Risk Factors for Nosocomial Gastrointestinal Bleeding and Use of Acid-Suppressive Medication in Non-Critically Ill Patients

BACKGROUND

It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted.

OBJECTIVE

To identify risk factors for nosocomial gastrointestinal bleeding in a cohort of non-critically ill hospitalized patients, develop a risk scoring system, and use this system to identify patients most likely to benefit from acid suppression.

DESIGN

Cohort study.

PATIENTS

Adult patients admitted to an academic medical center from 2004 through 2007. Admissions with a principal diagnosis of gastrointestinal bleeding or a principal procedure code for cardiac catheterization were excluded.

MAIN MEASURES

Medication, laboratory, and other clinical data were obtained through electronic data repositories maintained at the medical center. The main outcome measure—nosocomial gastrointestinal bleeding occurring outside of the intensive care unit—was ascertained via ICD-9-CM coding and confirmed by chart review.

KEY RESULTS

Of 75,723 admissions (median age = 56 years; 40 % men), nosocomial gastrointestinal bleeding occurred in 203 (0.27 %). Independent risk factors for bleeding included age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy. Risk of bleeding increased as clinical risk score derived from these factors increased. Acid-suppressive medication was utilized in > 50 % of patients in each risk stratum. Our risk scoring system identified a high risk group in whom the number-needed-to-treat with acid-suppressive medication to prevent one bleeding event was < 100.

CONCLUSIONS

In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit..     

Mortality in patients with community‐onset pneumonia at low risk of drug‐resistant pathogens: Impact of β‐lactam plus macrolide combination therapy

Background and objective

Drug‐resistant pathogen (DRP) risk stratification is important for choosing a treatment strategy for community‐onset pneumonia. Evidence for benefits of non‐antipseudomonal β‐lactam plus macrolide combination therapy (BLM) on mortality is limited in patients at low DRP risk. Risk factors for mortality remain to be clarified.

Methods

Post hoc analysis using a prospective multicentre study cohort of community‐onset pneumonia was performed to assess 30‐day differences in mortality between non‐antipseudomonal β‐lactam monotherapy (BL) and BLM groups. Logistic regression analysis was performed to assess the therapeutic effect and risk factors for mortality in patients at low DRP risk.

Results

In total, 594 patients with community‐onset pneumonia at low DRP risk (369 BL and 225 BLM) were analysed. The 30‐day mortality in BL and BLM was 13.8% and 1.8%, respectively (P < 0.001). Multivariate analysis showed that BLM reduced the 30‐day mortality (adjusted odds ratio: 0.28, 95% CI: 0.09–0.87) compared with BL. Independent prognostic factors for 30‐day mortality included arterial partial pressure of carbon dioxide (PaCO₂) > 50 mm Hg, white blood cell count < 4000/mm³, non‐ambulatory status, albumin < 3.0 g/dL, haematocrit < 30%, age ≥ 80 years, respiratory rate > 25/min and body temperature < 36°C.

Conclusion

In patients with community‐onset pneumonia at low DRP risk, BLM treatment reduced 30‐day mortality compared with BL. Independent risk factors for mortality are potential confounding factors when assessing antibiotic effects in randomized clinical trials.

     

Defining Appropriate Use of Proton-Pump Inhibitors Among Medical Inpatients

BACKGROUND

Proton-pump inhibitors (PPIs) are commonly used among medical inpatients, both for prophylaxis against upper gastrointestinal bleeding (UGIB) and continuation of outpatient use. While PPIs reduce the risk of UGIB, they also appear to increase the risk of hospital-acquired pneumonia (HAP) and Clostridium difficile infection (CDI). Depending upon the underlying risks of these conditions and the changes in those risks with PPIs, use of proton-pump inhibitors may lead to a net benefit or net harm among medical inpatients.

OBJECTIVE

We aimed to determine the net impact of PPIs on hospital mortality among medical inpatients.

DESIGN

A microsimulation model, using literature-derived estimates of the risks of UGIB, HAP, and CDI among medical inpatients, along with the changes in risk associated with PPI use for each of these outcomes. The primary outcome was change in inpatient mortality.

PARTICIPANTS

Simulated general medical inpatients outside the intensive care unit (ICU).

MAIN MEASURE

Change in overall mortality during hospitalization.

