Abstract
Background
Numerous studies have shown conflicting results regarding the natural history and outcomes with alcoholic cardiomyopathy (AC).
Hypothesis
Determining the trends in hospitalization among patients with AC and associated outcomes will facilitate a better understanding of this disease.
Methods
We conducted our analysis on discharge data from the Healthcare Cost and Utilization Project‐Nationwide Inpatient Sample (HCUP‐NIS) from 2002 through 2014. We obtained data from patients aged ≥18 years with diagnosis of “Alcoholic Cardiomyopathy.” Death was defined within the NIS as in‐hospital mortality. By using International Classification of Disease‐9th edition‐Clinical Modification (ICD‐9CM) diagnoses and diagnosis‐related groups different comorbidities were identified.
Results
We studied a total of 45 365 admissions among patients with AC. The absolute number of admissions decreased from 2002 to 2014 (3866‐2834 admissions). In‐hospital mortality was variable throughout study duration without a clinically relevant trend (Mean 4.5%, range 3.6%‐5.6%). The patients were mostly male (87%) and Caucasian (50.5%). Commonest age groups involved were 45‐59 years (46.7%) followed by 60‐74 years (29.2%). Trends in associated comorbidities such as smoking, drug abuse, depression, and hypertension increased over the same time period. Among all admissions, almost half were for cardiovascular etiologies (48.9%) and heart failure (≈24%) was the commonest reason for hospital admission.
Conclusion
While the overall admissions among patients with AC decreased over time, the proportion of patients with high‐risk characteristics such as smoking, depression, and drug abuse increased. Patients aged 45 and older were largely affected and cardiovascular etiologies predominated among causes for admission.
Keywords: alcohol, cardiomyopathy, hospitalizations, mortality
1. INTRODUCTION
Alcoholic cardiomyopathy (AC) is a form of acquired cardiomyopathy associated with both cardiac and skeletal muscle dysfunction among patients who consume >80 g of alcohol per day over a period of 5 years or greater.1 However, the actual amount of alcohol consumed varies widely depending on factors such as gender and rate of metabolism among those who develop AC. AC has emerged as an important cause of heart failure due to the rising awareness of disease and growing interest into its underlying pathophysiology and potential for reversibility. Prior studies conducted within European populations have reported the prevalence of excessive alcohol intake among patients with dilated cardiomyopathy to be 20%2 or as high as 47%,3 depending on the study. Continued efforts have been directed toward understanding factors that predict outcomes among heart failure admissions to reduce associated mortality and rehospitalizations.4, 5, 6, 7, 8 At present, there is minimal evidence available looking into trends associated with AC‐related hospitalizations. Studies regarding the natural history and prognosis of AC have been conflicting with some predicting a better prognosis whereas others showing higher mortality compared to idiopathic dilated cardiomyopathy. Alcohol cessation in this setting appears to significantly improved the long term outcomes with AC.9 With emerging data demonstrating an increase in alcohol consumption, high‐risk drinking, and alcohol abuse disorders,10 addressing AC assumes greater importance. Our study aims to identify recent trends in AC‐related hospitalizations and in‐hospital mortality within this patient subset using a large US national database.
2. METHODS
We conducted our analysis on unweighted hospital discharge data from the Healthcare Cost and Utilization Project‐Nationwide Inpatient Sample (HCUP‐NIS from 2002 through 2014. The Nationwide Inpatient Sample (NIS) is the largest, publicly available, all‐payer inpatient database in the United States. Annually, the NIS is composed of discharge‐level data from roughly 8 million hospitalizations and approximates a stratified sample of 20% of community hospitals in the United States. Each hospitalization within the database contains clinical and resource‐use information. Patients' diagnoses are documented in parallel, as both International Classification of Disease‐9th edition‐Clinical Modification (ICD‐9‐CM) and clinically meaningful clusters of ICD‐9‐CMs, termed Clinical Classification Software (CCS) codes. Core hospital stay files contain details on patient demographics (eg, age, sex, and race), ICD‐9‐CM diagnosis codes (15‐30, depending on the year), comorbidities, length of hospital stay, discharge status, in‐hospital mortality, and total charges. A comprehensive synopsis on NIS data is available at http://www.hcup-us.ahrq.gov. Patients aged ≥18 years who were admitted and had a diagnosis of “Alcoholic Cardiomyopathy” (ICD‐9CM codes 425.5) were included in the study. Patients with missing mortality data and those transferred out of hospital were excluded from the analysis. Trends in admissions from 2002 to 2014 were examined. Death was defined within the NIS as in‐hospital mortality. By using ICD‐9CM diagnoses and diagnosis‐related groups different comorbidities were identified (see Appendix).
