Frequency, Trend, Predictors, and Impact of Gastrointestinal Bleeding in Atrial Fibrillation Hospitalizations

Less major bleeding and higher hemoglobin after left atrial appendage closure in high-risk patients: Data from a long-term, longitudinal, two-center observational study

BACKGROUND

Left atrial appendage closure (LAAC) is a mechanical alternative for stroke prevention in patients at risk who cannot tolerate oral anticoagulation (OAC).

HYPOTHESIS

Our hypothesis was that the reduction of anticoagulation following LAAC results in a decrease of bleeding events and a rise in serum hemoglobin in a high-risk collective of patients with atrial fibrillation (AF).

METHODS

Bleeding events, use of erythrocyte concentrates, anticoagulation, embolic events, and serum hemoglobin levels before and following LAAC were compared over more than 4 years.

RESULTS

Seventy-five patients (CHA₂DS₂-VASc score 4.4 ± 1.7, HAS-BLED score 4.6 ± 1.1) were analyzed. Before LAAC (observation period 1.8 ± 1.8 years), 67 patients experienced 1.8 ± 1.4 bleeding events (0.9 ± 1.3 major) per year resulting in 0.7 ± 1.3 transfusions per year. After LAAC (2.6 ± 2.0 years), 26 patients (p < .0001 vs. before) had 0.6 ± 2.1 bleeding events (p < .0001), 0.2 ± 0.6 major bleedings (p < .0001) and received 0.6 ± 1.9 transfusions per year (p = .671). Fourteen patients had stroke before and 3 after LAAC (p = .008). Serum hemoglobin increased from initially 9.9 ± 3.0 to 11.9 ± 2.3 g/dL until the end of follow-up (p = .0005). Adverse embolic events did not differ before and after LAAC in our collective.

CONCLUSION

In this clinical relevant cohort of AF patients with high risk for stroke and intolerance to OAC, we show that LAAC was able to reduce the rate of stroke and bleeding events, which translated into a rising serum hemoglobin concentration.

Incidence, Predictors, and Outcomes of Major Bleeding Among Patients Hospitalized With Acute Heart Failure

Acute heart failure (AHF) is a common etiology of hospitalization and is associated with morbidity, including bleeding. In this study, the authors sought to assess the incidence, types, and associates of major bleeding in patients hospitalized with AHF. The National Inpatient Sample from October 2015 to December 2018 was used to identify patients with AHF. The incidence of common bleeding etiologies, and patient demographics, co-morbidities, associated acute cardiac diagnoses, and invasive procedures, were identified. The multivariable logistic regression was used to identify predictors of bleeding and the association of bleeding episodes with inpatient mortality. During the study period, 1,106,634 patients were admitted with a primary diagnosis of AHF, of whom 58,955 (5.3%) had an episode of bleeding. Common bleeding sources were gastrointestinal (25.7%), hematuria (24%), respiratory (23.6%), and procedure-related bleeding (2.5%). Major bleeding was more common in patients with AHF with preserved ejection fraction (odds ratio 1.14, confidence interval 1.12 to 1.16, p <0.001) versus AHF with reduced ejection fraction and in men (odds ratio 1.3, confidence interval 1.29 to 1.31, p <0.001). Major bleeding was associated with higher mortality (7.0% vs 2.4%, p <0.001), longer length of stay (7 vs 4 days, p <0.001), and higher inpatient costs ($49,658 vs $27,636, p <0.001). In conclusion, major bleeding occurs in 5.3% of patients hospitalized with AHF and is associated with higher inpatient mortality and costs and longer length of stay.

Temporal Trend, Prevalence, Predictors and Outcomes of Gastrointestinal Bleed in Hypertrophic Cardiomyopathy in the United States (from the National Inpatient Sample)

Gastrointestinal bleed (GIB) is an important complication in patients with hypertrophic cardiomyopathy (HC) although its prevalence, predictors and outcomes are unknown. The national inpatient sample 2011 to 2018 was analyzed to find hospitalizations with the diagnosis of HC. HC patients were divided into 2 groups: with and without GIB. Baseline characteristics between the 2 groups were compared (Table 2). Variables with p value of 0.2 or less from univariate logistic regression were included in the multivariate logistic regression to find an independent predictor of GIB in HC patients. Stata IC was used for all statistical analysis. Our study reported 242,172 HC hospitalizations between 2011 and 2018, out of which 13,231 (5.4%) also has a concurrent diagnosis of GIB. The GIB group was older (mean age ± SD: 70 ± 28 vs 65 ± 10, p <0.001), more likely to be female (62.5 vs 57%, p <0.001) and had higher burden of comorbidities . HC patients with GIB had higher in-hospital mortality rate (5.3 vs 3.1%, p <0.001), mean length of stay (7.8 vs 5.6 days, p <0.001) and mean total hospital cost ($100,294 vs 77,966, p <0.001). Age group >75, female, chronic kidney disease (CKD 3/4), end-stage renal disease, cirrhosis, coagulopathy and malnutrition were an independent predictor of GIB in HC patients. In conclusion, the prevalence of GIB during HC hospitalizations is increasing. Older, white, females with higher burden of comorbidities are at an increased risk of GIB in HC patients. Sex-based disparities in the prevalence of GIB in HC patients is an area of further research.