KEY RESULTS

New initiation of PPI therapy led to an increase in hospital mortality in about 90 % of simulated patients. Continuation of outpatient PPI therapy on admission led to net increase in hospital mortality in 79 % of simulated patients. Results were robust to both one-way and multivariate sensitivity analyses, with net harm occurring in at least two-thirds of patients in all scenarios.

CONCLUSIONS

For the majority of medical inpatients outside the ICU, use of PPIs likely leads to a net increase in hospital mortality. Even in patients at particularly high risk of UGIB, only those at the very lowest risk of HCAP and CDI should be considered for prophylactic PPI use. Continuation of outpatient PPIs may also increase expected hospital mortality. Apart from patients with active UGIB, use of PPIs in hospitalized patients should be discouraged.

     

Risk factors and mortality for nosocomial bloodstream infections in elderly patients

Objective

To determine risk factors for nosocomial bloodstream infection (BSI) and associated mortality in geriatric patients in geriatric and internal medicine wards at a university hospital.

Methods

Single-center retrospective (1992–2007), pairwise-matched (1:1-ratio) cohort study. Geriatric patients with nosocomial BSI were matched with controls without BSI on year of admission and length of hospitalization before onset of BSI. Demographic, microbiological, and clinical data are collected.

Results

One-hundred forty-two BSI occurred in 129 patients. Predominant microorganisms were Escherichia coli (23.2%), coagulase-negative Staphylococci (19.4%), Pseudomonas aeruginosa (8.4%), Staphylococcus aureus (7.1%), Klebsiella pneumoniae (5.8%) and Candida spp. (5.8%). Matching was successful for 109 cases. Compared to matched control subjects, cases were more frequently female, suffered more frequently from arthrosis, angina pectoris and pressure ulcers, had worse Activities of Daily Living-scores, had more often an intravenous or bladder catheter, and were more often bedridden. Logistic regression demonstrated presence of an intravenous catheter (odds ratio [OR] 7.5, 95% confidence interval [CI] 2.5–22.9) and being bedridden (OR 2.9, 95% CI 1.6–5.3) as independent risk factors for BSI. In univariate analysis nosocomial BSI was associated with increased mortality (22.0% vs. 11.0%; P = 0.029). After adjustment for confounding co-variates, however, nosocomial BSI was not associated with mortality (hazard ratio 1.3, 95% CI 0.6–2.6). Being bedridden and increasing age were independent risk factors for death.

Conclusion

Intravenous catheters and being bedridden are the main risk factors for nosocomial BSI. Although associated with higher mortality, this infectious complication seems not to be an independent risk factor for death in geriatric patients.     

Clinical features and treatment of ulcerative colitis-related severe gastroduodenitis and enteritis with massive bleeding after colectomy

Introduction

Ulcerative colitis (UC) has been recognised as a systemic immune disorder that is not as restricted as colitis. UC-related gastrointestinal lesions with bleeding can develop soon after colectomy and can progress rapidly. Therefore, we considered the clinical features and treatment of these UC-related lesions.

Methods

We reviewed the patient data in our UC surgery database to evaluate its prevalence and features.

Results

We found 7/1,100 patients with UC-related lesions between January 2000 and April 2013. These lesions developed at a mean of 24 (range 8–480) days after colectomy. Six of the seven patients suffered from gastrointestinal bleeding as an initial symptom that rapidly developed into massive bleeding or perforations. All of the patients were diagnosed with pancolitis; at the time of colectomy, fulminant, severe, moderate, and mild colitis were presented by four, one, one, and one patients, respectively. All patients with enteritis had consecutively developed other infectious complications, including anastomotic leakage, pyoderma gangrenosum, wound infection, and pneumonia. Although patients with bleeding did not respond to treatment with corticosteroids, they responded well to infliximab soon after its administration. Although six of the seven patients showed cytomegalo virus re-activation in blood or pathological examinations, ganciclovir was not effective in its elimination.

Conclusion

Although UC-related lesions with an unknown aetiology can occur after colectomy, immediate examination and treatment are required if gastrointestinal bleeding is found after surgery. Because gastrointestinal bleeding from UC-related lesions can worsen rapidly and may be related to mortality, early potent immunosuppressive therapy should be considered.     

Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: a systematic review and meta-analysis

Background

There are conflicting and inconsistent data regarding the gastrointestinal (GI) protective effect of cyclooxygenase-2 (COX-2) inhibitors and of non-steroidal anti-inflammatory drugs (NSAIDs) plus proton-pump inhibitors (PPI).

