Abstract
Introduction and background
Cardiovascular diseases (CVDs) encompass a range of disorders involving coronary artery diseases, valvular heart diseases, myocardial diseases, pericardial diseases, hypertensive heart diseases, heart failure (HF), and pulmonary artery diseases. Given the high prevalence of CVDs, understanding both overall and in-hospital mortality rates from these diseases is crucial. Unsurprisingly, most research, procedures, and new pharmacological interventions aim to reduce these rates. No recent studies have comprehensively detailed in-hospital mortality rates, demographics, and risk factors for all CVDs combined. Yet, in-hospital mortality rates due to CVD significantly impact patients' families and healthcare teams and serve as a critical measure of healthcare system development and effectiveness. Therefore, analyzing in-hospital mortality rates is essential for filling the gap in the recent comprehensive analysis of in-hospital mortality rates, demographics, and risk factors of all CVDs.
Method
The study used data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS) Databases of 2021 and HCUP tools. The NIS database extrapolates national estimates based on a stratified sample of 20% of US hospital discharges. Results were expressed as probability and relative risk using the t-test, with a P-value <0.05 being statistically significant. Statistical analyses were done using Stata statistical software version 18 (StataCorp LLC, College Station, TX, US).
Results
This study included 6,666,752 hospital admissions in the United States. Of these, 2,337,589 patients were admitted with CVDs and related symptoms, with 70,552 deaths occurring during hospitalization, resulting in an in-hospital mortality rate of 3.01% due to CVDs. Our study showed all CVD-induced in-hospital mortality combined was found to have a higher association with diabetes but a lower association with hypertension, hyperlipidemia, alcohol, and smoking.
Conclusion
The highest rates of cardiovascular disease in-hospital mortality are cardiac arrest, rupture of the cardiac wall as a complication of acute myocardial infarction, cardiogenic shock, rupture of papillary muscle as a complication of acute myocardial infarction, and rupture of chorda tendinea as a complication of acute myocardial infarction. The most common causes of CVD in-hospital mortality are non-ST-elevation myocardial infarction (NSTEMI) (19.20%), ST-elevation myocardial infarction (STEMI) (17.80%), cardiac arrest (15.10%), hypertensive heart disease with heart failure (12.50%), ventricular fibrillation (4.70%), ventricular tachycardia (3.30%), and aortic stenosis (2.10%). The most common risk factors for CVD in-hospital mortality are age, male gender, and diabetes. Proper diabetes control and management might be the highest preventive measure for all CVD-induced in-hospital mortality.
Keywords: cardiovascular diseases, demographics, in-hospital mortality, nationwide inpatient sample (nis), risk factors
Introduction
Cardiovascular diseases (CVDs) encompass a range of disorders involving coronary artery diseases, valvular heart diseases, myocardial diseases, pericardial diseases, hypertensive heart diseases, heart failure (HF), and pulmonary artery diseases. CVDs are the most common cause of death globally and in the United States. The World Health Organization has estimated that 12 million deaths occur worldwide every year due to heart diseases. The early prognosis of cardiovascular diseases can aid in making decisions on lifestyle changes in high-risk patients and reduce complications [1].
Over the last decades, although the age-standardized mortality rates of CVD declined by 27.3%, the number of deaths increased by 42.4% from 1990 to 2015. On the other hand, CVD led to over 17 million deaths, 330 million years of life lost, and 35.6 million years lived with disability in 2017 worldwide. Meanwhile, it was projected that CVD would be the cause of more than 23 million deaths in 2030 around the world [2].
Given the high prevalence of CVDs, understanding both overall and in-hospital mortality rates from these diseases is crucial. Unsurprisingly, most research, procedures, and new pharmacological interventions aim to reduce these rates.
Most of the previous studies have focused on CVD mortality in general and not on CVD in-hospital mortality rates. Yet, in-hospital mortality rates due to CVD significantly impact patients' families and healthcare teams and serve as a critical measure of healthcare system development and effectiveness. Therefore, analyzing in-hospital mortality rates is essential for evaluating and comparing healthcare quality.
Addressing patients with end-stage cardiovascular diseases through palliative care and goals of care discussions early can prevent the increase in in-hospital mortality due to cardiovascular diseases. It can reduce the number of unnecessary visits to the hospitals.