Demographics and baseline characteristics were summarized using descriptive statistics. Continuous data were expressed as mean ± one SD and analyzed using the student's t test or analysis of variance. Pearson's χ 2 test was used for analysis of categorical variables. Trend analyses were performed using the Mantel‐Haenszel test of trend. Our primary outcome was in‐hospital mortality. Results were considered statistically significant for P values <0.05. IBM spss V23.0 (Armonk, New York) was used to perform data analysis.
3. RESULTS
We identified a total of 45 365 patients with an associated diagnosis of AC. There were a total of 3866 admissions in 2002 compared with 2843 in 2014 as seen in Figure 1. The trend for an overall reduction in hospitalizations among AC patients was most notable following the year 2009. A large majority of the admitted patients were male (87%) and Caucasian race comprised 50.5% of all admissions as shown in Table 1. Those aged 45 to 59 years formed the largest age group (46.7%) followed by the 60 to 74‐year‐old age group (29.2%), together accounting for >75% of all admissions. Rate of in‐hospital mortality was 5.3% during the year 2002, fell to a nadir of 3.6% in year 2006, peaked at 5.6% in 2013, with overall hospital mortality trend between 2002 and 2014 showing marked variability instead of a clear pattern.
Figure 1.
Graph showing trends in hospitalizations and death for alcoholic cardiomyopathy
Table 1.
Demographics, annual hospitalizations, and in‐hospital mortality among adults with alcoholic cardiomyopathy from 2002 to 2014
| Variable | Year | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | Average | |
| Annual hospitalizations | 3866 | 3811 | 3780 | 3801 | 3833 | 3782 | 3887 | 3712 | 3036 | 3237 | 2942 | 2835 | 2843 | 45 365 (total) |
| In‐hospital mortality (%) | 5.3 | 4.3 | 4.8 | 4.1 | 3.6 | 3.9 | 4.2 | 3.9 | 5.1 | 5.1 | 4.6 | 5.6 | 4.9 | 4.5 |
| Male (%) | 87.5 | 86.9 | 28.88 | 87.2 | 86.1 | 87.4 | 85.5 | 87.3 | 87.4 | 85.0 | 87.1 | 87.6 | 87.8 | 87 |
| Caucasian (%) | 43.9 | 44.5 | 44.5 | 46.3 | 48.3 | 45.9 | 50.3 | 53.6 | 55.2 | 55.9 | 58.9 | 58.2 | 58.3 | 50.5 |
| African‐American (%) | 19.9 | 18.3 | 20.1 | 16.8 | 18 | 18.4 | 17.2 | 20.0 | 22.7 | 22.6 | 22.1 | 22.8 | 22.1 | 19.9 |
| Hispanic (%) | 5.3 | 7.2 | 6.5 | 8.1 | 7.2 | 6.7 | 6.7 | 6.8 | 7.6 | 7.3 | 8.5 | 9.2 | 8.8 | 7.3 |
| Other ethnicity/missing (%) | 30.9 | 30.0 | 28.9 | 28.8 | 26.5 | 29 | 25.8 | 19.6 | 14.5 | 14.2 | 10.5 | 9.7 | 10.8 | 22.4 |
| Age 18 to 44 (%) | 19.3 | 16.8 | 18.1 | 17.3 | 16.4 | 15.7 | 16 | 15.2 | 15.8 | 17 | 16.4 | 16.9 | 16.1 | 16.7 |
