Browsing by Author "Doshi, Rajkumar"

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    Absolute lymphocyte count as a predictor of mortality and readmission in heart failure hospitalization
    (Elsevier, 2022-03-05) Majmundar, Monil; Kansara, Tikal; Park, Hansang; Ibarra, Gabriel; Lenik, Joanna Marta; Shah, Palak; Kumar, Ashish; Doshi, Rajkumar; Zala, Harshvardhan; Chaudhari, Shobhana; Kalra, Ankur; Medicine, School of Medicine
    Background: There is renewed interest in pursuing frugal and readily available laboratory markers to predict mortality and readmission in heart failure. We aim to determine the relationship between absolute lymphocyte count (ALC) and clinical outcomes in patients with heart failure hospitalization. Methods: This was a retrospective cohort study of patients with heart failure. Patients were divided into two groups based on ALC, less than or equal to 1500 cells/mm3 and > 1500 cells/ mm3. The primary outcome was all-cause mortality. We did subgroup analysis based on ejection fraction and studied the association between ALC categories and clinical outcomes. Both ALC groups are matched by propensity score, outcomes were analyzed by Cox regression, and estimates are presented in hazard ratios (HR) and 95% confidence intervals (CI). Results: We included 1029 patients in the pre-matched cohort and 766 patients in the propensity-score matched cohort. The median age was 64 years (IQR, 54-75), and 60.78% were male. In the matched cohort, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality compared with ALC > 1500 cells/mm3 (HR 1.51, 95% CI: 1.17-1.95; P = 0.002). These results were reproducible in subgroups of heart failure. When ALC was divided into four groups based on their levels, the lowest group of ALC had the highest risk of mortality. Conclusions: In patients with heart failure and both subgroups, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality. Patients in lower groups of the ALC categories had a higher risk of mortality.
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    Comparison of 6-Month Outcomes of Endovascular vs Surgical Revascularization for Patients With Critical Limb Ischemia
    (American Medical Association, 2022-08-01) Majmundar, Monil; Patel, Kunal N.; Doshi, Rajkumar; Anantha-Narayanan, Mahesh; Kumar, Ashish; Reed, Grant W.; Puri, Rishi; Kapadia, Samir R.; Jaradat, Ziad A.; Bhatt, Deepak L.; Kalra, Ankur; Medicine, School of Medicine
    Importance: The Bypass Versus Angioplasty for Severe Ischemia of the Leg randomized controlled trial showed comparable outcomes between endovascular revascularization (ER) and surgical revascularization (SR) for patients with critical limb ischemia (CLI). However, several observational studies showed mixed results. Most of these studies were conducted before advanced endovascular technologies were available. Objective: To compare ER and SR treatment strategies for 6-month outcomes among patients with CLI. Design, setting, and participants: This retrospective, population-based cohort study used the Nationwide Readmissions Database to identify 66 277 patients with CLI who underwent ER or SR from January 1, 2016, to December 31, 2018. Data analyses were conducted from January 1, 2022, to February 8, 2022. A propensity score with 1:1 matching was applied. Patients with CLI who underwent ER or SR were identified, and those with missing information on the length of stay and/or younger than 18 years were excluded. Exposures: Endovascular or surgical revascularization. Main outcomes and measures: The primary outcome was a major amputation at 6 months. Significant secondary outcomes were in-hospital and 6-month mortality and an in-hospital safety composite of acute kidney injury, major bleeding, and vascular complication. Subgroup analysis was conducted for major amputation in high-volume centers. Results: A total of 66 277 patients were identified between 2016 and 2018 who underwent ER or SR for CLI. The Nationwide Readmissions Database does not provide racial and ethnic categories. The mean (SD) age of the cohort was 69.3 (12) years, and 62.5% of patients were male. A total of 54 546 patients (82.3%) underwent ER and 11 731 (17.7%) underwent SR. After propensity score matching, 11 106 matched pairs were found. Endovascular revascularization was associated with an 18% higher risk of major amputation compared with SR (997 of 10 090 [9.9%] vs 869 of 10 318 [8.4%]; hazard ratio, 1.18; 95% CI, 1.08-1.29; P = .001). However, no difference was observed in major amputation risk when both procedures were performed in high-volume centers. Endovascular revascularization and SR had similar mortality rates (517 of 11 106 [4.7%] vs 490 of 11 106 [4.4%]; hazard ratio, 1.06; 95% CI, 0.93-1.20; P = .39). However, the ER group had a 17% lower risk of in-hospital safety outcomes compared with the SR group (2584 of 11 106 [23.3%] vs 2979 of 11 106 [26.8%]; odds ratio, 0.83; 95% CI, 0.78-0.88; P < .001). Conclusions and relevance: The results of this study suggest that ER was safer, without any difference in mortality, but ER was associated with an increased risk of major amputation compared with SR. However, the risk of major amputation was similar when both procedures were performed at high-volume centers.
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    Invasive Versus Medical Management in Patients With Chronic Kidney Disease and Non-ST-Segment-Elevation Myocardial Infarction
    (American Heart Association, 2022) Majmundar, Monil; Ibarra, Gabriel; Kumar, Ashish; Doshi, Rajkumar; Shah, Palak; Mehran, Roxana; Reed, Grant W.; Puri, Rishi; Kapadia, Samir R.; Bangalore, Sripal; Kalra, Ankur; Medicine, School of Medicine
    Background: The role of invasive management compared with medical management in patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and advanced chronic kidney disease (CKD) is uncertain, given the increased risk of procedural complications in patients with CKD. We aimed to compare clinical outcomes of invasive management with medical management in patients with NSTEMI‐CKD. Methods and Results: We identified NSTEMI and CKD stages 3, 4, 5, and end‐stage renal disease admissions using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes from the Nationwide Readmission Database 2016 to 2018. Patients were stratified into invasive and medical management. Primary outcome was mortality (in‐hospital and 6 months after discharge). Secondary outcomes were in‐hospital postprocedural complications (acute kidney injury requiring dialysis, major bleeding) and postdischarge 6‐month safety and major adverse cardiovascular events. Out of 141 052 patients with NSTEMI‐CKD, 85 875 (60.9%) were treated with invasive management, whereas 55 177 (39.1%) patients were managed medically. In propensity‐score matched cohorts, invasive strategy was associated with lower in‐hospital (CKD 3: odds ratio [OR], 0.47 [95% CI, 0.43–0.51]; P<0.001; CKD 4: OR, 0.79 [95% CI, 0.69–0.89]; P<0.001; CKD 5: OR, 0.72 [95% CI, 0.49–1.06]; P=0.096; end‐stage renal disease: OR, 0.51 [95% CI, 0.46–0.56]; P<0.001) and 6‐month mortality. Invasive management was associated with higher in‐hospital postprocedural complications but no difference in postdischarge safety outcomes. Invasive management was associated with a lower hazard of major adverse cardiovascular events at 6 months in all CKD groups compared with medical management. Conclusions: Invasive management was associated with lower mortality and major adverse cardiovascular events but minimal increased in‐hospital complications in patients with NSTEMI‐CKD compared with medical management, suggesting patients with NSTEMI‐CKD should be offered invasive management.