Aim

To compare the adverse GI effects between COX-2 inhibitors and NSAIDs plus PPI.

Methods

We performed a systematic review of randomized trials comparing GI adverse effects between COX-2 inhibitors and NSAID plus PPI. Trials were identified in MEDLINE, EMBASE, and the Cochrane Library. Primary outcomes were major GI complications including hemorrhage, perforation, and obstruction.

Results

A total of nine trials involving 7,616 participants from 2002 to 2011 were included. All trials were randomized, double blinded, and placebo-controlled with moderate to high quality. COX-2 inhibitors were found to have significantly reduced the risk of major GI events, including perforation, obstruction, and bleeding (relative risk or RR 0.38, 95 % confidence interval or CI 0.25–0.56, p < 0.001); however, the benefit was significant only for patients who were at high risk for NSAID-related GI complications and long-term users. Additionally, the risk of diarrhea (RR 0.56, 95 % CI 0.35–0.9, p 0.02) and withdrawal (RR 0.77, 95 % CI 0.62–0.94, p 0.01) was significantly lower in use of COX-2 inhibitors, while the rate of dyspepsia was higher (RR 1.58, 95 % CI 1.26–1.98, p < 0.001).

Conclusions

COX-2 inhibitors significantly reduced the risk of perforation, obstruction, bleeding, diarrhea, and withdrawal due to GI adverse events, while the risk of dyspepsia was lower with NSAIDs plus PPI.     

Severity of Gastrointestinal Bleeding in Patients Treated with Direct-Acting Oral Anticoagulants

Background

Direct-acting oral anticoagulants (DOACs), which have gained approval for stroke prevention in nonvalvular atrial fibrillation and treatment of venous thromboembolism, have become increasingly preferred over warfarin given their predictable pharmacodynamics, lack of required monitoring, and superior outcomes. Direct-acting oral anticoagulants have been shown to be associated with an increased frequency of gastrointestinal bleeding compared with warfarin, but the severity and characteristics of gastrointestinal bleeding in these patients is poorly understood.

Comparison of infusion or low-dose proton pump inhibitor treatments in upper gastrointestinal system bleeding

Background

The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain.

Aim

To compare the treatment effects of continuous infusion and low-dose esomeprazole therapies in patients with non-variceal upper gastrointestinal (GI) bleeding.

Methods

This prospective clinical study compared continuous infusion of esomeprazole (80 mg bolus followed by 8 mg∕h continuous infusion for 72 h) and low-dose esomeprazole (40 mg twice daily IV) treatments in GI bleeding patients with peptic ulcer presenting a high risk of re-bleeding, who were administered a successful endoscopic homeostasis. The primary end point was the occurrence of re-bleeding during hospitalization and within one month of discharge. Secondary outcomes were defined as duration of hospitalization, need of transfusion, surgical treatment, and mortality rate. After 72 h, both groups were switched to oral esomeprazole therapy for one-month.

Results

A hundred thirty-two subjects were enrolled. Re-bleeding occurred in 11 (16.7%) patients in the infusion therapy group and in 12 (18.2%) patients in the low-dose group (P = 0.819) within the first 72 h. No patient experienced re-bleeding in the first month following discharge. There was no statistical significant difference between the two groups in terms of transfusion need, durations of hospitalization, need for surgery and mortality rate.

Conclusion

PPI infusion therapy following endoscopic hemostasis treatment was not found superior to low-dose PPI therapy in the terms of re-bleeding, need of surgery and mortality.     

Clinical features and outcomes in 348 patients with polyarteritis nodosa: A systematic retrospective study of patients diagnosed between 1963 and 2005 and entered into the French vasculitis study group database

Objective

Previous studies of polyarteritis nodosa (PAN) included patients with microscopic polyangiitis, because these entities were not distinguished prior to the Chapel Hill Consensus Conference (CHCC). This study was undertaken to describe the main characteristics of and long‐term outcomes in patients with well‐characterized PAN diagnoses.

Methods

We conducted a systematic retrospective study of 348 patients who were diagnosed as having PAN between March 1963 and October 2005, were registered in the French Vasculitis Study Group database, and satisfied the American College of Rheumatology and CHCC criteria. Patient characteristics and outcomes were analyzed and compared according to hepatitis B virus (HBV) status.

