Effect of the Diagnosis of Inflammatory Bowel Disease on Risk-Adjusted Mortality in Hospitalized Patients with Acute Myocardial Infarction, Congestive Heart Failure and Pneumonia

In-hospital outcomes and trends of patients with autoimmune diseases undergoing percutaneous coronary intervention. A nationwide analysis

BACKGROUND

The risk of coronary artery disease is exaggerated in patients with autoimmune diseases (AID). A higher risk of complications has been reported during and after percutaneous coronary intervention (PCI) in these patients. We aimed to analyze the in-hospital outcomes and trends of patients with AID, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) undergoing PCI.

METHOD

We identified all PCI procedures using the National In-patient Sample database from 2016 to 2020. Stratified them into cohorts with RA, SLE and IBD and compared them to cohorts without AID. The Chi-square test and multivariate logistic regression were used for analysis. A p-value <0.005 was considered statistically significant.

RESULT

We identified 2,367,475 patients who underwent PCI. Of these, 1.6 %, 0.5 %, and 0.4 % had RA, IBD and SLE respectively. The odds of mortality were lower among patients with IBD (aOR: 0.56; CI 0.38-0.81, p = 0.002) but patients with RA had higher odds of having composite major complications [(MC) including cerebrovascular accident (CVA), cardiac arrest, acute heart failure (AHF), ventricular arrhythmia (VA), major bleeding, and acute kidney injury (AKI)] (aOR: 0.90; CI 0.83-0.98, p = 0.013). Our SLE cohort had higher rates of CVA (p = 0.017) and AKI (p = 0.002). Our cohort with IBD had lower rates of cardiac arrest but had longer hospital length of stay (4.9 days vs 3.9 days) and they incurred higher hospital charges compared to cohort without IBD.

CONCLUSION

This study depicts the immediate adverse outcomes observed in patients with AID undergoing PCI. In contrast to those without AID, our cohorts with RA exhibited worse outcomes, as indicated by the higher odds of major complications. IBD is associated with lower risks of in-hospital adverse outcomes but with higher resource utilization.

Inflammatory bowel disease and associated cardiovascular disease outcomes: A systematic review

BACKGROUND

There is limited and conflicting data available regarding the cardiovascular disease outcomes associated with inflammatory bowel disease (IBD).

OBJECTIVE

We aim to perform a systematic review to evaluate the cardiovascular outcomes and mortality associated with IBD patients.

METHODS

A systematic literature search has been performed on PubMed, Embase, Cochrane, and Scopus from inception till May 2022 without any language restrictions.

RESULTS

A total of 2,029,941 patients were included in the analysis from 16 studies. The mean age of the patients was 45.6 years. More females were found compared with males (57% vs 43%). The most common risk factors for cardiovascular disease (CVD) included smoking (24.19%) and alcohol (4.60%). The most common comorbidities includes hypertension (30%), diabetes mellitus (14.41%), dyslipidemia (18.42%), previous CVD (22%), and renal disease (10%). Among outcomes, all-cause mortality among IBD patients was 1.66%; ulcerative colitis (UC): 15.92%; and Crohn disease (CD): 0.30%. Myocardial Infarction (MI) among IBD patients were 1.47%, UC: 30.96%; and CD: 34.14%. CVD events among IBD patients were 1.95%. Heart failure events among IBD patients were 5.49%, stroke events among IBD patients were 0.95%, UC: 2.63%, and CD: 2.41%, respectively.

CONCLUSION

IBD patients are at higher risk for adverse cardiovascular outcomes, especially in women. Although there remains a lack of concrete treatment algorithms and assessment parameters that better characterize IBD risk factors, nutritional modifications and physical activity should be at the forefront of CVD prevention in IBD.

State of the art review: coronary artery disease in patients with inflammatory bowel disease: mechanisms, prevalence, and outcomes

Extraintestinal disease manifestations of inflammatory bowel disease (IBD), such as arthritis and uveitis, have been well described in the medical literature. However, there has been growing evidence suggesting an association between IBD and both coronary artery disease (CAD) and acute myocardial infarctions (AMI). In this critical review, the pathogenesis of proatherogenic inflammatory markers (CD40-CD40L, IL-6, and TNF-α) are summarised along with clinical evidence that supports the association of these makers with CAD. Moreover, clinical data are examined that suggest an increased risk of AMI and CAD in IBD patients along with recent analyses of in-hospital and post-MI outcomes of AMI in IBD patients. This comprehensive review summarises and expands upon our understanding of the growing association between both CAD and AMI in IBD patients that potentially identifies IBD as a risk factor for developing CAD.

Inflammatory Bowel Disease Does Not Impact Mortality but Increases Length of Hospitalization in Patients with Acute Myocardial Infarction

BACKGROUND AND AIM

Inflammatory bowel diseases (IBD) have been associated with increased risk of cardiovascular events. We aimed to investigate the outcomes of myocardial infarction (MI) in patients with IBD.

