Hospital Mortality

IJCS

Original Article

Transcatheter Aortic Valve Implantation in Nonagenarians: In-Hospital Complications and One-Year Follow-Up Mortality

Nelson Durval Ferreira Gomes de Mattos et al. Rafael Lauria de Oliveira Constantino Gonzalez Salgado André Luiz Silveira Sousa … Andre Luiz da Fonseca Feijó Rodrigo Verney Castello Branco Giovanna Zadra de Mattos José Carlos Pizzolante Secco Luiz Antonio Ferreira Carvalho Helena Cramer Rey

Abstract

Background:

Aortic Stenosis (AS) is prevalent among elderly individuals and is associated with high mortality when untreated. Transcatheter Aortic Valve Implantation (TAVI) has emerged as a viable therapeutic alternative, particularly for patients with surgical contraindications. However, its application in nonagenarians remains controversial due to limited data in this very elderly population.

Objective:

To evaluate clinical outcomes in nonagenarian patients undergoing TAVI at a private quaternary hospital, with emphasis on mortality and in-hospital as well as one-year complications.

Methods:

A retrospective cohort study with prospective follow-up was conducted between 2009 and 2023. A total of 265 patients with symptomatic severe AS who underwent TAVI were included, of whom 40 were nonagenarians (≥ 89 years). Data were obtained from an institutional database and from the Brazilian Registry of Aortic Bioprosthesis Implantation by Catheter – New Technologies (RIBAC-NT). Comparisons between nonagenarians and younger patients were performed using the Student’s t-test for continuous variables and the chi-square (χ²) test for categorical variables. A p-value < 0.05 was considered statistically significant.

Results:

Among nonagenarians, 55% were female, 72.5% had hypertension, and 95% had chronic kidney disease. The technical success rate was 55%. Major complications included permanent pacemaker implantation (35%) and adverse events (45%). In-hospital mortality was 7.9%, with no statistically significant differences at 30 days (p = 0.40), 6 months (p = 0.35), and one year (p = 0.06) compared to younger patients.

Conclusion:

TAVI proved to be a safe and effective therapeutic option in nonagenarians, showing clinical outcomes comparable to those of younger individuals.

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Original Article

Applicability of SAPS 3 and APACHE II Scores in a Cardiac Intensive Care Unit: A Prospective Study

Rafael Petri Pinheiro et al. Leonardo Castro Luna Vanessa dos Reis von Doellinger Marcelo Goulart Correia … Bernardo Tura Stephan Lachtermacher

Abstract

Background

Prognostic scores such as the Simplified Acute Physiology Score (SAPS) and the Acute Physiology and Chronic Health Evaluation (APACHE) are essential for assessing performance and predicting mortality in Intensive Care Units (ICUs).

Objectives

To evaluate the performance of SAPS 3 (including the Latin America [LA] and Brazil [BR] versions) and APACHE II in predicting mortality in a cardiac intensive care unit (CICU).

Methods

Prospective cohort of patients admitted between June 2022 and May 2024, followed until discharge or death. Data were extracted from electronic medical records. The relationship between observed and predicted mortality was calculated using the Standardized Mortality Ratio (SMR), and discrimination was assessed by the Receiver Operating Characteristic (ROC) curve.

Results

A total of 573 patients were included, 288 (50%) with three or more comorbidities, median age 63 years [IQR: 53–72], and 344 (60%) male. Cardiovascular diseases accounted for 76% of admissions. Overall mortality was 15%. Mean SMR values were: 0.52 (95% CI: 0.32–0.72) for SAPS 3; 0.40 (95% CI: 0.26–0.54) for SAPS 3 Latin America (AL); 0.79 (95% CI: 0.41–1.16) for SAPS 3 Brazil (BR); and 0.86 (95% CI: 0.42–1.29) for APACHE II. The analysis of the area under the curve (AUC) was 0.805 for SAPS 3 and its adapted versions, and 0.704 for APACHE II.

Conclusions

SAPS 3, particularly SAPS 3 Brazil (BR), demonstrated greater accuracy than APACHE II. Despite mortality being above the national average, the SMR indicated that observed mortality was lower than predicted, suggesting good care performance in the unit.

