Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: A nationwide electronic health record analysis

George Williams; Vahed Maroufy; Laila Rasmy; Derek Brown; Duo Yu; Hai Zhu; Yashar Talebi; Xueying Wang; Emy Thomas; Gen Zhu; Ashraf Yaseen; Hongyu Miao; Luis Leon Novelo; Degui Zhi; Stacia M. DeSantis; Hongjian Zhu; Jose Miguel Yamal; David Aguilar; Hulin Wu

doi:10.3171/2020.2.FOCUS191002

Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: A nationwide electronic health record analysis

George Williams, Vahed Maroufy, Laila Rasmy, Derek Brown, Duo Yu, Hai Zhu, Yashar Talebi, Xueying Wang, Emy Thomas, Gen Zhu, Ashraf Yaseen, Hongyu Miao, Luis Leon Novelo, Degui Zhi, Stacia M. DeSantis, Hongjian Zhu, Jose Miguel Yamal, David Aguilar, Hulin Wu

Research output: Contribution to journal › Article › peer-review

5 Scopus citations

Abstract

OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH. METHODS The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined. RESULTS In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings. CONCLUSIONS In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.

Original language	English
Article number	1002
Journal	Neurosurgical Focus
Volume	48
Issue number	5
DOIs	https://doi.org/10.3171/2020.2.FOCUS191002
State	Published - May 1 2020

Bibliographical note

Funding Information:
The authors acknowledge the contributions from all members of the EHR Working Group at the Center for Big Data in Health Sciences CBD-HS. This project is supported by the CBD-HS at the School of Public Health, University of Texas Health Science Center at Houston (UTHealth), and partially supported (support on data preparation) by the SBMI Data Service Office and Data Science and Informatics Core for Cancer Research (funded by CPRIT grant no. RP170668) at UTHealth. Some of the trainees are supported by the NIH training grant no. 2T32GM074902. Because of the sensitive nature of the data collected for this study, requests to access the data from qualified researchers trained in human subject confidentiality protocols may be sent to Hulin Wu at hulin. wu@uth. tmc. edu.

Publisher Copyright:
© AANS 2020, except where prohibited by US copyright law.

Keywords

Dopamine
Mortality
Norepinephrine
Phenylephrine
Subarachnoid hemorrhage
Vasopressors

ASJC Scopus subject areas

Surgery
Clinical Neurology

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Williams, G., Maroufy, V., Rasmy, L., Brown, D., Yu, D., Zhu, H., Talebi, Y., Wang, X., Thomas, E., Zhu, G., Yaseen, A., Miao, H., Novelo, L. L., Zhi, D., DeSantis, S. M., Zhu, H., Yamal, J. M., Aguilar, D., & Wu, H. (2020). Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: A nationwide electronic health record analysis. Neurosurgical Focus, 48(5), Article 1002. https://doi.org/10.3171/2020.2.FOCUS191002

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abstract = "OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH. METHODS The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined. RESULTS In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings. CONCLUSIONS In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.",

keywords = "Dopamine, Mortality, Norepinephrine, Phenylephrine, Subarachnoid hemorrhage, Vasopressors",

author = "George Williams and Vahed Maroufy and Laila Rasmy and Derek Brown and Duo Yu and Hai Zhu and Yashar Talebi and Xueying Wang and Emy Thomas and Gen Zhu and Ashraf Yaseen and Hongyu Miao and Novelo, {Luis Leon} and Degui Zhi and DeSantis, {Stacia M.} and Hongjian Zhu and Yamal, {Jose Miguel} and David Aguilar and Hulin Wu",

note = "Funding Information: The authors acknowledge the contributions from all members of the EHR Working Group at the Center for Big Data in Health Sciences CBD-HS. This project is supported by the CBD-HS at the School of Public Health, University of Texas Health Science Center at Houston (UTHealth), and partially supported (support on data preparation) by the SBMI Data Service Office and Data Science and Informatics Core for Cancer Research (funded by CPRIT grant no. RP170668) at UTHealth. Some of the trainees are supported by the NIH training grant no. 2T32GM074902. Because of the sensitive nature of the data collected for this study, requests to access the data from qualified researchers trained in human subject confidentiality protocols may be sent to Hulin Wu at hulin. wu@uth. tmc. edu. Publisher Copyright: {\textcopyright} AANS 2020, except where prohibited by US copyright law.",

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Williams, G, Maroufy, V, Rasmy, L, Brown, D, Yu, D, Zhu, H, Talebi, Y, Wang, X, Thomas, E, Zhu, G, Yaseen, A, Miao, H, Novelo, LL, Zhi, D, DeSantis, SM, Zhu, H, Yamal, JM, Aguilar, D & Wu, H 2020, 'Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: A nationwide electronic health record analysis', Neurosurgical Focus, vol. 48, no. 5, 1002. https://doi.org/10.3171/2020.2.FOCUS191002

TY - JOUR

T1 - Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage

T2 - A nationwide electronic health record analysis

AU - Williams, George

AU - Maroufy, Vahed

AU - Rasmy, Laila

AU - Brown, Derek

AU - Yu, Duo

AU - Zhu, Hai

AU - Talebi, Yashar

AU - Wang, Xueying

AU - Thomas, Emy

AU - Zhu, Gen

AU - Yaseen, Ashraf

AU - Miao, Hongyu

AU - Novelo, Luis Leon

AU - Zhi, Degui

AU - DeSantis, Stacia M.

AU - Zhu, Hongjian

AU - Yamal, Jose Miguel

AU - Aguilar, David

AU - Wu, Hulin

N1 - Funding Information: The authors acknowledge the contributions from all members of the EHR Working Group at the Center for Big Data in Health Sciences CBD-HS. This project is supported by the CBD-HS at the School of Public Health, University of Texas Health Science Center at Houston (UTHealth), and partially supported (support on data preparation) by the SBMI Data Service Office and Data Science and Informatics Core for Cancer Research (funded by CPRIT grant no. RP170668) at UTHealth. Some of the trainees are supported by the NIH training grant no. 2T32GM074902. Because of the sensitive nature of the data collected for this study, requests to access the data from qualified researchers trained in human subject confidentiality protocols may be sent to Hulin Wu at hulin. wu@uth. tmc. edu. Publisher Copyright: © AANS 2020, except where prohibited by US copyright law.

PY - 2020/5/1

Y1 - 2020/5/1

N2 - OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH. METHODS The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined. RESULTS In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings. CONCLUSIONS In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.

AB - OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH. METHODS The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined. RESULTS In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings. CONCLUSIONS In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.

KW - Dopamine

KW - Mortality

KW - Norepinephrine

KW - Phenylephrine

KW - Subarachnoid hemorrhage

KW - Vasopressors

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Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: A nationwide electronic health record analysis

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

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