Results

At diagnosis, the mean ± SD age was 51.2 ± 17.3 years. The most frequent findings were general symptoms (93.1%), neurologic manifestations (79%), skin involvement (49.7%), abdominal pain (35.6%), and hypertension (34.8%); 66.2% had renal artery microaneurysms; 70.1% had histologically proven PAN. Patients with HBV‐related PAN (n = 123) had more frequent peripheral neuropathy, abdominal pain, cardiomyopathy, orchitis, and hypertension compared with patients with non–HBV‐related PAN (n = 225). During a mean ± SD followup of 68.3 ± 63.5 months, 76 patients (21.8%) relapsed (63 with non–HBV‐related PAN [28%] versus 13 with HBV‐related PAN [10.6%]; P < 0.001); 86 patients (24.7%) died (44 with non–HBV‐related PAN [19.6%] versus 42 with HBV‐related PAN [34.1%]; P = 0.003). Five‐year relapse‐free survival rates were 59.4% (95% confidence interval [95% CI] 52.6–67.0) versus 67.0% (95% CI 58.5–76.8) for non–HBV‐related PAN and HBV‐related PAN, respectively. Multivariate analysis retained age >65 years, hypertension, and gastrointestinal manifestations requiring surgery or at least consultation with a surgeon as independent predictors of death, whereas patients with cutaneous manifestations or non–HBV‐related PAN had a higher risk of relapse.

Conclusion

Our findings indicate that the rate of mortality from PAN remains high, especially for the elderly, and relapses do occur, particularly in patients with non–HBV‐related PAN with cutaneous manifestations.

     

Gastroprotection in Low-Dose Aspirin Users for Primary and Secondary Prevention of ACS: Results of a Cost-Effectiveness Analysis Including Compliance

Purpose

Low-dose aspirin (ASA) increases the risk of upper gastrointestinal (GI) complications. Proton pump inhibitors (PPIs) reduce these upper GI side effects, yet patient compliance to PPIs is low. We determined the cost-effectiveness of gastroprotective strategies in low-dose ASA users considering ASA and PPI compliance.

Methods

Using a Markov model we compared four strategies: no medication, ASA monotherapy, ASA+PPI co-therapy and a fixed combination of ASA and PPI for primary and secondary prevention of ACS. The risk of acute coronary syndrome (ACS), upper GI bleeding and dyspepsia was modeled as a function of compliance and the relative risk of developing these events while using medication. Costs, quality adjusted life years and number of ACS events were evaluated, applying a variable risk of upper GI bleeding. Probabilistic sensitivity analyses were performed.

Results

For our base case patients using ASA for primary prevention of ACS no medication was superior to ASA monotherapy. PPI co-therapy was cost-effective (incremental cost-effectiveness ratio [ICER] €10,314) compared to no medication. In secondary prevention, PPI co-therapy was cost-effective (ICER €563) while the fixed combination yielded an ICER < €20,000 only in a population with elevated risk for upper GI bleeding or moderate PPI compliance. PPI co-therapy had the highest probability to be cost-effective in all scenarios. PPI use lowered the overall number of ACS.

Conclusions

Considering compliance, PPI co-therapy is likely to be cost-effective in patients taking low dose ASA for primary and secondary prevention of ACS, given low PPI prices. In secondary prevention, a fixed combination seems cost-effective in patients with elevated risk for upper GI bleeding or in those with moderate PPI compliance. Both strategies reduced the number of ACS compared to ASA monotherapy.     

No disparity of the efficacy and all‐cause mortality between Asian and non‐Asian type 2 diabetes patients with sodium–glucose cotransporter 2 inhibitors treatment: A meta‐analysis

Aims/Introduction

To evaluate whether there is disparity of the efficacy and all‐cause mortality and other adverse effects between Asian and non‐Asian patients with sodium–glucose cotransporter 2 (SGLT2) inhibitors treatment.

Materials and Methods

Randomized clinical trials publicly available before January 2017, comparing SGLT2 inhibitors treatment with a placebo in type 2 diabetes patients were identified. The association between treatment and outcomes was estimated by computing the weighted mean difference for glycated hemoglobin level, blood pressure level, lipid profile levels and bodyweight, and the odds ratios for adverse events.

Results

A total of 17 trials with Asian patients were included and 39 trials with non‐Asian patients were included. Comparison of the glycated hemoglobin decreases corrected by a placebo between Asian and non‐Asian patients showed that there was a non‐significant difference of 0.05% between groups (P > 0.05). Comparisons of the bodyweight changes and blood pressure changes corrected by a placebo between Asian and non‐Asian patients did not show a significant difference between groups (P > 0.05). The risk of all‐cause mortality was not increased when compared with a placebo both in Asian and non‐Asian populations, and the risk of genital infection in Asian and non‐Asian populations were both significant increased.