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Editorial

ST-Segment Elevation Myocardial Infarction: Assessment of Quality of Care Before and After the COVID-19 Pandemic

Fernando Oswaldo Dias Rangel

In this article, Tavares et al. comparatively analyze quality indicators of care for 193 patients with ST-segment elevation myocardial infarction (STEMI) and relevant clinical outcomes before and during the COVID-19 pandemic.

An increase in mortality rates associated with cardiovascular diseases was observed in Brazil after the onset of the COVID-19 pandemic. Many patients did not leave their homes to seek hospital care, contributing to increased cardiovascular mortality.

[…]

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Original Article

A Geoprocessing Approach for Mortality and Social Vulnerability Analysis during the COVID-19 Pandemic

Andres Felipe Valencia Rendon et al. Isabela Mendes Volschan Manoella Novais Pereira Wagner Lima Monteiro … Alessandra de Freitas Pimentel Emilia Matos do Nascimento Basilio de Bragança Pereira Glaucia Maria Moraes de Oliveira

Abstract

Background

Brazil had high COVID-19 lethality/mortality with multiple social inequalities, where color/race was highly relevant, especially in Rio de Janeiro. Therefore, we hypothesize that COVID-19 hospitalized patients with a highly socially vulnerable background would have more significant in-hospital mortality.

Objective

To analyze the socioeconomic factors of social vulnerability and their association with COVID-19 mortality.

Methods

This work was a prospective study of 274 confirmed adult COVID-19 hospitalized patients in the University Hospital of Clementino Fraga Filho (HUCFF). The clinical features/blood chemistry information were collected from the clinical record. The ArcGIS Pro Software (Esri Gis mapping software, Redlands California-US) and a Python-based algorithm were used to determine in-app/in-map variable management relevance to the socioeconomic variables, inequity markers, and vulnerability. Our study also analyzed the transfers from other primary care institutions to our hospital in order to examine its potential delays in advanced medical care. Logistic regression and ROC curve were used to investigate in-hospital mortality for our statistical analysis. The significance level adopted in the statistical analysis was 5% Results: Male sex, total days of hospitalization, age, having more than three comorbidities, intensive care unit (ICU) admission, hemodialysis, and transfer from other hospitals showed statistical significance. Patients living in low-adequate households (p = 0.030) with high in-house individual agglomeration markers (p = 0.017) and transfers from another Primary Health Care (PHC) institution (p = 0.047) were associated with increased in-hospital mortality, with high ICU admission and mechanical ventilation.

Conclusions

In-hospital mortality due to COVID-19 was influenced by social individual background characteristics of vulnerability. Among other clinical parameters, these markers should be considered to predict the likelihood of complications related to the COVID-19 pandemic.

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Original Article

Analysis of the SHARPEN Score in the Prediction of In-Hospital Mortality of Patients With Infective Endocarditis Undergoing Cardiac Surgery

Mateus Correa Lech et al. Joel Stefani Lucas Fernando Fabra Miguel Gus Fernando Pivatto Júnior

Abstract

Background

The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out.

Objective

To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores.

Methods

Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant.

Results

A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores.

Conclusions

The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

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Original Article

Ischemic Stroke and Acute Myocardial Infarction: Trends in in-Hospital Mortality in Brazil from 1998 to 2018

Júlio Martinez Santos et al. Alessandra Barboza Resende Martinez Emerson de Jesus Silva Gustavo Roberto Santana … Romero Henrique de Almeida Barbosa David Fernandes Lima Matheus Rodrigues Lopes Johnnatas Mikael Lopes

Abstract

Background

Ischemic stroke and acute myocardial infarction (AMI) are cardiovascular diseases with high morbidity and mortality rates in Brazil and worldwide. Their outcomes are influenced by public policies aimed at mitigating risk factors and by investments in infrastructure of emergency support and quality of hospital care.

Objective

To analyze the trend in the proportion of in-hospital deaths from ischemic stroke and AMI in Brazil as a way of evaluating the effectiveness of urgency and emergency services.

Methods

Ecological time series study using data from the Hospital Information System. The outcome was the proportion of in-hospital deaths from ischemic stroke and AMI with stratification by sex and state. Prais-Winsten regression was used to analyze the trend between 1998-2018 with α≤0,05.

