Muhammad Shahreyar1,2, Tamunoinemi Bob-Manuel1, Rami N Khouzam1,2, Mohammad W Bashir3, Samian Sulaiman4, Oluwaseun Akinseye1,2, Arindam Sharma1, April Carter1, Samuel Latham1, Sanjay Bhandari4, Arshad Jahangir5,6. 1. Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA. 2. Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA. 3. University of Gdansk, Gdansk, Poland. 4. Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. 5. Aurora Cardiovascular Services, Aurora St. Luke's Medical Center, Milwaukee, WI, USA. 6. Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora St. Luke's Medical Center, Aurora Health Care, Milwaukee, WI, USA.
Abstract
BACKGROUND: Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. METHODS: All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. RESULTS: Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. CONCLUSIONS: Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.
BACKGROUND: Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. METHODS: All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. RESULTS: Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. CONCLUSIONS: Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.
Authors: James K Kirklin; David C Naftel; Francis D Pagani; Robert L Kormos; Lynne W Stevenson; Elizabeth D Blume; Marissa A Miller; J T Baldwin; J Timothy Baldwin; James B Young Journal: J Heart Lung Transplant Date: 2014-04-21 Impact factor: 10.247
Authors: R L Sacco; B Boden-Albala; R Gan; X Chen; D E Kargman; S Shea; M C Paik; W A Hauser Journal: Am J Epidemiol Date: 1998-02-01 Impact factor: 4.897
Authors: Laura Harvey; Christopher Holley; Samit S Roy; Peter Eckman; Rebecca Cogswell; Kenneth Liao; Ranjit John Journal: Ann Thorac Surg Date: 2015-06-09 Impact factor: 4.330
Authors: Jennifer A Frontera; Randall Starling; Sung-Min Cho; Amy S Nowacki; Ken Uchino; M Shazam Hussain; Maria Mountis; Nader Moazami Journal: J Heart Lung Transplant Date: 2016-12-23 Impact factor: 10.247
Authors: Mark S Slaughter; Joseph G Rogers; Carmelo A Milano; Stuart D Russell; John V Conte; David Feldman; Benjamin Sun; Antone J Tatooles; Reynolds M Delgado; James W Long; Thomas C Wozniak; Waqas Ghumman; David J Farrar; O Howard Frazier Journal: N Engl J Med Date: 2009-11-17 Impact factor: 91.245
Authors: James K Kirklin; David C Naftel; Robert L Kormos; Lynne W Stevenson; Francis D Pagani; Marissa A Miller; J T Baldwin; J Timothy Baldwin; James B Young Journal: J Heart Lung Transplant Date: 2013-02 Impact factor: 10.247
Authors: Hiroyuki Tsukui; Adib Abla; Jeffrey J Teuteberg; Dennis M McNamara; Michael A Mathier; Linda M Cadaret; Robert L Kormos Journal: J Thorac Cardiovasc Surg Date: 2007-06-04 Impact factor: 5.209
Authors: Walter M van den Bergh; Annemieke Oude Lansink-Hartgring; Abram L van Duijn; Annemarie E Engström; Jaap R Lahpor; Arjen J C Slooter Journal: J Cardiothorac Surg Date: 2015-10-15 Impact factor: 1.637