Heart failure is a leading cause of readmissions in the United States, although treatment has come along away, palliative care is often not appropriately offered in advanced heart failure. The purpose of this study was to use a large database of national in-patient sample to find out the use of palliative care in acute heart failure admissions. Data from 2002 to 2017 was used for analysis. Simple linear regression was used for trend analysis over the years. Variables that were statistically significant in univariate analysis were used in single-step (entry method) multiple logistic analysis. The use of palliative care was found to be low at 4.1%, although recent trends have shown an increase (from 0.4% in 2002 to 6.2% in 2017). Women (0.3% in 2002 to 6.5% in 2017) and Caucasians (0.6% in 2002 to 6.9% in 2017) had a higher proportion of PC encounters as compared to men (0.5% in 2002 to 5.9% in 2017) and other racial minorities, increasing age (OR, 1.04[CI; 1.03-1.04], p < 0.01), female gender (OR, 1.03[CI; 1.02-1.03], p < 0.01), do not resuscitate status (OR, 10.62[CI; 10.53-10.70], p < 0.01), diabetes mellitus (OR, 1.10[CI; 1.01-1.11], p < 0.01), liver disease (OR, 1.63[CI; 1.60-1.66], p < 0.01), renal failure (OR, 1.40[CI; 1.39-1.41], p < 0.01), acute myocardial infarction (OR, 1.28[CI; 1.27-1.30], p < 0.01), and cardiogenic shock (OR, 2.89[CI; 2.84-2.93], p < 0.01) were associated with higher odds of having PC encounter. In conclusion, the use of palliative care has increased in the United States over the years, however, it is still low as compared to other high-income countries.

There is limited data on the in-hospital outcomes of cardiogenic shock (CS) secondary to takotsubo syndrome (TS). We aimed to assess the incidence, predictors, and outcomes of CS in hospitalized patients with TS. All patients with TS were identified from the National Inpatient Sample database from September 2006 to December 2017. The cohort was divided into those with versus without CS and logistic regression analysis was used to identify predictors of CS and mortality in patients admitted with TS. A total of 260,144 patients with TS were included in our study, of whom 14,703 (6%) were diagnosed with CS. In-hospital mortality in patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01). TS patients with CS had a higher incidence of malignant arrhythmias like ventricular tachycardia or ventricular fibrillation (15.0% vs 4%, p <0.01) and non-shockable cardiac arrests (12% vs 2%, p <0.01). Independent predictors of CS were male gender, Asian and Hispanic ethnicity, increased burden of co-morbidities including congestive heart failure, chronic pulmonary disease, and chronic diabetes. Independent predictors of mortality were male gender, advanced age, history of congestive heart failure, chronic renal failure, and chronic liver disease. In conclusion, CS occurs in approximately 6% of patients admitted with TS, in-hospital mortality in TS patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01), male gender and increased burden of co-morbidities at baseline were independent predictors of CS and mortality.

Background

Representation trends of women, older adults, and ethnic/racial minorities in randomized controlled trials (RCTs) of atrial fibrillation (AF) are uncertain.

Methods

We systematically reviewed 134 AF related RCTs (phase II and III) encompassing 149,162 participants using Medline and ClinicalTrials.gov through April 2019 to determine representation trends of women, older patients (≥75 years), and ethnic/racial minorities. Weighted data on the prevalence of AF from epidemiological studies were used to compare the representation of the studied groups of interest in AF RCTs to their expected burden of the disease.

Results

Only 18.7% of the RCTs reported proportion of older patients, and 12.7% RCTs reported ethnic/racial minorities. The proportions of women in RCTs versus general population were 35.2% and 35.1%, of Hispanics were 11.9% and 5.2%, of Blacks were 1.2% and 5.7%, of American Indian/Alaskans were 0.2% and 0.2%, of Asians were 14.2% and 2.4%, of native Hawaiian/Pacific Islanders were 0.05% and 0.1% and of non-Whites were 19.5% and 22.5%, respectively. The weighted mean age (SD) across the trials was 65.3 (3.2) years which was less than the corresponding weighted mean age of 71.1 (4.5) years in the comparative epidemiological data.

Conclusion

The reporting of older patients and ethnic/racial minorities was poor in RCTs of AF. The representation of women and American Indian/Alaskan natives matched their expected population share of disease burden. Hispanics and Asians were over-represented and Blacks, native Hawaiian/Pacific Islanders and non-Whites were under-represented in RCTs of AF.

BACKGROUND Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established. METHODS AND RESULTS The Nationwide Readmission Database was used to identify 30-day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all-cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30-day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30-day readmission rate for HF did not show a significant decline during the study period (P_trend=0.06); however, all-cause readmission rates decreased significantly (P_trend=0.03). HF readmissions were comparable between high- and low-volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end-stage renal disease were independent predictors of 30-day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non-HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non-HF readmission. CONCLUSIONS During the study period from 2015 to 2018, 30-day HF readmissions after TAVR remained steady despite all-cause readmissions decreasing significantly. All-cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low-, medium-, and high-volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non-HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR.