bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P61: Weighing More than the Risks: Cardiologists' Prescription of Warfarin for Atrial Fibrillation Patients
Authors: Garavalia Linda S , Garavalia Brian J , Simon Teresa , Daniel William , Decker Carole
Published: July 2021

Introduction:
Prior research indicates underprescription of warfarin to reduce cardioembolism for eligible atrial fibrillation (AF) patients. Physicians' reluctance to prescribe warfarin for AF patients may be due to perceived increased risk of bleeding or underestimation of stroke risk. However, other factors may influence decisions for warfarin treatment. The purpose of the present study was to develop an in-depth understanding of the cardiologist's decision making process for warfarin anticoagulation and the management of AF.

Methods:
Qualitative in-depth interviews were conducted with 16 (14 male) cardiologists in a large Midwestern cardiology practice affiliated with an urban hospital. Interviews ranged from 15-35 minutes, culminating in nearly 200 pages of transcripts, and took place in person (n=6) at the hospital or over the telephone (n=10). On average, participants had 13 years of experience in treating patients and all had experience with AF patients who had excessive bleeds and/or strokes within the past 12 months. Interviews were conducted until thematic saturation occurred.

Results:
Descriptive content analysis found that cardiologists reported consideration of a range of clinical factors: rate and rhythm control, CHADS
2
score, patient co-morbidities, and other prescribed medications in their decision to aggressively treat according to accepted AF treatment guidelines. Additionally, their decision also considered more subjective factors such as the likelihood a patient would comply with a complex therapy and knowledge of patients' drug and alcohol use. “You have to risk profile them individually and go from there” was a recurrent observation.

Conclusions:
The decision making process used by cardiologists in determining warfarin anticoagulation in the treatment of AF is complex. The cardiologist considers a range of factors when prescribing warfarin beyond the clinical risks including more subjective lifestyle and cultural issues. When these other unmeasurable factors, such as the burden of treatment and lifestyle, are entered into the equation by cardiologists, anticoagulation may be less appealing, regardless of actual clinical risk.
Abstract P82: Identification of Potential Candidates for Implantable Cardioverter-Defibrillators (ICDs) for Primary Prevention via Echocardiography Screening
Authors: Rajeswaran Yasotha , McNamara Robert L , Curtis Jeptha , Lampert Rachel
Published: July 2021

Introduction:
ICDs save lives in patients with depressed ejection fraction (EF) and heart failure and/or myocardial infarction However, under-utilization of ICDs is well documented. The potential benefit of identifying appropriate ICD candidates via echocardiography-laboratory-based screening is unknown.

Methods:
We sought to determine whether individuals who were identified as having a depressed EF on echo reports, and who were otherwise eligible, were receiving primary-prevention ICDs. We performed a retrospective review of charts of patients who had LVEF ≤ 35% on echos done between October 2009 and March 2010 to determine appropriateness for ICD and whether implantation was performed within the following 6 months. Potentially appropriate was defined as those with EF</= 35%, diagnosis of heart failure and/or myocardial infarction, and absence of exclusion criteria (prior ICD, limited life-expectancy, major psychiatric illness, or dementia, MI/revascularization within 40 days.)

Results:
Four hundred and four patients with EF ≤ 35% were identified. Of these,160 (40%) already had ICDs and in 4 (1%), data were insufficient. Two were admitted for ICD. 124 (31%) were ineligible: 36 with life-limiting co-morbidity, 32 expired, 11 had recent MI, and 45 showed improvement in EF at subsequent echo. ICD refusal was documented in 4 patients. The remaining 110 patients were considered potentially eligible for primary-prevention ICD (27% of low-EF echos). Of these, 41 (37%) received an ICD and 69 (63%) did not. Of potential candidates with primary follow-up with a cardiologist, (N=82) 40% received an ICD, versus 28% followed by an internist (N= 28, p NS).

Conclusions:
Echocardiography screening identified many patients with low EF with potential benefit from primary-prevention ICD implantation. Less than half of these received ICDs. Identifying the reasons for nonreferral and whether an echo-based reminder system can improve appropriate ICD referral are important avenues of future research.
Abstract P85: Diversity of Educational Providers Among Anticoagulation Clinics: Results of a National Survey
Authors: Leidal Adam , Barnes Geoffery D , Salata Brian , Froehlich James B , Kaatz Scott
Published: July 2021

Background:
Due to the difficulty and complexity in managing warfarin, anticoagulation clinics must provide adequate patient education to ensure patient safety. Nevertheless, strategies to educate anticoagulation patients vary widely. We intend to describe the self-reported educational practices of anticoagulation clinics across the United States.

Methods:
A 31-question online survey was sent to all members of the Anticoagulation Forum, a network of healthcare providers who work in the field of thromboembolic disease. 264 unique clinics responded to the survey. Each reported question had at least 244 responses. Descriptive statistics are reported.

Results:
Most clinics provide general education through reading materials (92%) and in-person interactions (89%). Few clinics educate by means of video (27%), website (17%), and other methods (8%). Pharmacists (PharmDs) and nurses (RNs) combine to provide the majority (80%) of general anticoagulation education. 39% and 24% of clinics reported that PharmDs and RNs, respectively, provide almost all (>90%) of the general education. 36% and 24% of clinics reported that PharmDs and RNs, respectively, provide almost all (>90%) of the dietary education. 3.3% of all clinics reported that dieticians provides more than 30% of all dietary education. 90% of clinics use literature and 84% of clinics use personal teaching methods to educate their patients on diet. The provider is typically PharmDs and RNs, as they combine for 78% of all dietary education provided by the clinics. In addition to dietary education, 71% of clinics reported using dietary changes to control out-of-range INR values.

