Mortality of patients with acute coronary syndromes still remains high: A follow‐up study of 1188 consecutive patients admitted to a university hospital

Background. Based on randomized clinical trials, mortality of acute coronary syndrome (ACS) has been considered to be relatively low. The prognosis of clinical presentations of ACS in real‐life patient cohorts has not been well documented.

Aim. The aim of this study was to evaluate actual clinical outcome across the whole spectrum of ACS in a series of unselected prospectively collected consecutive patients from a defined geographical region, all admitted to one university hospital.

Methods. A total of 1188 patients with ST‐elevation myocardial infarction (STEMI), non‐ST‐elevation MI (NSTEMI) or unstable angina pectoris (UA) were included.

Results. In‐hospital mortality was 9.6%, 13% and 2.6% (P<0.001) and mortality at a median follow‐up of 10 months 19%, 27% and 12% (P<0.001), for the three ACS categories, respectively. In multivariate Cox regression analysis age, diabetes mellitus type 1, diuretic use at admission, creatinine level, lower systolic blood pressure, STEMI and NSTEMI ACS category were associated with higher mortality during follow‐up.

Conclusions. In an unselected patient cohort, short‐term mortality of MI patients, especially those classified as NSTEMI, still was high despite increasing use of proven treatment modalities.     

Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department?

Objective

Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes.

Design and setting

This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500).

Measurements

Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care.

Main results

Admission from the hospital ward was associated with lower family ratings of quality of dying [β ?0.90, 95 % confidence interval (CI) ?1.54, ?0.26, p = 0.006] and satisfaction (total score β ?3.97, 95 % CI ?7.89, ?0.05, p = 0.047; satisfaction with care domain score β ?5.40, 95 % CI ?9.44, ?1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95 % CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95 % CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95 % CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95 % CI 1.04, 1.82, p = 0.025).

Conclusion

Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.     

Balance of power--do patients use researchers to survive hospital?

This paper focuses on the way research study participants interpret their contact with researchers. Much has been made of the unequal power relationship between researcher and researched, but the case study presented here suggests that patient participants may be 'using' researchers to further their own agenda and to attempt to manipulate or control aspects of their care within the hospital setting.     

Patient flow in the emergency department: is timeliness to events related to length of hospital stay?

Management of critically ill patients occurs frequently in emergency departments (ED) while waiting for intensive care beds to become available. The purpose of this study was to investigate effects of timeliness of interventions in the ED on ED outcomes and hospital length of stay. Sample size was 1536 intensive care unit admissions. Timeliness to first medication and order for intensive care unit bed to leaving the ED influenced both ED and hospital length of stay. Timely interventions affect outcomes, access, and quality of care.     

Are unplanned readmissions to hospital really preventable?

All John Hunter Hospital readmission data for October 1998 were examined. Twenty-four readmissions out of 3081 total admissions (0.8%) were defined as adverse events (unplanned readmissions) being nominally due to inappropriate medical management. The 24 adverse events comprised 5.5% of the 437 readmissions. A further five readmissions occurred because scheduled theatre was cancelled. Remaining readmissions were due to the condition of the patient in each case. Of the 16 highly preventable adverse events, 10 were allocated to the minor temporary category of severity. It is difficult to evaluate these readmission rates because there are no comparable findings in other Australian studies. The adverse events showed no particular association with patient age, sex, hospital of original admission or hospital specialty. While they were technically preventable, after medical record review a senior clinician identified these as extremely difficult cases, indicating that better outcomes may not have been possible.     

Who should be taking aspirin to prevent coronary events?

The decision to prescribe aspirin to prevent a coronary event is not straightforward, and requires physicians to balance the risk of a coronary event with the risk of adverse events from aspirin. Although evidence-based medicine shows the way, it does not answer all the questions, especially for patients at intermediate risk.     

Are adverse events of nevirapine and efavirenz related to plasma concentrations?