| Age 45 to 59 (%) | 42.5 | 44.7 | 44.8 | 45.9 | 47.4 | 46.4 | 45.0 | 46.9 | 49.4 | 49.6 | 51.1 | 47.7 | 48.9 | 46.7 |
| Age 60 to 74 (%) | 29.0 | 29.8 | 28.5 | 28.4 | 29.3 | 29.4 | 30.3 | 30.5 | 29.3 | 27.5 | 28.1 | 30.2 | 29.7 | 29.2 |
| Age 75 and above (%) | 9.2 | 8.7 | 8.5 | 8.4 | 6.9 | 8.5 | 8.7 | 7.4 | 5.5 | 5.9 | 4.4 | 5.3 | 5.3 | 7.3 |
The prevalence of comorbidities such as chronic pulmonary disease, smoking, liver disease, depression, drug abuse, coagulopathy, and hypertension are shown in Table 2. The rate of smoking more than doubled from 27.4% to 59.1% from 2002 to 2014 (Ptrend <0.01). The prevalence of drug abuse and depression has also doubled from 6% to near 13% in these patients between 2002 and 2014 (Ptrend <0.01) (Figure 2). The rate of liver disease gradually increased over the study period from 15% to 19% (Ptrend <0.01). Hypertension is another comorbidity that doubled in rate from 32% to 60% (Ptrend <0.01). On the other hand, prevalence of chronic pulmonary disease affected close to 31% of the admissions with associated AC with minimal variation in prevalence rates over the years. Among all admissions, almost half were for cardiovascular etiologies (22 177 admissions, 48.9%) and heart failure (24%) was the most common reason for hospital admission.
Table 2.
Associated comorbidities among adults hospitalized for alcoholic cardiomyopathy from 2002 to 2014
| Variable | Year | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | Average | |
| HIV/AIDS (%) | 0.4 | 0.3 | 0.1 | 0.3 | 0.2 | 0.2 | 0.2 | 0.2 | 0.2 | 0.1 | 0.1 | 0.1 | 0.2 | 0.2 |
| Deficiency anemias (%) | 10.2 | 10.2 | 10.5 | 10.5 | 11.9 | 14.0 | 16.3 | 16.9 | 16.8 | 19.4 | 18.0 | 19.6 | 18.8 | 14.5 |
| Chronic pulmonary disease (%) | 30.5 | 31.6 | 29.9 | 31.3 | 33.8 | 32.7 | 30.2 | 30.6 | 29.6 | 29.1 | 29.3 | 28.8 | 29.8 | 30.7 |
| Smoking (%) | 27.4 | 27.3 | 26.9 | 32.4 | 34.3 | 36.0 | 38.3 | 45.5 | 52.9 | 51.1 | 53.7 | 55.1 | 59.1 | 40.3 |
| Coagulopathy (%) | 7.2 | 7.4 | 8.1 | 8.8 | 8.7 | 10.1 | 10.5 | 12.2 | 12.4 | 14.8 | 14.0 | 14.5 | 16.0 | 10.9 |
| Depression (%) | 6.2 | 5.4 | 5.7 | 7.0 | 7.6 | 9.1 | 9.5 | 9.9 | 11.4 | 13.1 | 12.7 | 12.1 | 13 | 9.2 |
| Drug abuse (%) | 6.5 | 7.6 | 8.2 | 10.2 | 10.0 | 10.8 | 8.9 | 9.6 | 11.0 | 10.9 | 12.9 | 12.9 | 13.9 | 10 |
| Hypertension (%) | 32.1 | 37.8 | 40.2 | 42.4 | 45.8 | 47 | 50.8 | 50.3 | 54.7 | 56.6 | 57.7 | 58.4 | 60.0 | 48.1 |
| Liver disease (%) | 15.2 | 14.9 | 15.3 | 16.2 | 15.5 | 15.7 | 16.9 | 17.6 | 17.1 | 18.4 | 20.3 | 19.5 | 19.8 | 16.9 |
Figure 2.
