Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15‐Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Vallabhajosyula, Saraschandra; Prasad, Abhiram; Dunlay, Shannon M.; Murphree, Dennis H.; Ingram, Cory; Mueller, Paul S.; Gersh, Bernard J.; Holmes, David R.; Barsness, Gregory W.

doi:10.1161/jaha.119.011954

Cited by 90 publications

(61 citation statements)

References 39 publications

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“…During the period between 1 January 2000 through 31 December 2016, a retrospective cohort of admissions from the HCUP-NIS with a primary diagnosis of AMI (International Classification of Disease-9 Clinical Modification [ICD-9CM] 410.x; International Classification of Disease-10 Clinical Modification [ICD-10CM] I21.x-22.x) receiving ECMO support (ICD-9CM 39.65; ICD-10CM 5A15223) were identified consistent with prior literature [7]. Deyo's modification of Charlson Comorbidity Index was used to identify co-morbid diseases and prior methodology was used to identify cardiac and non-cardiac procedures [2,3,7,8,11,[13][14][15][16][17][18][19][20][21][22][23]. We identified relevant complications and categorized them as (a) vascular complications-arterial injury, acquired arterio-venous fistula, and vascular complications requiring surgery; (b) lower limb amputation; (c) hematologic-post-operative hemorrhage, hemolytic anemia, thrombocytopenia, and blood transfusion; and (d) neurologic-ischemic or hemorrhagic stroke ( Supplementary Table S1).…”

Section: Methodsmentioning

confidence: 99%

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Vallabhajosyula

Bell

Sandhu

et al. 2020

JCM

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Background: There are limited data on complications in acute myocardial infarction (AMI) admissions receiving extracorporeal membrane oxygenation (ECMO). Methods: Adult (>18 years) admissions with AMI receiving ECMO support were identified from the National Inpatient Sample database between 2000 and 2016. Complications were classified as vascular, lower limb amputation, hematologic, and neurologic. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, and length of stay. Results: In this 17-year period, in~10 million AMI admissions, ECMO support was used in 4608 admissions (<0.01%)-mean age 59.5 ± 11.0 years, 75.7% men, 58.9% white race. Median time to ECMO placement was 1 (interquartile range [IQR] 0-3) day. Complications were noted in 2571 (55.8%) admissions-vascular 6.1%, lower limb amputations 1.1%, hematologic 49.3%, and neurologic 9.9%. There was a steady increase in overall complications during the study period (21.1% in 2000 vs. 70.5% in 2016). The cohort with complications, compared to those without complications, had comparable adjusted in-hospital mortality (60.7% vs. 54.0%; adjusted odds ratio 0.89 [95% confidence interval 0.77-1.02]; p = 0.10) but longer median hospital stay (12 [IQR 5-24] vs. 7 [IQR 3-21] days), higher median hospitalization costs ($458,954 [IQR 260,871] vs. 302,255 [IQR 173,660]), fewer discharges to home (14.7% vs. 17.9%), and higher discharges to skilled nursing facilities (44.1% vs. 33.9%) (all p < 0.001). Conclusions: Over half of all AMI admissions receiving ECMO support develop one or more severe complications. Complications were associated with higher resource utilization during and after the index hospitalization.

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Section: Methodsmentioning

confidence: 99%

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Vallabhajosyula

Bell

Sandhu

et al. 2020

JCM

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“…Similarly, Law et al demonstrated a decline in all time periods of IHD in septic shock patients; however, when adjusted for acute respiratory failure, only the delayed IHD cohort had a temporal decrease [11]. The timing of in-hospital events remains extremely crucial in critical illness since many clinical interventions, such as fluid resuscitation, PCI, MCS, targeted temperature management, vasoactive medications and intensive care monitoring are geared towards the first 24-48 h of critical illness [11,13,16,20]. Therefore, studies evaluating the timing of events aid in prognostication, resource planning and advanced care planning [11,13,16,20].…”

Section: Discussionmentioning

confidence: 98%

“…The timing of in-hospital events remains extremely crucial in critical illness since many clinical interventions, such as fluid resuscitation, PCI, MCS, targeted temperature management, vasoactive medications and intensive care monitoring are geared towards the first 24-48 h of critical illness [11,13,16,20]. Therefore, studies evaluating the timing of events aid in prognostication, resource planning and advanced care planning [11,13,16,20]. In AMI-CS, most mortality analyses and predictive models have used IHD, 28-day or 30-day mortality as the end-points, with little additional granularity on the timing of IHD during the index hospitalization [10].…”

Section: Discussionmentioning

confidence: 99%

Epidemiological Trends in the Timing of In-Hospital Death in Acute Myocardial Infarction-Cardiogenic Shock in the United States

Vallabhajosyula

Dunlay

Bell

et al. 2020

JCM

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Background: There are limited data on the epidemiology and timing of in-hospital death (IHD) in patients with acute myocardial infarction-cardiogenic shock (AMI-CS). Methods: Adult admissions with AMI-CS with IHDs were identified using the National Inpatient Sample (2000–2016) and were classified as early (≤2 days), mid-term (3–7 days), and late (>7 days). Inter-hospital transfers and those with do-not-resuscitate statuses were excluded. The outcomes of interest included the epidemiology, temporal trends and predictors for IHD timing. Results: IHD was noted in 113,349 AMI-CS admissions (median time to IHD 3 (interquartile range 1–7) days), with early, mid-term and late IHD in 44%, 32% and 24%, respectively. Compared to the mid-term and late groups, the early IHD group had higher rates of ST-segment-elevation AMI-CS (74%, 63%, 60%) and cardiac arrest (37%, 33%, 29%), but lower rates of acute organ failure (68%, 79%, 89%), use of coronary angiography (45%, 56%, 67%), percutaneous coronary intervention (33%, 36%, 42%), and mechanical circulatory support (31%, 39%, 50%) (all p < 0.001). There was a temporal increase in the early (adjusted odds ratio (aOR) for 2016 vs. 2000 2.50 (95% confidence interval (CI) 2.22–2.78)) and a decrease in mid-term (aOR 0.75 (95% CI 0.71–0.79)) and late (aOR 0.34 (95% CI 0.31–0.37)) IHD. ST-segment-elevation AMI-CS and cardiac arrest were associated with the increased risk of early IHD, whereas advanced comorbidity and acute organ failure were associated with late IHD. Conclusions: Early IHD after AMI-CS has increased between 2000 and 2016. The populations with early vs. late IHD were systematically different.

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“…29 Given the severity of disease and poor prognosis in this patient cohort, we expected a higher consultation rate. [33][34][35][36][37][38] It is possible that providers did not consider involvement of palliative care until all life-prolonging measures had been attempted or exhausted. This is supported by the low rates of documented GoC discussions, leaving little time to involve palliative care providers prior to a patient's death.…”

Section: Discussionmentioning

confidence: 99%

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Brooten

Buckenheimer

Hallmark

et al. 2020

WestJEM

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Introduction: Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality. Methods: This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults. Results: We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%. Conclusion: The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area. [West J Emerg Med. 2020;21(4)935-942.]

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Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15‐Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Cited by 90 publications

References 39 publications

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Epidemiological Trends in the Timing of In-Hospital Death in Acute Myocardial Infarction-Cardiogenic Shock in the United States

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

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