OBJECTIVE: The relationships between adverse events (AEs) and plasma concentrations of nevirapine (NVP) and efavirenz (EFV) were investigated as part of the large, international, randomized 2NN study. METHODS: Treatment-naive, HIV-1-infected patients received NVP (once or twice daily), EFV or their combination, each in combination with lamivudine and stavudine. Blood samples were collected on day 3 and weeks 1, 2, 4, 24 and 48. Concentrations of NVP and EFV were quantitatively assessed by a validated HPLC assay. Individual Bayesian estimates of the area under the plasma concentration-time curve over 24 h (AUC24h), and minimum and maximum plasma concentrations (Cmin and Cmax) as measures for drug exposure of NVP and EFV, were generated using a previously developed population pharmacokinetic model. Pharmacokinetic parameters were compared for patients with and without central nervous system (CNS) and psychiatric AEs, hepatic events, liver enzyme elevations (LEEs) and rash. Furthermore, it was investigated whether a clear cut-off for a pharmacokinetic parameter could be identified above which the incidence of AEs was clearly increased. AEs were also related to demographic parameters and baseline characteristics. RESULTS: In total, from 1077 patients, NVP (3024 samples) and EFV (1694 samples) plasma concentrations and AE data (825 observations) were available. For all patients Cmin, Cmax and AUC24h were determined. When corrected for known covariates of gender, CD4 cell count at baseline, region, hepatitis coinfection and possible interactions between these factors, no significant associations between AEs and any tested exposure parameter of NVP was observed. Also, no target Cmin value, above which patients were at increased risk for AEs, could be established. On the other hand, geographical region, hepatitis coinfection, CD4 cell count and gender were found to be significantly related with the incidence of CNS and psychiatric AEs, hepatic events, LEEs and rash during the treatment with NVP. The occurrence of elevated liver enzymes during the first 6 weeks in the EFV-containing arm was significantly (P = 0.036) correlated to the exposure of EFV (Cmin). Only hepatitis coinfection impacted on LEEs during the first 6 weeks of treatment. With an EFV Cmin above 2.18 mg/l during the induction phase, patients were 4.4 (range 1.3-15.5) times more at risk for elevated liver enzymes. No other correlations between AEs and EFV pharmacokinetics or patient characteristics could be identified. CONCLUSIONS: Pharmacokinetic parameters of NVP did not have a relationship to AEs in the 2NN trial when corrected for known covariates. The value of periodical drug monitoring of NVP as a way to prevent toxicity is therefore limited. Treating physicians should instead focus on factors that are more predictive of AEs (gender, CD4 count and hepatitis coinfection). High EFV Cmin levels resulted in elevated liver enzyme values during the first 6 weeks of treatment. Regular measurement of EFV levels and liver enzymes at the start of therapy may therefore be advised.     

Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?

Objectives

Symptoms are compared among patients with coronary artery disease (CAD) admitted to the emergency department with or without acute coronary syndrome (ACS). Sex and age are also assessed.

Methods

A secondary analysis from the PROMOTION (Patient Response tO Myocardial Infarction fOllowing a Teaching Intervention Offered by Nurses) trial, an multicenter randomized controlled trial, was conducted.

Results

Of 3522 patients with CAD, at 2 years, 565 (16%) presented to the emergency department, 234 (41%) with non-ACS and 331 (59%) with ACS. Shortness of breath (33% vs 25%, P = .028) or dizziness (11% vs 3%, P = .001) were more common in non-ACS. Chest pain (65% vs 77%, P = .002) or arm pain (9% vs 21%, P = .001) were more common in ACS. In men without ACS, dizziness was more common (11% vs 2%; P = .001). Men with ACS were more likely to have chest pain (78% vs 64%; P = .003); both men and women with ACS more often had arm pain (men, 19% vs 10% [P = .019]; women, 26% vs 13% [P = .023]). In multivariate analysis, patients with shortness of breath (odds ratio [OR], 0.617 [confidence interval [CI], 0.410-0.929]; P = .021) or dizziness (OR, .0311 [CI, 0.136-0.708]; P = .005) were more likely to have non-ACS. Patients with prior percutaneous coronary intervention (OR, 1.592 [CI, 1.087-2.332]; P = .017), chest pain (OR, 1.579 [CI, 1.051-2.375]; P = .028), or arm pain (OR, 1.751 [CI, 1.013-3.025]; P <.042) were more likely to have ACS.

Conclusions

In patients with CAD, shortness of breath and dizziness are more common in non-ACS, whereas prior percutaneous coronary intervention and chest or arm pain are important factors to include during ACS triage.     

Are the thorax Computed Tomography findings of ICU patients diagnosed with COVID-19 pneumonia related to the duration of hospital stay and mortality?

IntroductionQuantitative thorax Computed Tomography (CT) is used to determine the severity of COVID-19 pneumonia. With a new approach, quantitative thoracic CT is to contribute to the triage of patients with severe COVID-19 pneumonia in the ICU and to evaluate its relation with mortality by taking into account the vaccination status.MethodsFifty-six patients who had a diagnosis of COVID-19 pneumonia confirmed in the adult ICU were evaluated retrospectively. To evaluate the degree of parenchymal involvement, the quantitative CT “craniocaudal diameter of the thorax/craniocaudal largest lesion diameter (CCDT/CCDL)” ratio and semi-quantitative total CT severity scores (TCTSS) (0:0%; 1:1–25%; 2:26–50%; 3:51–75% and 4:76–100%) were calculated. Both methods were analyzed with comparative ROC curves for predicting mortality. The effects of vaccines on thorax CT findings and laboratory parameters were also investigated.ResultsThe sensitivities and specificities were found to be 72.5%, 75.61%, and 80%, 73.33% when CCDT/CCDL and TCTSS cutoff value was taken <1.4, and >9, respectively, to predict mortality in COVID-19 pneumonia (Area Under the Curve = AUC = 0.797 and 0.752). Both methods predicted mortality well and no statistical differences were detected between them (p = 0.3618). In vaccinated patients, CRP was higher (p = 0.045), and LDH and ferritin were lower (p = 0.049, p = 0.004). The number of lobes involved was lower in the vaccinated group (p = 0.001).ConclusionsThe quantitative CT score (CCDT/CCDL) may play as important a role as TCTSS in diagnosing COVID-19 pneumonia, determining the severity of the disease, and predicting the related mortality. COVID-19 vaccines may affect laboratory parameters and cause less pneumonia on thoracic CT than in unvaccinated individuals.     

Evolution of coronary stents in patients with diabetes: are clinical outcomes still improving?

Diabetic patients are prone to diffuse and accelerated atherosclerosis, which increases the likelihood of requiring myocardial revascularization. Diabetes mellitus is a strong risk factor for restenosis following coronary stenting, with greater need for repeat revascularization and inferior clinical outcomes. Despite the recent advances in drug-eluting stent technology, diabetic patients are still at higher risk of adverse clinical events after coronary angioplasty. The focus of this review is to describe the evolution of the percutaneous management of diabetic patients with coronary artery disease and to define if any real progress has been made in terms of safety and efficacy with the use of the second generation drug-eluting stents in this high-risk population.     

Should elderly patients be admitted to the intensive care unit?

As the general population ages, an increasing number of patients over 80 years are being admitted to the intensive care unit (ICU). Selection of older patients for ICU admission results in lower rates of co-morbidities and underlying fatal diseases. After adjustment for disease severity, ICU and post-ICU mortality rates are higher in elderly patients than in younger populations. Age itself explains only a small part of the increased hospital mortality, suggesting that specific information such as functional, cognitive, and nutritional status, as well as co-morbidities, should be collected to predict mortality in elderly ICU patients. The long-term prognosis depends chiefly on functional status, whereas initial disease severity no longer influences mortality. According to our review, it is impossible to define evidence-based recommendations for ICU admission of the elderly. This justifies further studies that encompass several aspects, such as the initial triage process and the long-term prognosis (mortality, autonomy and quality of life).     

Insurance status of patients admitted to specialty cardiac and competing general hospitals: are accusations of cherry picking justified?

BACKGROUND: There has been widespread concern that procedurally oriented specialty hospitals select well-insured patients for admission, while avoiding the underinsured, but data are limited. OBJECTIVE: To determine if specialty cardiac hospitals admit a higher proportion of well-insured patients than general hospitals and/or preferentially transfer patients with less generous insurance to other acute care hospitals. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of patients admitted to specialty cardiac and general hospitals with acute myocardial infarction (AMI; N = 41,863), congestive heart failure (CHF; N = 51,696), percutaneous coronary intervention (PCI; N = 73,966), and coronary artery bypass grafting (CABG; N = 33,327) using 2000-2004 all-payor data from Arizona, California, and Texas. MAIN OUTCOME MEASURES: Proportion of all admissions in specialty and general hospitals with more generous insurance (Medicare or private insurance), interhospital transfer patterns of patients with less generous insurance by specialty and general hospitals. RESULTS: Specialty hospitals admitted a higher proportion of patients with more generous insurance for both the medical cohort (AMI and CHF) (92.4% vs. 89.0%; P < 0.0001) and revascularization cohort (PCI and CABG) (94.3% vs. 90.6%; P < 0.0001). After adjustment for patient demographics, comorbidity, and the distance that each patient lived from the nearest specialty and general hospital, odds of admission to specialty hospitals were significantly higher for patients with more generous insurance compared to patients with less generous insurance for the medical cohort [odds ratio (OR), 1.16; 95% confidence interval (CI), 1.07-1.27; P < 0.001] and revascularization cohort (OR, 1.17; 95% CI, 1.08-1.27; P < 0.001). In Cox proportional hazards models, there was no evidence that specialty hospitals were more or less likely to transfer patients with more or less generous insurance to another hospital. LIMITATIONS: The analysis was limited to 3 states and we were unable to track the care of patients after transfer. CONCLUSIONS: Patients with more generous insurance are significantly more likely to gain admission to specialty hospitals. Alternatively, we found no evidence that specialty hospitals preferentially transfer patients with less generous insurance who are admitted. Overall, these findings suggest that specialty hospitals may contribute to segregation of the healthcare system along socioeconomic lines.     

Outcome of patients with injection drug use–associated endocarditis admitted to an intensive care unit

Purpose

The purpose of this study was to study the outcome of patients with injection drug use–associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).

Material and Methods

A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.

Results

Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.

Conclusions

Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.