BackgroundIn ST-elevation myocardial infarction (STEMI), acute kidney injury (AKI) may increase subsequent morbidity and mortality. Still, it remains difficult to predict AKI risk in these patients. We sought to 1) determine the frequency and clinical outcomes of AKI and, 2) develop, validate and compare a web-based tool for predicting AKI.Methods & findingsIn a racially diverse series of 1144 consecutive STEMI patients, Stage 1 or greater AKI occurred in 12.9% and was severe (Stage 2–3) in 2.9%. AKI was associated with increased mortality (5.7-fold, unadjusted) and hospital stay (2.5-fold). AKI was associated with systolic dysfunction, increased left ventricular end-diastolic pressures, hypotension and intra-aortic balloon counterpulsation. A computational algorithm (UT-AKI) was derived and internally validated. It showed higher sensitivity and improved overall prediction for AKI (area under the curve 0.76) vs. other published indices. Higher UT-AKI scores were associated with more severe AKI, longer hospital stay and greater hospital mortality.ConclusionsIn a large, racially diverse cohort of STEMI patients, Stage 1 or greater AKI was relatively common and was associated with significant morbidity and mortality. A web-accessible, internally validated tool was developed with improved overall value for predicting AKI. By identifying patients at increased risk, this tool may help physicians tailor post-procedural diagnostic and therapeutic strategies after STEMI to reduce AKI and its associated morbidity and mortality.

BackgroundThere are poorer outcomes following ST elevation myocardial infarction in blacks compared to white patients despite comparable door‐to‐reperfusion time. We hypothesized that delays to hospital presentation may be contributory.Methods and ResultsWe conducted a retrospective analysis of the 1144 patients admitted for STEMI in our institution from 2008 to 2013. The door‐to‐balloon time (D2BT) and symptom‐onset‐to‐door time (SODT) were compared by race. Bivariate analysis was done comparing the median D2BT and SODT. Stratified analyses were done to evaluate the effect of race on D2BT and SODT, accounting for insurance status, age, sex and comorbidities. The mean age was 59±13 years; 56% of this population was black and 41% was white. Males accounted for 66% of this population. The median D2BT was 60 minutes (interquartile range [IQR] 42–82), and median SODT was 120 minutes (IQR 60–720). There was no significant difference in D2BT by race (P=0.86). Black patients presented to the emergency room (ER) later than whites (SODT=180 [IQR 60–1400] vs 120 [IQR 60–560] minutes, P<0.01) and were more likely to be uninsured (P<0.01). After controlling for comorbidities, insurance, and socioeconomic status, blacks were 60% more likely to present late after a STEMI (OR 1.6, P<0.01). A subset analysis excluding transferred patients showed similar results.ConclusionsBlack patients present later to the ER after STEMI with no difference in D2BT compared to whites. This difference in time to presentation may be one of the factors accounting for poor outcomes in this population.

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Introduction: Time to reperfusion has been shown to be a major predictor of mortality after an ST elevation myocardial infarction (STEMI). Reducing delays to ER presentation should significantly improve time to reperfusion. This study sought to explore the factors that predict late presentation to ER after STEMI. Methods: A retrospective analysis was conducted using data from our tertiary institution 2008-2013. All patients admitted for STEMI during this period were identified. The “Symptom onset to door time (SODT)” was computed and a binary outcome variable (late presentation) was defined as a SODT >180 minutes. The role of patient demographics, insurance status, socioeconomic factors, mode of transportation, and comorbidities were controlled for in the multivariable regression analysis to identify the predictors of late presentation. A subset analysis was conducted excluding patients transferred from outlying facilities. Results: During this period, 1144 patients were admitted for acute STEMI, with 348 of these patients having been transferred from outlying facilities. Mean age was 59 (+12.8) years, males accounted for 67% of this population, 28% had private insurance, 50% had public insurance and 22% were uninsured; 56% of this population was Black. 47.5% of patients presented after 180 minutes. On bivariate analysis, blacks, older age, insurance status, female gender and a family history of coronary artery disease were predictors of late presentation after STEMI. On controlling for confounders in our model, the only significant predictors for late presentation were race and insurance status. A subset analysis excluding transferred patients showed qualitatively similar results. Conclusion: Minority patients, publically insured and uninsured patients are more likely to present late after a STEMI, this difference in time to presentation may be a surrogate for health literacy in these populations and may be ameliorated by better health education.

Objective: We evaluated the safety of baricitinib 4 mg at 24 weeks for the treatment of moderate to severe rheumatoid arthritis (RA).Methods: Multiple databases were searched from inception up to November 26, 2019 for randomized controlled trials comparing baricitinib 4 mg with placebo for the treatment of moderate to severe RA. The safety outcomes of interest were the incidence of serious adverse events, adverse events leading to study discontinuation, all infections, and serious infections. Adjusted risk ratios (RRs) with 95% confidence intervals (CIs) were pooled for safety outcomes. The Cochrane tool was used to assess the risk of bias.Results: This analysis included four randomized controlled trials with 3106 patients. For serious adverse events, the pooled RR (95% CI) was 1.09 (0.76-1.57). For adverse events leading to study discontinuation, the pooled RR (95% CI) was 1.41 (0.94-2.11). For all reported infections, the pooled RR (95% CI) was 1.24 (1.10-1.40), For serious infections, pooled RR (95% CI) was 0.97 (0.51-2.57).Conclusions: Patients with RA taking 4 mg baricitinib daily did have an increased risk of infections; however, the incidence of serious adverse events, adverse events leading to study discontinuation, or serious infections were not significantly different in patients treated with baricitinib 4 mg compared with placebo.