Association of atrial fibrillation and various cancer subtypes

BACKGROUND

Studies have shown that the incidence of atrial fibrillation (AF) in cancer is most likely due to the presence of inflammatory markers. The purpose of our study is to determine the association of AF with different cancer subtypes and its impact on in-hospital outcomes.

METHODS

Data were obtained from the National Inpatient Sample database between 2005 and 2015. Patients with various cancers and AF were studied. ICD-9-CM codes were utilized to verify variables. Patients were divided into three age groups: Group 1 (age < 65 years), Group 2 (age 65-80 years), and Group 3 (age > 80 years). Statistical analysis was performed using Pearson chi-square and binary logistic regression analysis to determine the association of individual cancers with AF.

RESULTS

The prevalence of AF was 14.6% among total study patients (n = 46 030 380). After adjusting for confounding variables through multivariate regression analysis, AF showed significant association in Group 1 with lung cancer (odds ratio, OR = 1.92), multiple myeloma (OR = 1.59), non-Hodgkin lymphoma (OR = 1.55), respiratory cancer (OR = 1.55), prostate cancer (OR = 1.20), leukemia (OR = 1.12), and Hodgkin's lymphoma (OR = 1.03). In Group 2, the association of AF with multiple myeloma (1.21), lung cancer (OR = 1.15), Hodgkin lymphoma (OR = 1.15), non-Hodgkin lymphoma (OR = 1.12), respiratory cancer (OR = 1.08), prostate cancer (OR = 1.06), leukemia (OR = 1.14), and colon cancer (OR = 1.01) were significant. In Group 3, AF showed significant association with non-Hodgkin lymphoma (OR = 1.06), prostate (OR = 1.03), leukemia (OR = 1.03), Hodgkin's lymphoma (OR = 1.02), multiple myeloma (OR = 1.01), colon cancer (OR = 1.01), and breast cancer (OR = 1.01). The highest mortality was found in lung cancer in age <80 and prostate cancer in age >80.

CONCLUSION

In patients age <80 years, AF has significant association with lung cancer and multiple myeloma, whereas in patients age >80 years, it has significant association with non-Hodgkin lymphoma and prostate cancer. In patients age <80 years, increased mortality was seen in AF with lung cancer and in patients age >80 years, increased mortality was seen in those with AF and prostate cancer.

TWITTER ABSTRACT

In age <80, lung cancer and multiple myeloma have a strong association with AF while thyroid and pancreatic cancers have no association with AF at any age. In age greater than 80, NHL and prostate cancer have a significant association with AF.

Burden of atrial fibrillation in patients with rheumatic diseases

BACKGROUND

Studies have suggested that atrial fibrillation (AF) in patients with rheumatic diseases (RD) may be due to inflammation.

AIM

To determine the highest association of AF among hospitalized RD patients and to determine morbidity and mortality associated with AF in hospitalized patients with RD.

METHODS

The National inpatient sample database from October 2015 to December 2017 was analyzed to identify hospitalized patients with RD with and without AF. A subgroup analysis was performed comparing outcomes of AF among different RD.

RESULTS

The prevalence of AF was 23.9% among all patients with RD (n = 3949203). Among the RD subgroup, the prevalence of AF was highest in polymyalgia rheumatica (33.2%), gout (30.2%), and pseudogout (27.1%). After adjusting for comorbidities, the odds of having AF were increased with gout (1.25), vasculitis (1.19), polymyalgia rheumatica (1.15), dermatopolymyositis (1.14), psoriatic arthropathy (1.12), lupus (1.09), rheumatoid arthritis (1.05) and pseudogout (1.04). In contrast, enteropathic arthropathy (0.44), scleroderma (0.96), ankylosing spondylitis (0.96), and Sjorgen’s syndrome (0.94) had a decreased association of AF. The mortality, length of stay, and hospitalization costs were higher in patients with RD having AF vs without AF. Among the RD subgroup, the highest mortality was found with scleroderma (4.8%), followed by vasculitis (4%) and dermatopolymyositis (3.5%).

CONCLUSION

A highest association of AF was found with gout followed by vasculitis, and polymyalgia rheumatica when compared to other RD. Mortality was two-fold higher in patients with RD with AF.