), and deep vein thrombosis (6% vs. 4%; all p < .001) compared with patients without psoriasis (n = 55,059; matched by age, sex, and race). When stratified by sex, women with psoriasis were more likely to have multiple cardiovascular risk factors and ASCVD (odds ratio: 2.6; 95% confidence interval [2.1-3.1]) compared with men with psoriasis (odds ratio: 1.2; 95% confidence interval [0.9-1.4]; interaction p < .01). The association between psoriasis and ASCVD in women remained unchanged after multivariable adjustment for traditional cardiovascular risk factors. Conclusion/UNASSIGNED:Psoriasis was associated with cardiovascular disease and risk factors in young hospitalized patients, with stronger associations among women than among men.

BACKGROUND:The impact of thrombocytopenia on revascularization and outcomes in patients presenting with acute myocardial infarction remains poorly understood. We sought to evaluate associations between thrombocytopenia, in-hospital management, bleeding, and cardiovascular outcomes in patients hospitalized for acute myocardial infarction in the United States. METHODS:Patients hospitalized from 2004 to 2014 with a primary diagnosis of acute myocardial infarction were identified from the National Inpatient Sample. Management of acute myocardial infarction was compared between patients with and without thrombocytopenia. Multivariable logistic regression models were used to estimate odds of in-hospital adverse events stratified by thrombocytopenia and adjusted for demographics, cardiovascular risk factors, comorbidities, and treatment. RESULTS:A total of 6,717,769 patients were hospitalized with a primary diagnosis of acute myocardial infarction and thrombocytopenia was reported in 219,351 (3.3%). Patients with thrombocytopenia were older, more likely to have other medical comorbidities, were more likely to undergo coronary artery bypass grafting (28.8% vs. 8.2%, p<0.001), and were less likely to receive a drug eluting stent (15.5% vs. 29.5%, p<0.001). After multivariable adjustment, thrombocytopenia was independently associated with nearly two-fold increased odds of in-hospital mortality (aOR 1.91, 95% CI 1.86-1.97). Thrombocytopenia was also independently associated with ischemic stroke, cardiogenic shock, cardiac arrest and bleeding complications. CONCLUSIONS:Patients with thrombocytopenia in the setting of acute myocardial infarction had increased odds of bleeding, cardiovascular outcomes, and mortality compared with patients without thrombocytopenia. Future investigations to mitigate the poor prognosis of patients with acute myocardial infarction and thrombocytopenia are warranted.

OBJECTIVE:To assess the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its individual phenotypes of coronary artery disease (CAD), peripheral artery disease (PAD), and cerebrovascular disease by age and sex in a large US cohort of hospitalized patients with systemic lupus erythematosus (SLE). METHODS:A nested case-control study of adults with and without SLE was conducted from the January 1, 2008, through December 31, 2014, National Inpatient Sample. Hospitalized patients with SLE were matched (1:3) by age, sex, race, and calendar year to hospitalized patients without SLE. The prevalences of CAD, PAD, and cerebrovascular disease were evaluated, and associations with SLE were determined after adjustment for common cardiovascular risk factors. RESULTS:Among the 252,676 patients with SLE and 758,034 matched patients without SLE, the mean age was 51 years, 89% were women, and 49% were white. Patients with SLE had a higher prevalence of ASCVD vs those without SLE (25.6% vs 19.2%; OR, 1.45; 95% CI, 1.44-1.47; P<.001). After multivariable adjustment, SLE was associated with a greater odds of ASCVD (adjusted odds ratio [aOR], 1.46; 95% CI, 1.41-1.51). The association between SLE and ASCVD was observed in women and men and was attenuated with increasing age. Also, SLE was associated with increased odds of CAD (aOR, 1.42; 95% CI, 1.40-1.44), PAD (aOR, 1.25; 95% CI, 1.22-1.28), and cerebrovascular disease (aOR, 1.68; 95% CI, 1.65-1.71). CONCLUSION/CONCLUSIONS:In hospitalized US patients, SLE was associated with increased ASCVD prevalence, which was observed in both sexes and was greatest in younger patients.

BACKGROUND:Prior registry data suggest that 4%-20% of patients require noncardiac surgery (NCS) within 2 years of percutaneous coronary intervention (PCI). Contemporary data on NCS after PCI in the United States among women and men are limited. We determined the rate of early hospital readmission for NCS and associated outcomes in a large cohort of patients who underwent PCI in the United States. METHODS:Adults undergoing PCI between January 1 and June 30, 2014, were identified from the Nationwide Readmission Database. Patients readmitted for NCS within 6 months of PCI were identified. Outcomes of interest were in-hospital death, myocardial infarction (MI), and bleeding defined by International Classification of Diseases, Ninth Revision, codes. RESULTS:Among 221,379 patients who underwent PCI and survived to hospital discharge, 3.5% (n = 7,696) were readmitted for NCS within 6 months post-PCI, and 41% of these hospitalizations were elective. Early NCS was complicated by MI in 4.7% of cases, and 21% of perioperative MIs were fatal. Bleeding was recorded in 32.0% of patients. All-cause mortality occurred in 4.4% of patients (n = 339) readmitted for surgery. The risk of death or MI was greatest when NCS was performed within the first month after PCI. CONCLUSIONS:Despite clear guidelines to avoid surgery early after PCI, NCS was performed in 1 of every 29 patients with recent PCI, corresponding to as many as ~30,000 patients each year nationwide. Surgical mortality and perioperative MI were high in this setting. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.