METHODS

We performed a cross-sectional study utilizing data from the Nationwide Inpatient Sample from the years 1998 to 2010. ICD-9-CM codes were used to identify patients with Crohn's disease (CD) (555.X), ulcerative colitis (UC) (556.X), and acute MI (410.X). Outcomes in patients with MI with and without IBD were compared. Univariate analysis was performed. Multivariate logistic regression was used to determine the effect of UC and CD on in-hospital MI mortality after adjusting for confounders.

RESULTS

A total of 2,629,161 MI, 3,607 UC and 3784 CD patients were analyzed. UC (odds ratio [OR], 1.12; 95% CI 0.98-1.29) and CD (OR 0.99; 95% CI 0.86-1.15) did not affect in-hospital mortality in patients with MI. There was no difference between in-hospital mortality in patients with MI with or without UC (7.75% vs. 7.05%; p = 0.25) or in patients with MI with or without CD (6.50% vs. 6.59%; p = 0.87). The length of stay (LOS) was higher in IBD patients and total charges were statistically higher in patients with UC as compared to non-IBD patients ($65,182 vs. $53,542; p < 0.001).

CONCLUSIONS

This study shows that IBD does not impact in-hospital mortality from MI. However, patients with MI with IBD have longer LOS. Patients with UC have higher total hospitalization charges than patients with MI without IBD. Further prospective studies are needed to assess the outcomes of MI in IBD patients.

Acute Coronary Syndromes and Inflammatory Bowel Disease: The Gut-Heart Connection

(1) Background: Inflammatory bowel disease (IBD) induces a process of systemic inflammation, sharing common ground with acute coronary syndromes (ACS). Growing evidence points towards a possible association between IBD and an increased risk of ACS, yet the topic is still inconclusive. Therefore, we conducted a systematic review aiming to clarify these gaps in the evidence. (2) Methods: We conducted a systematic search on EMBASE, Cochrane Library, and PubMed, identifying observational studies published prior to November 2020. The diagnosis of IBD was confirmed via histopathology or codes. Full articles that fulfilled our criteria were included. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). (3) Results: We included twenty observational studies with a total population of ~132 million subjects. Fifteen studies reported a significant association between ACS and IBD, while the remaining five studies reported no increase in ACS risk in IBD patients. (4) Conclusions: ACS risk in IBD patients is related to hospitalizations, acute active flares, periods of active disease, and complications, with a risk reduction during remission. Interestingly, a general increase in ACS risk was reported in younger IBD patients. The role of corticosteroids and oral contraceptive pills in increasing the ACS risk of IBD patients should be investigated.

Epidemiology and Clinical Outcomes of Patients With Inflammatory Bowel Disease Presenting With Acute Coronary Syndrome

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased acute coronary syndrome (ACS) risk. Data are limited regarding the epidemiology and outcomes of ACS in patients with IBD.

METHODS

A retrospective cohort analysis of patients with IBD admitted for ACS in the U.S. Healthcare Cost and Utilization Project National Inpatient Sample for 2005 to 2015 was conducted. We analyzed trends in IBD-ACS admissions and mortality, differences in risk profiles, management strategies, and in-hospital mortality between IBD-ACS and non-IBD ACS and between ulcerative colitis (UC) and Crohn disease (CD).

RESULTS

We studied 6,872,415 non-IBD ACS and 24,220 IBD-ACS hospitalizations (53% with CD). During the study period, the number of hospitalizations for IBD-ACS increased, particularly those related to CD. Compared with non-IBD ACS, patients with IBD-ACS had a lower prevalence of cardiovascular risk factors and similar rates of coronary angiography and revascularization. The in-hospital mortality rate was lower with IBD-ACS (3.9%) compared with non-IBD ACS (5.3%; odds ratio, 0.81; 95% confidence interval, 0.69-0.96; P = 0.011) and was stable between 2005 and 2015. Risk factors, ACS management strategies, and mortality were similar between CD and UC. Coagulopathy, weight loss, and gastrointestinal bleeding were more frequent in IBD-ACS and were strong independent predictors of mortality.

CONCLUSIONS

Hospitalizations for ACS in patients with IBD increased in recent years but death rates were stable. The ACS-related risk profiles and mortality were modestly favorable with IBD-ACS than with non-IBD ACS and were similar between CD and UC. Complications more frequently associated with IBD were strongly associated with mortality. These findings indicate that aggressive management of IBD and ACS comorbidities is required to improve outcomes.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

Outcomes of Percutaneous Coronary Intervention in Patients With Crohn's Disease and Ulcerative Colitis (from a Nationwide Cohort)