Results

The proportion of deaths from AMI and ischemic stroke declined in the time series (p<0.001), decreasing annually by 0.17% and 0.25%, respectively. In 20 years, it reduced 43.76% (ischemic stroke) and 32.39% (AMI) in both sexes. However, the decline was more evident in the South and Southeast regions.

Conclusion

The reduction in hospital deaths from AMI and ischemic stroke was heterogeneous among Brazilian regions, which may be related to inequality in emergency services and hospital support.

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Original Article

Sociodemographic Profile of Acute Myocardial Infarction in Rio De Janeiro, Brazil (2010-2019)

Lucas André de Carvalho

Abstract

Background

Cardiovascular Diseases (CVDs) are the main cause of mortality in Brazil, which includes acute myocardial infarction (AMI). In 2017, 12% of deaths caused by infarction in Brazil occurred in the state of Rio de Janeiro, characterizing it as an important “hotspot” in the country.

Objectives

This study aimed to characterize the population affected by AMI over the past decade within the state so as to guide future public policies related to CVDs.

Methods

Secondary data of patients affected by AMI between 2010 and 2019 were obtained by DATASUS. In-hospital case-fatality rates, mortality rates, and proportional mortality were calculated using information gathered by the Mortality Information System (SIM) and demographic statistics produced by the Brazilian Institute of Geography and Statistics (IBGE).

Results

The main results showed that in-hospital case-fatality rates were higher in women, patients aged 60 years and over, the black color/race, and the state’s Northwest region. The mortality rate was higher among men, especially in the South-central region and those over 50 years of age. People aged 40-49 years presented a considerable risk of death by infarction. The major categories of data classified as “ignored” in hospital admissions and death certificates were those related to race and education level.

Conclusions

Prevention should not only focus on the elderly, but also on people over 40, especially men. The incompleteness of electronic public data systems can affect the use of race/color or education level as epidemiological variables. New studies should be conducted to understand why the South-central region is so heavily affected by infarction.

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Letter to the Editor

Effectiveness of Rapid Response Teams and the Importance of Preprints

Hermano Alexandre Lima Rocha et al. Sabrina Gabriele Maia Oliveira Rocha Antônia Célia de Castro Alcântara

To the Editor of the International Journal of Cardiovascular Sciences,

We have read with interest the Point of View: “Performance of the Rapid Response Systems in Health Care Improvement: Benefits and Perspectives” by Viviane Cordeiro Veiga and Salomón Soriano Ordinola Rojas, published ahead of print in the International Journal of Cardiovascular Sciences on April 15, 2019. Rapid response teams to treat trauma patients in Australia 30 years ago, in 1989. From the outset, the aim was to early recognize signs of deterioration and provide a quick response, hence the name of the methodology. The discussion about the activation criteria is relevant and up to date and was treated in a solid manner by the authors in the introduction of the point of view. Indeed, it is known that this is the cause of part of the heterogeneity of results found in studies on the subject.

[…]

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Original Article

Decompensated Heart Failure with Mid-Range Ejection Fraction: Epidemiology and In-Hospital Mortality Risk Factors

Gabriela Paiva Cavalcanti et al. Camila Sarteschi Glory Eithne Sarinho Gomes Carolina de Araújo Medeiros … José Henrique Martins Pimentel André Rabelo Lafayette Maria Celita Almeida Paulo Sérgio Rodrigues Oliveira Silvia Marinho Martins

Abstract

Background:

Recently, a new HF entity, with LVEF between 40-49%, was presented to comprehend and seek better therapy for HF with preserved LVEF (HFpEF) and borderline, in the means that HF with reduced LVEF (HFrEF) already has well-defined therapy in the literature.

Objective:

To compare the clinical-therapeutic profile of patients with HF with mid-range LVEF (HFmrEF) with HFpEF and HFrEF and to verify predictors of hospital mortality.

Method:

Historical cohort of patients admitted with decompensated HF at a supplementary hospital in Recife/PE between April/2007 – August/2017, stratified by LVEF (< 40%/40 – 49/≥ 50%), based on the guideline of the European Society of Cardiology (ESC) 2016. The groups were compared and Logistic Regression was used to identify predictors of independent risk for in-hospital death.