Conclusions

Overall, according to the present meta‐analysis, comparison of the efficacy in SGLT2 inhibitors treatment between Asian and non‐Asian type 2 diabetes patients showed no significant difference in glycated hemoglobin reduction and bodyweight reduction. Furthermore, no disparity was found in the risk of all‐cause mortality or hypoglycemia in SGLT2 inhibitors treatment between Asian and non‐Asian patients.     

The association between blood urea nitrogen to creatinine ratio and mortality in patients with upper gastrointestinal bleeding

Background and study aims

Azotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients.

Effectiveness of combination therapy versus monotherapy with a third-generation cephalosporin in bacteraemic pneumococcal pneumonia: A propensity score analysis

Objective

Combining a macrolide or a fluoroquinolone to beta-lactam regimens in the treatment of patients with moderate to severe community-acquired pneumonia is recommended by the international guidelines. However, the information in patients with bacteraemic pneumococcal pneumonia is limited.

Le cavernome portal : cause rare d’hémorragie digestive et d’ictère

Introduction

Rupture of esophageal varices due to schistosoma induced portal hypertension remains the major etiology of non ulcer gastrointestinal bleeding in Madagascar. The author reports two cases of portal cavernoma, a rare etiology of gastrointestinal bleeding.We want to increase the knowledge of this pathology and to discuss its management in our centre.

Observation

The first patient had esophageal varices diagnosed 6 years ago and the second one had a history of jaundice of unclear etiology 6 years ago. Both were admitted for upper gastrointestinal bleeding. Upper gastrointestinal endoscopy showed stage III esophageal varices. Abdominal ultrasonography led to the diagnosis of portal cavernoma. The exploration of an associated portal biliopathy was not feasible in our centre due to the lack of transhepatic or retrograde endoscopic cholangiography and Magnetic Resonance Imaging. We medically managed the gastrointestinal bleeding. Betablocker drugs were prescribed to prevent the recurrence of any gastrointestinal bleeding.

Conclusion

Portal cavernoma is a rare but possible etiology of gastrointestinal bleeding and jaundice. Management of these two complications is difficult in our country due to the lack of investigation and therapeutic tools.     

Continuous proton pump inhibitor treatment decreases upper gastrointestinal bleeding and related death in rural area in Japan

Background and Aims: Proton pump inhibitors (PPI) have been rarely used for prevention of upper gastrointestinal bleeding (UGIB) induced by non‐steroidal anti‐inflammatory drugs (NSAIDs) and/or aspirin in Japan. The increased incidence of UGIB in the aged society is becoming a serious problem. The aim of this study was to retrospectively evaluate whether PPI can prevent UGIB. Methods: We examined records of 2367 patients (aged 67.9 ± 15.1 years, male 1271) attending the only hospital serving the rural area, with little population movement. We investigated the correlation between the frequency of usage of medicine (PPI, histamine 2 receptor antagonists [H2RA], NSAIDs, aspirin) and incidence of UGIB over 12 years. UGIB was defined as cases with hematemesis and/or melena and definite bleeding at upper gastrointestinal endoscopy. The annual incidence of UGIB of inhabitants (16 065 ± 375.3 persons/year) was evaluated. The frequency of usage of medicine was compared with the total number of patients prescribed any medication (1080 ± 33.2 persons/year). Results: The frequency of PPI usage has increased significantly 4.6%→30.8% (P < 0.05). NSAIDs and aspirin usage increased significantly in the latter half of the survey period (P < 0.05). The annual incidence of UGIB significantly decreased 160.8 →23.6/100 000 inhabitants per annum (P ≤ 0.05) due to widespread use of PPI. No patients died due to UGIB after 2006. The incidence of UGIB and the prevalence of PPI usage were found to have a negative correlation (r = ?0.804, P = 0.0016). Conclusions: By widespread use of PPI, UGIB and related death has declined significantly. This survey showed that continuous PPI treatment decreases UGIB and related death in community medicine.     

Changes in the Clinical Outcomes of Variceal Bleeding in Cirrhotic Patients: A 10-Year Experience in Gangwon Province, South Korea

Background/Aims

Variceal rupture is one of the main causes of mortality in cirrhotic patients. However, there are limited data on the long-term outcomes of variceal bleeding.