Background and Purpose- Perioperative stroke is associated with significant morbidity and mortality. Conventional cardiovascular risk scores have not been compared to predict acute stroke after noncardiac surgery. Methods- Patients undergoing noncardiac surgery between 2009 and 2010 were identified from the US National Surgical Quality Improvement Program (n=540 717). Patients were prospectively followed for 30 days postoperatively for the primary outcome of stroke. Established cardiovascular and perioperative risk scores (CHADS₂, CHA₂DS₂-VASc, Revised Cardiac Risk Index, Mashour et al risk score, Myocardial Infarction or Cardiac Arrest risk score, and National Quality Improvement Project American College of Surgeons surgical risk calculator) were assessed to predict perioperative stroke. Results- Stroke occurred in the perioperative period of 1474 noncardiac surgeries (0.27%). Patients with perioperative stroke were older, more frequently male, had lower body mass index, and were more likely to have undergone vascular surgery or neurosurgery than patients without stroke ( P<0.001 for each comparison). All risk prediction models were associated with increased risk of perioperative stroke (C statistic [AUC] range, 0.743-0.836). The Myocardial Infarction or Cardiac Arrest risk score (AUC, 0.833) and American College of Surgeons surgical risk calculator (AUC, 0.836) had the most favorable test characteristics and a greater ability to discriminate perioperative stroke when compared with Revised Cardiac Risk Index, CHADS₂, CHA₂DS₂-VASc, and Mashour risk scores ( P for comparison, <0.001; Delong). Risk scores did not provide consistent discriminative ability across surgery types and were least predictive in vascular surgery (AUC range, 0.588-0.672). Conclusions- The Myocardial Infarction or Cardiac Arrest risk score and American College of Surgeons surgical risk calculator surgical risk scores provide excellent risk discrimination for perioperative stroke in most patients undergoing noncardiac surgery. Stroke prediction was less optimal in patients undergoing vascular surgery.

Pulmonary hypertension (PH), defined by a mean pulmonary artery pressure of >25mm Hg at rest, is strongly associated with morbidity and mortality in the perioperative period. The prevalence and outcomes of PH among patients referred for major noncardiac surgery in the United States are unknown. Patients ≥18 years of age hospitalized for noncardiac surgery were identified from Healthcare Cost and Utilization Project's National Inpatient Sample data from 2004 to 2014. Pulmonary hypertension was defined by International Classification of Diseases, Ninth Revision diagnosis codes. The primary outcome was perioperative major adverse cardiovascular events (MACCE), defined as in-hospital death, myocardial infarction, or ischemic stroke. Among 17,853,194 hospitalizations for major noncardiac surgery, 143,846 (0.81%) had PH. MACCE occurred in 8.3% of hospitalizations with any diagnosis of PH in comparison to 2.0% of those without PH (p <0.001), driven by an increased frequency of death (4.4% vs 1.1%, p <0.001) and nonfatal myocardial infarction (3.2% vs 0.6%, p <0.001). After adjusting for demographics, clinical covariates, and surgery type, PH remained independently associated with MACCE (aOR 1.43, 95% CI 1.40 to 1.46). In conclusion, PH is associated with perioperative major adverse cardiovascular events. Careful patient selection, recognition of perioperative risks, and appropriate intraoperative hemodynamic monitoring may improve perioperative cardiovascular outcomes.

Background/UNASSIGNED:Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction with symptoms and ECG changes mimicking acute myocardial infarction (AMI). The objective of the present study was to evaluate in-hospital death and hospital readmission in patients with TTS and to compare outcomes to patients with AMI. Methods/UNASSIGNED:Patients diagnosed with TTS and AMI were identified using the United States Nationwide Readmission Database from 2010-2014. In-hospital outcomes for the index admission, and rates and causes of 30-day readmissions were compared between TTS patients and AMI patients without TS. Results/UNASSIGNED:61,412 patients with TTS and 3,470,011 patients with AMI without TTS were identified. Patients with TTS were younger, more often women (89% vs. 41%), and less likely to have cardiovascular risk factors than AMI patients. Mortality during the index admission was lower in TTS compared to AMI (2.3% vs. 10.2%, p < 0.0001). Cardiogenic shock occurred at the same frequency (5.7%) with TTS or AMI. Among TTS survivors, 7,132 patients (11.9%) were readmitted within 30 days, and mortality associated with readmission was 3.5%. The most common reason for readmission after TTS was heart failure (10.6% of readmissions). Conclusions/UNASSIGNED:TTS is associated with substantial morbidity and mortality. Although outcomes are more favorable than AMI, ∼2% of patients died in-hospital and ∼12% of survivors were readmitted within 30-days; heart failure was the most frequent indication for re-hospitalization. Careful outpatient follow-up of TTS patients may be warranted to avoid readmissions. Condensed Abstract/UNASSIGNED:We evaluated in-hospital death and hospital readmission in patients with Takotsubo syndrome (TTS) and compared outcomes to those of patients after acute myocardial infarction (AMI) in the United States using the Nationwide Readmission Database from 2010-2014. Mortality during the index admission was lower with TTS than AMI (2.3% vs. 10.2%, p < 0.0001). Readmission within 30 days occurred in 11.9% of TTS survivors associated with 3.5% mortality during readmission. Readmission rates were lower after TTS than AMI (16.7%), p < 0.0001 vs. TTS. The most common reason for readmission was heart failure (10.6% of TTS survivors). TTS is associated with substantial morbidity and mortality.

BACKGROUND:Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States. METHODS:Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients. RESULTS:A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS. CONCLUSIONS:The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.