Results:

A sample of 493 patients, most with HFrEF (43%), HFpEF (30%) and HFmrEF (26%). Average age of 73 (± 14) years, 59% men. Hospital mortality 14%, readmission within 30 days 19%. In therapeutics, it presented statistical significance among the 3 groups, spironolactone, in HFrEF patients. Hospital death and readmission within 30 days did not make difference. In the HFmrEF group, factors independently associated with death were: valve disease (OR: 4.17, CI: 1.01-9.13), altered urea at admission (OR: 6.18, CI: 1.78-11.45) and beta-blocker hospitalization (OR: 0.29, CI: 0.08-0.97). In HFrEF, predictors were: prior renal disease (OR: 2.84, CI: 1.19-6.79), beta-blocker at admission (OR: 0.29, CI: 0.12-0.72) and ACEI/ ARB (OR: 0.21, CI: 0.09-0.49). In HFpEF, only valve disease (OR: 4.61, CI: 1.33-15.96) and kidney disease (OR: 5.18, CI: 1.68-11.98) were relevant.

Conclusion:

In general, HFmrEF presented intermediate characteristics between HFrEF and HFpEF. Independent predictors of mortality may support risk stratification and management of this group.

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Viewpoint

Performance of the Rapid Response Systems in Health Care Improvement: Benefits and Perspectives

Viviane Cordeiro Veiga et al. Salomón Soriano Ordinola Rojas

Introduction

In the last two decades, the rapid response systems (RRS) have been explored as initiatives to increase the safety of hospitalized patients. The main function is to identify and treat patients at risk, or who are presenting signs of clinical instability, and to prevent adverse events during hospital stay, with a consequent reduction in in-hospital mortality. Every year in the United States, more than 200,000 intrahospital cardiac arrests (CAs) occur, most of which could be avoided. RRS are formed by two health care components called the afferent limb and the efferent limb. The afferent limb is represented by the health care team in the admission units, responsible for the care of hospitalized patients and trained to activate the afferent limb, when physiological changes that predict adverse events are detected, especially cardiac arrests. The efferent limb is represented by a team of health care professionals, who respond to codes, and may be headed by a physician, a nurse or a physiotherapist. The efferent limb is better known as the rapid response team (RRT). In addition to these health care components, the rapid response systems must also have two other components, namely the administrative arm, which provides the necessary documentation and is responsible for the systems daily activities and the quality and governance arm, which contributes to continuous improvement and reassessment of the system. These systems have been implemented around the globe, but still in a non-uniform way in institutions and health systems with different characteristics. However, in Brazil, there are few reports on this issue.^,

[…]

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Original Article

C-reactive Protein is a Predictor of Mortality in ST-segment Elevation Acute Myocardial Infarction

Sibele Sauzem Milano et al. Orlando Victorino de Moura Júnior Arthur Augusto Souza Bordin Gustavo Lenci Marques

Abstract

Background:

Inflammation is a major component of the response to tissue injury caused by myocardial infarction. High-sensitivity C-reactive protein (hs-CRP) levels might be a simple marker of the severity of this inflammatory response, providing prognostic information.

Objective:

To associate hs-CRP level on admission and other clinical characteristics with in-hospital mortality of patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods:

A retrospective cohort study of patients admitted with STEMI was carried out. Patients were analyzed regarding clinical characteristics, reperfusion therapy, hs-CRP on admission and outcomes. Continuous variables were analyzed by non-parametric Mann-Whitney U test and categorical variables by chi-square test. A p value of < 0.05 was considered statistically significant.

Results:

Of the 118 patients analyzed, 20 died during hospitalization. Higher levels of hs-CRP (p = 0.001) and older ages (p = 0.003) were observed among those patients who died. Logistic regression showed that a one unit increase in hs-CRP increased the risk of death by 15% (p = 0.0017), after adjustment for established risk factors. Similarly, each one-year increase in age increases the risk of death by 6.6% (p = 0.003).

Conclusion:

Our results demonstrate a strong association between hs-CRP obtained on admission and in-hospital mortality after STEMI. It suggests that hs-CRP can be a marker of inflammatory response to myocardial ischemia, providing prognostic information regarding the risk of death.

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