Graph showing trends in depression, drug abuse, and smoking (smoking represented on right vertical axis. Drug abuse and depression represented on left vertical axis)
The incidence of cardiorespiratory failure dramatically increased over time (9%‐47%) as noted in Table 3. The rates of atrial fibrillation/flutter remained stable at 30% throughout the study period. Rates of acute venous thromboembolism within this patient population remain low. The average hospitalization‐related costs increased significantly during the study period ($30 753‐$62 619, Ptrend <0.01).
Table 3.
In‐hospital events for hospital admission among adults with alcoholic cardiomyopathy from 2002 to 2014
| Variable | Year | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | Average | |
| Acute cardiorespiratory failure (%) | 9.0 | 9.6 | 9.2 | 11.0 | 13.1 | 16.1 | 26.6 | 32.3 | 35.5 | 37.4 | 38.7 | 43.5 | 47.2 | 23.9 |
| Ventilator use (%) | 9.05 | 8.3 | 8.4 | 8.4 | 8.5 | 9.1 | 10.5 | 9.5 | 9.5 | 9.2 | 8.5 | 10.2 | 9.3 | 9.1 |
| Atrial fib/flutter (%) | 27.8 | 30.1 | 30.3 | 31.7 | 31.1 | 30.7 | 29.3 | 30.4 | 31.3 | 33.6 | 34.0 | 34.3 | 34.2 | 31.2 |
| Acute DVT (%) | 0.0 | 0.1 | 0.2 | 0.9 | 1.0 | 1.1 | 1.2 | 1.4 | 1.2 | 1.1 | 1.7 | 1.0 | 1.6 | 0.9 |
| Acute PE (%) | 0.6 | 0.8 | 0.7 | 0.9 | 0.7 | 1.2 | 1.1 | 1.3 | 1.4 | 1.3 | 1.4 | 1.3 | 1.6 | 1.1 |
| Total hospital charges (US $) | 30 753 | 35 852 | 34 072 | 36 456 | 42 404 | 44 343 | 50 032 | 53 630 | 50 433 | 52 662 | 54 405 | 59 541.3 | 62 619 | 44 234 |
Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism.
4. DISCUSSION
There are four main findings from our study. First, the number of admissions with an associated diagnosis of AC has declined slightly between 2002 and 2014. Secondly, rate of in‐hospital mortality among these admissions varied widely through the years without a clinically significant uptrend or downtrend. Third, proportion of patients belonging to Caucasian race and associated comorbidities including smoking, drug abuse, depression, and hypertension have significantly increased over the time period (Figure 2). Fourth, acute heart failure was the commonest etiology for admission in a quarter of the patients and half of all admissions occurred for cardiovascular etiologies.
The patterns of decline in hospital admissions with an accompanying variable but flat rate of in‐hospital mortality during the study duration might be due to advances in outpatient and inpatient healthcare with greater awareness of the condition within the medical community. It is likely that increasingly sicker patients were admitted over time, as can be noted in the increased rates for most comorbidities over time. The lower rates of AC‐related hospitalization also coincides with the general decreasing trend in the annual per capita consumption of alcohol in the United States, which has plateaued recently since the year 2007.11 However, this decrease in AC‐related hospitalization is likely multifactorial and additional factors such as comorbidity burden, social support, insurance coverage, and healthcare utilization behaviors may also have played a role.6, 12 Nevertheless, the importance of reducing alcohol consumption to help modify the disease course9, 13 in an attempt to reduce mortality is paramount. The presence of continued alcohol consumption might be getting in the way of prognostic improvement, despite ongoing advancements in current heart failure medical therapy. Meanwhile, survey data has shown that compared to the early 2000s, since 2012 there has been an increase in alcohol use, high‐risk drinking, and alcohol abuse disorders. This increase was found to be greatest among women, older adults, racial/ethnic minorities, and individuals with lower educational level and family income.10 Therefore, with this recently increasing trend in alcohol consumption, it will be important to look into the trends of AC‐related admissions in the next 5 to 10 years.
Majority of admitted AC patients were male. Women tend to have lower rates of alcohol consumption, binge drinking, and other alcohol‐related issues although they are more susceptible to developing alcoholic cardiomyopathy (AC) at smaller total life time doses of alcohol use.14, 15 Majority of the hospitalizations for AC over the last 13 years have been in the middle to elderly age groups. This is consistent with recent data about increased alcohol consumption among the elderly population.10 While preventative education starting at an early age remains important, our findings highlight the increased susceptibility of the older population (45‐59 years) to the adverse effects of alcohol. With age, there is an incremental loss of lean body mass and concomitant reduction of volume of distribution leading to higher blood alcohol levels. Further, delayed gastric and hepatic metabolism of substances, coupled with increasing poly‐pharmacy results in an increased susceptibility of these patients to alcohol‐induced adverse effects such as AC.16
The uptrend for admissions among Caucasian patients, increased from approximately 40% to near 60% between 2002 and 2014. Both African American and Hispanic patients also saw slight uptrend in the proportion of patients admitted, but the absolute percent increase by 2014 was much smaller in comparison. Another study indicated a decrease in the general hospitalization rates in heart failure across all races over the past couple of years.17 These differences could be attributed to racial disparities in access to healthcare leading to different rates of utilization of healthcare services. The patterns of alcohol consumption among different ethnic groups are also different.10 It must be noted that though the proportion of certain racial trends increased from 2002 to 2014, the absolute number of patients in most groups did not change by much considering the downtrend in number of overall burden of hospitalizations.
The prevalence of chronic pulmonary diseases among patients with AC was approximately 30% and has remained unchanged through the years studied. Meanwhile, trends in smoking had nearly doubled. This may reflect the likely high prevalence of concomitant tobacco use in this population as the neurobiological mechanisms and the psychosocial triggers involved in alcohol and nicotine use share remarkable similarity.18 It is worthwhile to note that depression was also highly prevalent and doubled from 6.2% to 13% over the time period. This possibly reflects concomitant maladaptive coping behaviors and cocausation with depression precipitating alcohol use and vice versa.19 Rates of hypertension, however, have doubled from 30% to 60% over the studied timeframe. This requires close attention, considering the ill effect of high blood pressure on the cardiovascular system. The rate of liver disease including but not limited to cirrhosis in our cohort was between 15% and 19%. This is in comparison to other population based studies where they estimated the rates of liver cirrhosis to be as low as 0.27% and as high as 7% in ethnic minorities.20, 21 Rate of liver disease is expectedly higher in our population as we selected specifically patients with diagnosis of alcoholic cardiomyopathy. However, this data does not differentiate between alcoholic and nonalcoholic causes of liver disease and includes non‐cirrhotic liver involvement.
A third of patients hospitalized with AC had concomitant atrial fibrillation. This is important as it was found that among patients with alcohol cardiomyopathy, one of the factors independently associated with death or subsequent cardiac transplantation was atrial fibrillation.13 The rates of acute respiratory failure have increased over the studied time frame, this may partly be due to the concomitant doubled rates of smoking, advances in diagnosis, prompt recognition, and management in terms of supportive mechanical ventilation. The cost of hospitalization has also increased and almost doubled approximately from $30 000 to $60 000 per hospitalization. This can likely be attributed to the rising healthcare costs and increased severity of illness among presenting patients. Considering that half the admissions were for cardiovascular reasons and a quarter of patients were admitted for acute heart failure, it may be hypothesized that data for other cardiovascular diseases may have a role in preventing admissions and improving outcomes within that subset of the population.5, 7, 22, 23
Our study has several limitations due to the administrative nature of the database and reliance on accuracy of coding. However, these limitations are counterbalanced by the considerable sample size and absence of selection bias. The findings of our study are limited to index stay and cannot be extrapolated to postdischarge events. It is also likely that the actual rate of AC may be underestimated because of undercoding given that a number of patients would present as heart failure exacerbations, thereby altering code used. In addition to this, there is difficulty in actually making the diagnosis of AC itself clinically due to absence of specific diagnostic criteria and the need to rule out other causes of cardiomyopathy as well. However, looking into a big population database might be a good way to study such a difficult to diagnose disease process. We did not include 30‐day mortality in this study, only in‐patient mortality. We were unable to do any subgroup analysis especially to look into whether there is increased mortality among certain population subsets such as those with hypertension and coronary artery disease. We were also not able to further identify the ethnic minorities included under the “other” race category.