Methods

We investigated the incidence and mortality of variceal bleeding at three endoscopic centers in Gangwon province during 3 periods (August 1996 to July 1997, August 2001 to July 2002, and August 2006 to July 2007).

Results

A total of 1,704 upper gastrointestinal (GI) bleedings occurred during the study periods. Peptic ulcers were found in 825 patients (48.5%), and variceal ruptures were found in 607 patients (35.6%). The variceal bleeding rate did not decrease in each period (26.0% vs 43.7% vs 33.9%, respectively). In the variceal bleeding group, the 6-week mortality rate steadily and significantly decreased (15.5% vs 10.8% vs 6.4%, respectively, p=0.027). In addition, the mortality rate was significantly higher in the variceal bleeding group than in the non-variceal bleeding group (10.4% vs 2.0%, p<0.001; odds ratio, 5.659; 95% confidence interval, 3.445 to 9.295).

Conclusions

Variceal bleeding was still the major cause of upper GI bleedings and did not decrease in prevalence over the 10-year period in Gangwon province, South Korea. However, the mortality rate of variceal bleeding decreased significantly.     

Diagnostic utility of surgical lung biopsies in elderly patients with indeterminate interstitial lung disease

Background and objective

Idiopathic pulmonary fibrosis (IPF) is increasingly diagnosed by clinical and computed tomography (CT) criteria; however, surgical lung biopsy (SLB) may still be required in patients who lack definite CT features of usual interstitial pneumonia (UIP). We reviewed a cohort of elderly patients who underwent SLB, to evaluate the benefit of SLB in diagnosing idiopathic interstitial pneumonia (IIP).

Methods

We searched the pathology records of Mayo Clinic for ambulatory patients at least 75 years old, who underwent SLB between 2000 and 2012 for indeterminate IIP. Histologic slides were reviewed and clinical data were extracted from the record.

Results

A total of 55 patients (35 male) were enrolled. Median (interquartile range) age was 77 (76–80) years. Forced vital capacity was 70 (61–76)% and diffusing capacity of the lungs for carbon monoxide was 48 (42–54)% of predicted. In total, 37 (67%) patients had IPF, including 61% of those with HRCT findings inconsistent with UIP. Thirty‐day mortality was 10% and 90‐day mortality was 15%.

Conclusion

The high mortality rate of SLB complicates the risk–benefit analysis in elderly patients with IIP. The expected value of the SLB is probably highest when the HRCT features are inconsistent with UIP, due to the frequent (39%) retrieval of patterns other than UIP.

     

Percutaneous Coronary Interventions and Hemodynamic Support in the USA: A 5 Year Experience

Objectives

To compare the utilization and outcomes in patients who had percutaneous coronary interventions (PCIs) performed with intra‐aortic balloon pump (IABP) versus percutaneous ventricular assist devices (PVADs) such as Impella and TandemHeart and identify a sub‐group of patient population who may derive the most benefit from the use of PVADs over IABP.

Background

Despite the lack of clear benefit, the use of PVADs has increased substantially in the last decade when compared to IABP.

Methods

We performed a cross sectional study including using the Nationwide Inpatient Sample. Procedures performed with hemodynamic support were identified through appropriate ICD‐9‐CM codes.

Results

We identified 18,094 PCIs performed with hemodynamic support. IABP was the most commonly utilized hemodynamic support device (93%, n = 16, 803) whereas 6% (n = 1069) were performed with PVADs and 1% (n = 222) utilized both IABP and PVAD. Patients in the PVAD group were older in age and had greater burden of co‐morbidities whereas IABP group had higher percentage of patients with cardiac arrest. On multivariable analysis, the use of PVAD was a significant predictor of reduced mortality (OR 0.55, 0.36–0.83, P = 0.004). This was particularly evident in sub‐group of patients without acute MI or cardiogenic shock. The propensity score matched analysis also showed a significantly lower mortality (9.9% vs 15.1%; OR 0.62, 0.55–0.71, P < 0.001) rate associated with PVADs when compared to IABP.

Conclusion

This largest and the most contemporary study on the use of hemodynamic support demonstrates significantly reduced mortality with PVADs when compared to IABP in patients undergoing PCI. The results are largely driven by the improved outcomes in non‐AMI and non‐cardiogenic shock patients. (J Interven Cardiol 2015;28:563–573)