Materials and methods
Data source
The study used data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), the Agency for Healthcare Research, Quality HCUP Databases of 2021, HCUP tools and products, including Clinical Classifications Software (CCS) or Clinical Classifications Software Refined (CCSR), Elixhauser Comorbidity Software (HCUP, AHRQ, Rockville, Maryland, US) and the HCUP-NIS 2016-2021 Diagnoses and Procedures Frequency Sheet. The NIS database extrapolates national estimates based on a stratified sample of 20% of US hospital discharges [3-6].
We have used the HCUP tools to obtain the different cardiovascular diseases with their ICD-10-CM codes reported under the NIS. Elixhauser Comorbidity Software was used to help show the associated comorbid conditions with each CVD.
Study population
The study included 2,337,589 patients with CVDs who were admitted to the United States hospital in 2021. The study also included 70,552 patients who died with CVDs during the hospitalization [3-6].
We have studied the rates and trends of in-hospital mortality of patients admitted to hospitals in the United States with cardiovascular diseases and symptoms in 2021. We have divided the cardiovascular diseases into groups, including valvular diseases, hypertension and hypertensive heart diseases, heart failure, cardiomyopathies, coronary artery diseases and their complications, intracardiac thrombosis, coronary artery dissection and aneurysm, pulmonary artery diseases, pericardial diseases, myocarditis, arrhythmias, thoracic aortic dissection and aneurysms, orthostatic hypotension, chest pain, and cardiogenic shock. All patients included in the study had one of the listed cardiovascular diagnoses as a primary diagnosis for hospital admission. Categorization was based on the NIS reporting and clinical relationship between diseases.
We have studied the rate of each CVD's in-hospital mortality compared to the total number of patients admitted with the same disease. We have also studied the risk factors in patients who died during hospitalization due to all CVDS combined by comparing them to the risk factors in patients who survived the hospitalizations with all CVDs combined.
Patient characteristics
We have studied demographics, including age, race, gender, hospital region, hospital location, and patient location. We classify the age as equal to or above 65 and below 65. The gender was classified into male and female. The race was classified into White, Black, Hispanic, Asian, Native American, and others, as reported under the NIS. Patient location was classified based on the counties with population numbers. We have also studied risk factors associated with hypertension, diabetes, hyperlipidemia, obesity, smoking, and alcohol use disorder, which were obtained from the comorbidity software under the NIS.
Outcome measures
The outcomes evaluated were in-hospital mortality, risk factors associated with in-hospital mortality, and associated comorbid conditions. We have used the ICD-10-CM coding system to identify patients admitted to the hospital in the USA with a primary cardiovascular diagnosis. We have identified the percentage of patients who had died during the admission to the total patients admitted with all cardiovascular diseases.
Statistical analysis
Weighted data were used to calculate the percentage of in-hospital mortality for individual cardiovascular diseases, and unweighted data were used to study the risk factors associated with in-hospital mortality. Results were expressed as probability and relative risk using the t-test to compare the risk factors between the two variables, which include patients who died during the hospitalization and patients who survived the hospitalizations. Statistical analyses were done using Stata statistical software version 18 (StataCorp LLC, College Station, TX, US). Stata tables were generated and included the different variables used in the study.
Results
Some CVDs can have very high mortality rates. Still, they do not represent the most common causes of CVD in-hospital mortality due to the low incidence of these diseases. For example, the in-hospital mortality rate for patients with a rupture of the cardiac wall as a complication of acute myocardial infarction is 71.70%. However, it represents only 0.2% of the total CVD-induced in-hospital mortality. It is important to understand the difference between the most fatal and common causes of in-hospital mortality (Table 1) [3-6].
Table 1. Rates of in-hospital mortality in patients admitted with cardiovascular diseases and symptoms.
The study used data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research, Quality HCUP Databases of 2021, HCUP tools and products including Clinical Classifications Software (CCS) or Clinical Classifications Software Refined (CCSR), Elixhauser Comorbidity Software and HCUP-NIS 2016-2021 Diagnoses and Procedures Frequency Sheet [3-6].
| Cardiovascular diseases | Total number of patients presented with each CVD | Total number of patients who died during hospitalization from each CVD | Percentage of patients who died during hospitalization to the number of patients presented with each CVD | Percentage of patients who died during hospitalization to the total number of patients died from all CVDS | |
| Valvular diseases | Rheumatic mitral stenosis | 1,115 | 75 | 6.7% | 0.1% |
| Rheumatic mitral stenosis with insufficiency | 1,535 | 63 | 4.2% | 0.08% | |
| Rheumatic disorders of both mitral and aortic valves | 8,180 | 320 | 3.9% | 0.4% | |
| Disorders of both mitral and tricuspid valves | 4,770 | 140 | 2.9% | 0.1% | |
| Comb rheumatic disorder of mitral, aortic and tricuspid valves | 5,735 | 270 | 4.7% | 0.3% | |
| Acute and subacute infective endocarditis | 11,620 | 595 | 5.1% | 0.8% | |
| Nonrheumatic mitral insufficiency | 28,740 | 550 | 1.9% | 0.7% | |
| Nonrheumatic mitral prolapse | 1,920 | 25 | 1.3% | 0.03% | |
| Nonrheumatic mitral stenosis | 870 | 64 | 7.3% | 0.08% | |
| Nonrheumatic aortic stenosis | 94,425 | 1505 | 1.5% | 2.1% | |
| Nonrheumatic aortic insufficiency | 4,985 | 105 | 2.1% | 0.1% | |
| Nonrheumatic aortic stenosis with insufficiency | 10,860 | 260 | 2.3% | 0.3% | |
| HTN and hypertensive heart diseases | Essential hypertension | 7,090 | 10 | 0.1% | 0.01% |
| Hypertensive heart disease with HF | 468,864 | 9225 | 1.9% | 12.5% | |
| Hypertensive heart disease without HF | 1,095 | 15 | 1.3% | 0.02% | |
| Hypertensive urgency | 72,095 | 150 | 0.2% | 0.2% | |
| Hypertensive emergency | 65,350 | 180 | 0.2% | 0.2% | |
| Heart failure | Acute systolic heart failure | 9,610 | 205 | 2.1% | 0.2% |
| Acute on chronic systolic heart failure | 30,745 | 1175 | 3.8% | 1.6% | |
| Acute diastolic heart failure | 5,260 | 105 | 1.9% | 0.1% | |
| Acute on chronic diastolic heart failure | 21,665 | 775 | 3.5% | 1.1% | |
| Acute combined systolic and diastolic heart failure | 2,155 | 60 | 2.7% | 0.08% | |
| Acute on chronic combined systolic and diastolic heart failure | 15,060 | 595 | 3.9% | 0.8% | |
| Acute right heart failure | 520 | 45 | 8.6% | 0.06% | |
| Acute on chronic right heart failure | 1,375 | 130 | 9.4% | 0.1% | |
| End-stage heart failure | 605 | 120 | 19.8% | 0.1% | |
| Cardiomyopathies | Dilated cardiomyopathy | 3,290 | 120 | 3.6% | 0.1% |
| Obstructive hypertrophic cardiomyopathy | 3,420 | 50 | 1.4% | 0.06% | |
| Alcoholic cardiomyopathy | 590 | 20 | 3.3% | 0.02% | |
| Cardiomyopathy, unspecified | 1,450 | 85 | 5.8% | 0.1% | |
| Ischemic cardiomyopathy | 3,450 | 235 | 6.8% | 0.3% | |
| Coronary artery diseases and associated complications | Unstable angina | 6,630 | 5 | 0.1% | 0.006% |
| Angina pectoris, unspecified | 2,300 | 5 | 0.2% | 0.006% | |
| ST elevation myocardial infarction | 156,385 | 13055 | 8.3% | 17.8% | |
| Non-ST elevation myocardial infarction | 406,815 | 14125 | 3.4% | 19.2% | |
| Myocardial infarction type 2 | 9,735 | 295 | 3% | 0.4% | |
| Ventricular septal defect as current comp following AMI | 125 | 35 | 28% | 0.04% | |
| Thrombosis of atrium/auric append/ventricle as comp following AMI | 110 | 5 | 4.5% | 0.006% | |
| Takotsubo syndrome | 9,110 | 210 | 2.3% | 0.2% | |
| Rupture of card wall w/o hemopericardium as current comp following AMI | 230 | 165 | 71.7% | 0.2% | |
| Rupture of chorda tendineae as current comp following AMI | 95 | 30 | 31.5% | 0.04% | |
| Rupture of papillary muscle as current comp following AMI | 185 | 75 | 40.54% | 0.1% | |
| Post-infarction angina | 1,735 | 5 | 0.2% | 0.006% | |
| Coronary artery dissection and aneurysm | Coronary artery aneurysm | 175 | 10 | 5.7% | 0.01% |
| Coronary artery dissection | 885 | 20 | 2.2% | 0.02% | |
| Pulmonary artery diseases | Primary pulmonary hypertension | 1,225 | 85 | 6.9% | 0.1% |
| Pulmonary hypertension, unspecified | 4,650 | 145 | 3.1% | 0.1% | |
| Secondary pulmonary arterial hypertension | 2,650 | 195 | 7.3% | 0.2% | |
| Pulmonary hypertension due to left heart disease | 855 | 60 | 7% | 0.08% | |
| Pulmonary hypertension due to lung diseases and hypoxia | 1,205 | 105 | 8.7% | 0.1% | |
| Chronic thromboembolic pulmonary hypertension | 935 | 65 | 5.3% | 0.08% | |
| Chronic Cor pulmonale | 620 | 20 | 3.2% | 0.02% | |
| Chronic pulmonary embolism | 875 | 10 | 1.1% | 0.01% | |
| Aneurysm of pulmonary artery | 165 | 10 | 6% | 0.01% | |
| Pericardial diseases | Infective pericarditis | 1,880 | 15 | 0.7% | 0.02% |
| Acute pericarditis, unspecified | 7,825 | 85 | 1% | 0.1% | |
| Chronic constrictive pericarditis | 730 | 30 | 4.1% | 0.04% | |
| Hemopericardium, not elsewhere classified | 375 | 45 | 12% | 0.06% | |
| Pericardial effusion (noninflammatory) | 21,310 | 750 | 3.5% | 1% | |
| Post-cardiotomy syndrome | 685 | 5 | 7.2% | 0.006 | |
| Myocarditis | Infective myocarditis | 1,420 | 15 | 1.1% | 0.02% |
| Acute myocarditis, unspecified | 1,245 | 20 | 1.6% | 0.02% | |
| Myocarditis, unspecified | 2,545 | 15 | 0.5% | 0.02% | |
| Arrhythmias | Atrioventricular block, first degree | 1,785 | 15 | 0.8% | 0.02% |
| Atrioventricular block, second degree | 14,705 | 120 | 0.8% | 0.1% | |
| Atrioventricular block, complete | 42,880 | 1095 | 2.5% | 1.4% | |
| Bifascicular block | 965 | 15 | 1.5% | 0.02% | |
| Long QT syndrome | 600 | 30 | 5% | 0.04% | |
| Cardiac arrest, cause unspecified | 15,435 | 11115 | 72% | 15.1% | |
| Supraventricular tachycardia | 37,065 | 345 | 0.93% | 0.4% | |
| Ventricular tachycardia | 48,475 | 2430 | 5% | 3.3% | |
| Atrial fibrillation | 390,370 | 1525 | 0.3% | 2% | |
| Atrial flutter | 52,540 | 405 | 0.7% | 0.5% | |
| Ventricular fibrillation | 13,220 | 3490 | 26.3% | 4.7% | |
| Sick sinus syndrome | 38,020 | 335 | 0.8% | 0.4% | |
| Thoracic aortic dissection and aneurysm | Dissection of thoracic aorta | 11,150 | 1335 | 11.9% | 1.8% |
| Thoracic aortic aneurysm, ruptured | 815 | 200 | 24.5% | 0.2% | |
| Thoracic aortic aneurysm, without rupture | 10,085 | 230 | 2.2% | 0.3% | |
| Chest pain | Precordial pain | 3,395 | 10 | 0.2% | 0.01% |
| Other chest pain | 76,680 | 55 | 0.1% | 0.07% | |
| Chest pain, unspecified | 41,690 | 65 | 0.1% | 0.08% | |
| Cardiogenic shock | Cardiogenic shock | 1,500 | 705 | 47% | 0.9% |
| Intracardiac thrombosis | Intracardiac thrombosis | 2,060 | 45 | 2.1% | 0.06% |
Our study showed that the highest in-hospital mortality rates were found in patients admitted with cardiac arrest (72%), rupture of the cardiac wall as a complication of acute myocardial infarction (71.70%), cardiogenic shock (47%), rupture of papillary muscle as a complication of acute myocardial infarction (40.54%), rupture of chorda tendineae as a complication of acute myocardial infarction (30.51%), ventricular septal defect as a complication of acute myocardial infarction (28%), ventricular fibrillation (26.30%), ST-elevation myocardial infarction (STEMI) involving the left main coronary artery (26.10%), ruptured thoracic aortic aneurysm (24.50%), end stage heart failure (19.80%), STEMI of unspecified site (13.50%), hemopericardium (12%), dissection of thoracic aorta (11.90%), STEMI involving other coronary artery of the anterior wall (9.70%), acute on chronic right heart failure (9.40%), pulmonary hypertension due to lung disease (8.70%), acute right heart failure (8.60%), STEMI involving the left anterior descending coronary artery (7.40%), and nonrheumatic valve mitral stenosis (7.30%) (Table 1) [3-6].
However, from the quantitative standpoint, the most common causes of in-hospital mortality from CVDs were non-ST-elevation myocardial infarction (NSTEMI) (19.20%), STEMI (17.80%), cardiac arrest (15.10%), hypertensive heart disease with heart failure (12.50%), ventricular fibrillation (4.70%), ventricular tachycardia (3.30%), and aortic stenosis (2.10%) of all CVD-induced in-hospital mortality (Table 1) [3-6].
The analysis of in-hospital mortality risk factors and demographics in patients admitted with all CVDs combined by comparing them to patients who survived the hospitalization where P-value <0.05 was statistically significant: most of these patients were aged 65 years or older (RR = 1.5185, P < 0.0001), male (RR = 1.0846, P <0.0001), and of Asian race (RR = 1.2857, P <0.0001). A significant proportion resided in not metropolitan or micropolitan counties (RR = 1.0734, P = 0.0192) and were admitted to urban teaching hospitals (RR = 1.1464, P < 0.0001), particularly in the western region (RR = 1.0939, P < 0.0001) (Table 2) [3-6].
Table 2. Demographics and risk factors of all CVDs in-hospital mortality combined compared to all patients admitted with CVDs.
The study used data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research, Quality HCUP Databases of 2021, HCUP tools and products including Clinical Classifications Software (CCS) or Clinical Classifications Software Refined (CCSR), Elixhauser Comorbidity Software and HCUP-NIS 2016-2021 Diagnoses and Procedures Frequency Sheet [3-6].
| Risk factors | Total number of patients admitted to the hospitals with CVDs | Number of patients who died during the hospitalization | Number of patients with all CVDs who survived the hospitalization | Probability | Relative risk | P-value | |
| Age | ≥65 | 289,866 | 10,338 | 279,528 | 3.50% | 1.5185 | <0.0001 |
| <65 | 172,605 | 4,054 | 168,551 | 2.30% | 0.6586 | <0.0001 | |
| Gender | Male | 253,586 | 8,178 | 245,408 | 3.20% | 1.0846 | <0.0001 |
| Female | 208,779 | 6,208 | 202,571 | 2.97% | 0.922 | <0.0001 | |
| Race | White | 320,938 | 9,914 | 311,024 | 3.08% | 0.9761 | 0.1749 |
| Black | 65,958 | 1,725 | 64,231 | 2.60% | 0.8186 | <0.0001 | |
| Hispanic | 39,215 | 1,147 | 38,068 | 2.92% | 0.9347 | 0.0259 | |
| Asian or Pacific Islander | 10,761 | 430 | 10,331 | 3.90% | 1.2929 | <0.0001 | |
| Native American | 2,359 | 72 | 2,284 | 3.05% | 0.982 | 0.8756 | |
| Other | 11,254 | 472 | 10,782 | 4.19% | 1.2857 | <0.0001 | |
| Hospital location | Rural | 36,195 | 1,037 | 35,158 | 2.86% | 0.9145 | 0.0049 |
| Urban non-teaching | 82,107 | 2,290 | 79,817 | 2.78% | 0.8765 | <0.0001 | |
| Urban teaching | 344,147 | 11,065 | 333,082 | 3.21% | 1.1464 | <0.0001 | |
| Hospital region | Northeast | 85,551 | 2,607 | 82,944 | 3.04% | 0.9746 | 0.2278 |
| Midwest | 102,702 | 3,083 | 99,619 | 3.00% | 0.9549 | 0.0213 | |
| South | 190,530 | 5,901 | 184,629 | 3.09% | 0.9919 | 0.6277 | |
| West | 83,687 | 2,801 | 80,886 | 3.34% | 1.0939 | <0.0001 | |
| Patient location | Central counties of metro areas of ≥1 million population | 122,291 | 3,793 | 118,498 | 3.10% | 0.9952 | 0.7973 |
| Fringe counties of metro areas of ≥1 million population | 114,344 | 3,290 | 111,054 | 2.87% | 0.9021 | <0.0001 | |
| Counties in metro areas of 50,000-249,999 population | 46,371 | 1,410 | 44,961 | 3.04% | 0.9746 | 0.3513 | |
| Counties in metro areas of 250,000-999,999 population | 97,201 | 3,182 | 94,019 | 3.27% | 1.0668 | 0.0011 | |
| Micropolitan counties | 44,891 | 1,481 | 43,410 | 3.29% | 0.9697 | 0.2525 | |
| Not metropolitan or micropolitan counties | 34,618 | 1,150 | 33,468 | 3.32% | 1.0734 | 0.0192 | |
| Smoking | Present | 80,933 | 1,775 | 79,158 | 2.19% | 0.6629 | <0.0001 |
| Alcohol | Present | 20,720 | 609 | 20,111 | 2.93% | 0.942 | 0.1432 |
| Hyperlipidemia | Present | 277,545 | 6,496 | 271,049 | 2.34% | 0.5459 | <0.0001 |
| Diabetes | Present | 169,028 | 5,456 | 163,572 | 3.22% | 1.6073 | <0.0001 |
| Hypertension | Present | 300,301 | 8,996 | 291,305 | 2.99% | 0.8994 | <0.0001 |
The highest incidence of CVD-induced in-hospital mortality among patients admitted to urban teaching hospitals can be explained by the complexity of cardiovascular cases either directly admitted or transferred to the teaching hospitals.
Our study showed that patients with all CVD-induced in-hospital mortality combined were found to have higher association with diabetes (RR = 1.6073, P < 0.0001) but lower association with hypertension (RR = 0.8994, P < 0.0001), hyperlipidemia (RR = 0.5459, P < 0.0001), alcohol (RR = 0.942, P = 0.1432), and smoking (RR = 0.6629, P < 0.0001) (Table 2) [3-6].
Despite hypertension, hyperlipidemia, and smoking being major risk factors for coronary artery diseases, they are not associated with CVD-induced in-hospital mortality due to the fact of combining all cardiovascular diseases as a common factor, which includes coronary and noncoronary diseases.
Discussion
During the 20th century, there was a transition from communicable diseases to noncommunicable diseases as the most common causes of death. Public health and medical technologies dramatically reduced the communicable diseases ravages worldwide in little over a century by reducing involuntary exposure to pathogens (e.g., safer water, sewer, and food security systems; vector control), reducing the susceptibility of individuals to infection if exposed to the pathogen (e.g., immunization), and improving survivability among infected individuals (antibiotics) [7]. Currently, CVDs are non-communicable diseases and the leading cause of death worldwide [8-10].
The causes and risk factors of CVDs can be multifactorial, including genetics and lifestyle. Studies estimated that CVD heritability ranges between 40% and 50% [11-13]. Genetic testing can help in the early detection of CVDs [14]. Adequate lifestyle modification, such as physical activity, a healthy diet, weight loss, and smoking cessation, helps to reduce the risk of CVDs [15,16].
Individuals with preexisting or undiagnosed diseases who are at higher risk of subsequent morbidity or mortality may be more likely to be inactive. Therefore, the perceived benefits of exercise may merely represent the absence of such concomitant disease [17].
Diabetes is one of the most important risk factors for CVDs. It increases the risk for ischemic heart disease, and it causes neuropathy, retinopathy, and nephropathy, which worsens the morbidity of CVD patients. Diabetes is estimated as the sixth leading cause of disability worldwide [18]. Studies showed that one out of every two patients with diabetes is unaware of his disease, and even well-known diabetic patients might not be aware of the role of diabetes in CVD [19-21]. Diabetes control is more likely to reduce the CVD risk and mortality [22].
The Diabetes Control and Complications Trial (DCCT) showed a 41% risk reduction of cardiovascular events in type 1 diabetes. Moreover, during the post-trial nine-year follow-up observational period of the DCCT-Epidemiology of Diabetes Interventions and Complications (EDIC) trial, despite the loss of the original difference in HbA1c as a consequence of conventional treatment switching to an intensive approach and the less tight glycemic control in patients intensively treated, a risk reduction for any cardiovascular event (42%; P = 0.02) and for nonfatal myocardial infarction, stroke, or death for CVD (57%; P = 0.02) was fully achieved [23].
One of the new medications that help with controlling diabetes has shown an effect on cardiovascular protection and improving mortality in heart failure patients [24].
Frequent hospitalization can predict increased mortality risk. One of the most important measures for these patients with frequent hospitalization is the proper transition between hospital and home. Adequate care plans and close follow-up after discharge will help to reduce hospitalization and mortality [25]. Goals of care discussion and advanced care planning should be addressed early for patients with end-stage CVDs, like end-stage heart failure patients [26].
For example, in patients with HF, the use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and use an integrated care approach. Healthcare providers are using transition programs to achieve their goals. The comprehensive transition of care planning includes determining needs and resources in high-risk patients such as home health, palliative, or hospice care [27].
Medication nonadherence is another problem that might contribute to increased mortality in CVD patients [28]. Medication adherence should be addressed with every follow-up for these patients. Telehealth has played a role in patients' self-care adherence [29].
Studies showed a relationship between in-hospital mortality and nursing level of education [30]. According to Kalisch and Xie [31], missed nursing care is substantial, and similar levels are found in a number of hospitals. The reasons for missed nursing care in hospitals include staffing resources, material resources, and communication issues. The higher the staffing levels, the fewer occurrences of missed nursing care. Missed nursing care predicts adverse events (i.e., falls, pressure ulcers, new infections, and patient mortality) [31].
New and modern technologies, such as genetic testing and implantable devices, can help reduce the mortality risk from CVDs [32]. These implantable devices include pacemakers, defibrillators, and left ventricular assist devices [33].
Genetic tests can aid in establishing a diagnosis, guide medical management, and add to our understanding of inheritance patterns and for family counseling purposes. However, the utility of genetic testing depends on a multitude of factors, including but not limited to the specific condition, the patient's age, and the testing methodology [34].
Using modern technology in communication with patients can help reduce mortality. For example, sending text messages to patients with CVD can improve their control of risk factors [35].
Limitations
Some mild cardiovascular diseases (Table 1) with meager in-hospital mortality rates might not be even the primary cause of death for these patients, and their in-hospital mortality might be due to another pathology during the hospitalization course. For instance, in cases where patients with essential hypertension die during hospitalization, the cause of death likely differs from the primary diagnosis at admission. Also, some common CVD-induced in-hospital mortality can be secondary to a primary CVD that is not mentioned. For example, if patients were admitted with cardiac arrest and died during the hospitalization, it is probably secondary to a primary CVD that led to cardiac arrest and has not been mentioned.
Conclusions
Our study showed that the most common causes of in-hospital mortality from CVDs were in patients admitted with NSTEMI (19.20%), STEMI (17.80%), cardiac arrest (15.10%), hypertensive heart disease with heart failure (12.50%), ventricular fibrillation (4.70%), ventricular tachycardia (3.30%), and aortic stenosis (2.10%) of all CVD-induced in-hospital mortality. However, the highest rates of CVD-induced in-hospital mortality are in patients admitted with cardiac arrest (72%), rupture of the cardiac wall as a complication of acute myocardial infarction (71.70%), cardiogenic shock (47%), rupture of papillary muscle as a complication of acute myocardial infarction (40.54%), rupture of chorda tendineae as a complication of acute myocardial infarction (30.51%), ventricular septal defect as a complication of acute myocardial infarction (28%), ventricular fibrillation (26.30%), STEMI involving the left main coronary artery (26.10%), ruptured thoracic aortic aneurysm (24.50%), end-stage heart failure (19.80%), STEMI of unspecified site (13.50%), hemopericardium (12%), dissection of thoracic aorta (11.90%), STEMI involving other coronary artery of the anterior wall (9.70%), acute on chronic right heart failure (9.40%), pulmonary hypertension due to lung disease (8.70%), acute right heart failure (8.60%), STEMI involving the left anterior descending coronary artery (7.40%), and nonrheumatic valve mitral stenosis (7.30%).
Demographically, the highest in-hospital mortality rates of all patients with CVD combined were observed in patients aged ≥ 65 years, predominantly Asian and male. The most common risk factor for all CVD-induced in-hospital mortality is diabetes.
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Michael Morgan, Vikas Yellapu, Cara Ruggeri, Daryn Short
Acquisition, analysis, or interpretation of data: Michael Morgan, Vikas Yellapu, Cara Ruggeri, Daryn Short
Drafting of the manuscript: Michael Morgan, Vikas Yellapu, Cara Ruggeri, Daryn Short
Critical review of the manuscript for important intellectual content: Michael Morgan, Vikas Yellapu, Cara Ruggeri, Daryn Short
References
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