In conclusion, our study is unique in that we identified a downtrend in admissions among patients with AC in over a 13‐year period. Half the admissions occurred for cardiovascular etiologies and in‐hospital mortality among all admissions remained fairly unchanged in the absence of a clinically relevant trend. The commonest affected age group was patients in the 45 to 59‐year age group followed by the 60 to 74‐year age group. Comorbidities such as depression are often overlooked and many of these comorbidities could be potentially modifiable risk factors to help curb subsequent cardiovascular sequelae as a result of AC. Further studies are needed to address this subset of the heart failure population and validate the results.
ACKNOWLEDGMENTS
No study specific funding was used to support this work. The authors are solely responsible for the study design, conduct and analyses, and drafting and editing of the manuscript and its final contents. All authors had access to the data and a role in writing the manuscript.
Conflicts of interest
The authors declare no potential conflict of interests.
| Variable | ICD‐9CM codes |
|---|---|
| Hypertension with and without complications, diabetes with and without complications, chronic pulmonary disease, peripheral vascular disorders, renal failure, obesity, coagulopathy, liver disease, depression, valvular disease, drug abuse, alcohol abuse, deficiency anemia, chronic blood loss anemia, collagen vascular disease or rheumatoid arthritis, hypothyroidism, liver disease, lymphoma, metastatic cancer, solid tumor without metastasis, depression, coagulation disorder | Elixhauser comorbidity measures within database |
| Dyslipidemia | 272.0, 272.1, 272.2, 272.3, 272.4 |
| Current or past smoker | 305.1, V158.2 |
| History of stroke without residual defects or transient ischemic attack | V125.4, 438 |
| History of myocardial infarction | 412 |
| History of DVT or PE | V125.1, V125.5 |
| History of GI disease | V127.x |
| Long term antiplatelet use | V586.3, V586.6 |
| Long term anticoagulant use | V586.1 |
| Vasopressor use | Procedure code 00.17 |
| Ventilator use | Procedure codes 967.0, 967.1, 967.2, 960.4, 960.5 |
| Atrial fibrillation or flutter | 427.31, 427.32 |
| Ventricular tachycardia or fibrillation | 427.1, 427.41, 427.42 |
| Coronary artery disease | 414.xx, V458.1, V458.2 |
| Non ST elevation MI | 410.70, 410.71, 410.72 |
| Hypercoagulable disease | 289.81, 289.82, 270.4 |
| Ischemic stroke | 433.x1 |
| Transient ischemic attack | 435.x |
| Shock | 785.5x |
| Percutaneous coronary intervention | Procedure codes 00.66, 17.55, 36.01, 36.02, 36.05, 36.06, 36.07 |
| Coronary artery bypass grafting | Procedure codes 361.x |
| Swan Ganz catheter insertion | 372.1, 372.3, 896.3, 896.4, 896.6, 896.7, 896.8 |
| Intra‐aortic balloon pump use | Procedure code 376.1 |
| Acute mesenteric ischemia | 557.0 |
| Atheroembolism | 445.0x, 445.8x, 444 |
| Hemorrhagic stroke or intracranial bleed | 430, 431, 432.x |
| Gastrointestinal bleeding | 578.0, 578.1, 578.9 |
| Hemoptysis | 786.30, 786.31, 786.39 |
| Unspecified hemorrhage | 459.0 |
| Transfusion of blood products | V58.2, Procedure codes 99.0x |
Ram P, Lo KB, Shah M, Patel B, Rangaswami J, Figueredo VM. National trends in hospitalizations and outcomes in patients with alcoholic cardiomyopathy. Clin Cardiol. 2018;41:1423–1429. 10.1002/clc.23067
Pradhum Ram and Kevin B. Lo contributed equally to this study.
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