Cardiac Tamponade Among Permanent Pacemaker Recipients
What are the trends and predictors of cardiac tamponade among permanent pacemaker (PPM) recipients in the United States between the years of 2008 and 2012?
The National (Nationwide) Inpatient Sample (NIS) database was used to identify PPM implantations and to analyze clinical factors associated with increased risk of tamponade before hospital discharge.
Among 922,549 patients who received PPMs, cardiac tamponade occurred in 2,595 (0.28%) patients. The incidence rate steadily increased from 0.26% in 2008 to 0.35% in 2012 (p < 0.0001). While the mean age and gender distribution did not change over the years, the rate of in-hospital mortality increased among patients who developed tamponade. After multivariate adjustment for patient and hospital characteristics, female sex (odds ratio [OR], 1.23; p = 0.011), dual-chamber pacemakers (OR, 1.68; p < 0.004), and chronic liver disease (OR, 3.18; p < 0.001) were found to be independently associated with greater risk of tamponade. Hypertension (OR, 0.71; p = 0.021) and atrial fibrillation (OR, 0.78; p = 0.002) were associated with a lower odds of tamponade.
The burden of cardiac tamponade associated with PPM implantation has steadily increased in the United States from 2008 to 2012. Female sex, dual-chamber implantations, and chronic liver disease conferred greater risk.
The present study is very concerning, as the NIS database is a robust survey of hospitals across the United States. In merely 4 years, the risk of tamponade increased by 35%. This is not explained by the aging of the population, although increasing comorbidities may have played a role. Some identified risks, such as female gender, have previously been shown to be associated with tamponade after implantable cardioverter-defibrillator (ICD) placement. Unfortunately, anticoagulation data were not available for query in the database. It was around the year span from 2008 to 2012 that many physicians embraced the practice of performing device implantations without warfarin interruption. While studies suggested that maintaining therapeutic international normalized ratio is associated with fewer complications than bridging with heparin, I just wonder if this may have affected how we approach the risks of anticoagulation and antiplatelet drugs in general. The authors indicate that the risk of tamponade was lower in patients with atrial fibrillation, but it remains unknown if this may have been due to single-chamber implantations. It would be very interesting to evaluate the impact that the lead type and size may have had, but unfortunately, this information was not available in the NIS. If we had a nationwide pacemaker database, like we do for ICDs, many of these questions might be answerable.
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