Patients with inflammatory bowel disease (IBD) are at an increased risk of ischemic heart disease. However, there is limited evidence on how their outcomes after percutaneous coronary intervention (PCI) compare with those without IBD. All PCI-related hospitalizations from the National Inpatient Sample from 2004 to 2015 were included, stratified into 3 groups: no-IBD, Crohn's disease (CD), and ulcerative colitis (UC). We assessed the association between IBD subtypes and in-hospital outcomes. A total of 6,689,292 PCI procedures were analyzed, of which 0.3% (n = 18,910) had an IBD diagnosis. The prevalence of IBD increased from 0.2% (2004) to 0.4% (2015). Patients with IBD were less likely to have conventional cardiovascular risk factors and more likely to undergo PCI for an acute indication, and to receive bare metal stents. In comparison to patients without IBD, those with IBD had reduced or similar adjusted odds ratios (OR) of major adverse cardiovascular and cerebrovascular events (CD OR 0.69, 95% confidence interval (CI) 0.62 to 0.78; UC OR 0.75, 95% CI 0.66 to 0.85), mortality (CD: OR 0.94, 95% CI 0.79 to 1.11; UC OR 0.35, 95% CI 0.27 to 0.45) or acute cerebrovascular accident (CD: OR 0.73, 95% CI 0.60 to 0.89; UC: OR 0.94, 95% CI 0.77 to 1.15). However, IBD patients had an increased odds for major bleeding (CD: OR 1.42 95% CI 1.23 to 1.63, and UC: OR 1.35 95% CI 1.16 to 1.58). In summary, IBD is associated with a decreased risk of in-hospital post-PCI complications other than major bleeding that was significantly higher in this group. Long term follow-up is required to evaluate the safety of PCI in IBD patients from both bleeding and ischemic perspectives.

Inflammatory bowel disease and the risk for cardiovascular disease: Does all inflammation lead to heart disease?

Inflammation has a strong role in the development of atherosclerotic cardiovascular disease (ASCVD). Several systemic inflammatory conditions have been linked to an increased risk of ASCVD; however, this has not been well established in Inflammatory Bowel Disease (IBD). IBD is comprised of Ulcerative Colitis and Crohn's disease, both of which involve chronic inflammation of the intestinal tract, often with evidence of systemic involvement. Several ASCVD risk factors such as smoking, diabetes, poor diet and the presence of obesity may increase the risk of ASCVD in patients suffering from IBD, despite a lower prevalence of hypertension and hypercholesterolemia. Medications used to treat IBD and target inflammation, such as steroids, may also accelerate the risk of the risk for ASCVD heart failure while exacerbating ASCVD risk factors. Several studies have demonstrated an elevated risk of acute myocardial infarction and stroke in these patients, most notably in women and in younger patients. Some cohort studies have also suggested a link between IBD and both atrial fibrillation and heart failure, particularly during periods of active flares. All IBD patients, particularly younger individuals, should be screened for ASCVD risk factors with aggressive risk factor modification to reduce the risk of cardiovascular events. Further research is needed to identify how to prevent and treat cardiovascular events that occur in patients with IBD, particularly during active flares.

Hospital costs, length of stay and prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease

AIM

To examined the prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease (IBD) by comparing the diagnostic codes for these procedures in patients with IBD and a control group of patients.

METHODS

The National Inpatient Sample database (NIS) is part of the Healthcare Cost and Utilization Project (HCUP), the largest publicly available inpatient healthcare database in the United States. The NIS samples about 20% of discharges from all community hospitals participating in HCUP, representative of more than 95% of the United States population, with approximately 7000000 hospitalizations reported annually. NIS contains data on diagnoses, procedures, demographics, length of stay (LOS), co-morbidities and outcomes. ICD-9-CM diagnostic codes for primary hospitalizations for arthroplasty of the hip or knee with a co-diagnosis of IBD [combining both Crohn’s disease (CD) and ulcerative colitis (UC)] were used to identify study subjects for cost and LOS analysis for NIS from 1999-2012. Statistical analysis: 1: 2 propensity score matching between IBD vs a control group based on following factors: Patient age, gender, race, total co-morbidities, # of procedures, admission type, insurance, income quartiles, and hospital bed size, location and hospital teaching status. Categorical variables were reported as frequency and compared by χ² tests or Fisher’s exact tests. Individual 1:3 matching was also performed for patients carrying diagnostic codes for CD and for patients with the diagnostic code for UC. After matching, continuous variables were rcompared with Wilcoxon signed rank or Paired T-tests. Binary outcomes were compared with the McNemar’s test. This process was performed for the diagnosis of hip or knee arthroplasty and IBD (CD and UC combined). Prevalence of the primary or secondary diagnostic codes for these procedures in patients with IBD was determined from NIS 2007.

RESULTS

Costs and mortality were similar for patients with IBD and controls, but LOS was significantly longer for hip arthroplasties patients with IBD, (3.85 +/-2.59 d vs 3.68 +/-2.54 d, respectively, P = 0.009). Costs, LOS and survival from the procedures was similar in patients with CD and UC compared to matched controls. These results are shown in Tables 1-10. The prevalence of hip arthroplasty in patients with IBD was 0.5% in 2007, (170/33783 total patients with diagnostic codes for IBD) and was 0.66% in matched controls (P = 0.0012). The prevalence of knee arthroplasty in patients with IBD was 1.36, (292/21202 IBD patients) and was 2.22% in matched controls (P < 0.0001).

CONCLUSION

Costs and mortality rates for hip and knee arthroplasties are the same in patients with IBD and the general population, while a statistical but non-relevant increase in LOS is seen for hip arthroplasties in patients with IBD. Compared to the general population, arthroplasties of the hip and knee are less prevalent in hospitalized patients with IBD.