Conclusion:
This national survey illustrates the diversity in providers of patient education among anticoagulation clinics. Dietary education was only minimally provided by registered dieticians. Traditional materials are primarily used with few clinics utilizing web-based education. The majority of clinics reported using dietary changes in addition to warfarin dose changes to manage out-of-range INR values. Exploring these differing provider strategies and tools may be useful in developing a more structured and effective anticoagulation educational plan.
Abstract 117: Decreasing Heart Failure 30 Day Readmission Rate- a Single Center Experience
Authors: Hamad Eman A , Piña Ileana
Published: July 2021

Objectives:
To investigate the etiology of the high heart failure (HF) 30 day re admission rate by using Clinical Looking Glass (CLG) in order to improve quality of care

Methods:
CLG is a patented software tool designed at Montefiore to time-effectively acquire medical data to improve patient care and clinical practice. Using CLG we looked into all patients admitted with the primary diagnosis of heart failure in 2010 and re-admitted in 30 days. ICD 9 codes used- 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, and 428.9. 12,851 patients were admitted for HF and 2657 (20%) were readmitted in 30 days. We randomly picked 50 patients from the 30 day readmit group and performed chart reviews on them. We compared the baseline characteristics of both groups to assure that the 50 patients were representative of the whole group.

Results:
Out of the 12851 patients admitted with the diagnosis of HF in 2010 (51% Female, 49% male, 34% Black, 27% White, 29% other), 70% had Medicare, 22% Medicaid, 8% Private insurance. Overall, 39% were discharged home, 28% Skilled nursing facility, and 25% other. The representative 50 patients had a similar breakdown of demographics and baseline characteristics.

Conclusions:
60% of the patients were incorrectly coded as being admitted for CHF. Only 16% of the 50 patients had a 30-day CHF readmission that was correctly diagnosed. This preliminary observation raises doubt about reliance on hospital coding system to determine overall quality of care and performance.
Abstract 149: Disparities In Utilization Of Drug-eluting Stents By Payer Across Racial Groups
Authors: Wu Chuntao , Dyer Anne-Marie
Published: July 2021

Background:
Payer and race differences in utilization of drug-eluting stents (DES) have been reported, but the interaction between payer and race has not been well studied.

Objectives:
To examine if the impact of payer on utilization of DES is dependent on race.

Methods and Results:
A total of 77,142 stenting procedures performed between July 2006 and December 2007 were identified from the California’s hospital discharge database. Compared to private insurance, Medicaid, Medicare, and self-pay were associated with lower likelihood of receiving DES, the respective adjusted odds ratios (ORs) for receiving DES instead of bare-metal stents were 0.71 (95% confidence interval (CI): 0.66-0.77, P<0.0001), 0.82 (95% CI: 0.78-0.87, P<0.0001), and 0.46 (95% CI: 0.41-0.51, P<0.0001), controlling for patient characteristics including race/ethnicity. The adjusted ORs for Medicaid in comparison to private insurance ranged from 0.56 (P<0.001) in black to 0.74 (P=0.01) in Asian patients; the adjusted ORs for Medicare in comparison to private insurance ranged from 0.68 (P<0.001) in black to 0.97 (P=0.69) in Asian patients; and the adjusted ORs for self-pay in comparison to private insurance ranged from 0.35 (P<0.001) in black to 0.50 (P<0.001) in white patients.

Conclusions:
The disparities in utilization of DES by payer are in general consistent across race/ethnicity groups.
Abstract 159: Acute Ischemic Stroke Quality Indicators: Implementation of Evidence-Based Practice to Improve Compliance
Authors: Mazabob Janine M , Brown Gerard , Livesay Sarah , Suarez Jose , Bershad Eric , Nguyen Thuy
Published: July 2021

Background and Purpose:
Stroke is the leading cause of adult disability in the United States. Compliance with the stroke quality indicators reinforces that a stroke center is adhering to the evidence based standards of care in acute stroke patients. Hardwiring a process in the delivery of care during hospitalization will ensure improved compliance of these quality indicators.

Methods:
A core multidisciplinary team was formed that included neurointensivists, neurologist, neurointerventional radiologist, pharmacist, emergency room and neuro intensive care staff along with neuroscience administration staff. Directors of the various services impacted by the stroke patients were invited on an ad hoc basis. Retrospective chart reviews were performed to collect data on a monthly basis for the following quality indicators: DVT prophylaxis Discharged on antithrombotics Patients with a-fib receiving anticoagulation Thrombolytic therapy administration Antithrombotic by end of day 2 Discharged on cholesterol meds Dysphagia screening Stroke education Smoking cessation education Assessed for Rehab Overall compliance with these indicators was on target but areas for improvement were noted in the following areas: stroke education, discharged on statin, thrombolytic therapy administration and patients with a-fib receiving anticoagulation. Aggressive action plans for each of these areas were developed and implemented. Initiatives included standardized electronic order sets, electronic admission, consult, history and physical templates with the quality indicators listed. Presentation of compliance results with a review of outliers were part of monthly section meetings. In order to understand process deviations further discussions with section chiefs resulted in investigation and resolution of issues that led to the variances. Hiring of a research registered nurse and a stroke coordinator were added to the existing stroke service team.

Results:
Dramatic improvement was achieved with no indicator falling below <85.2% (85.2 out 100) for an entire year. Gold Plus achievement level with the American Stroke Association was achieved within a three year period. Target Stroke Honor Role was also achieved during this time period.

Conclusions:
A cohesive project team was able to identify barriers, recommend process changes and ensure the implementation of change within the institution. Data collection and process revision is ongoing
Abstract 18: Aldosterone Antagonists Prevent Sudden Cardiac Death in patients with Left Ventricular Systolic Dysfunction: a Meta-Analysis of Randomized Controlled Trials
Authors: Bapoje Srinivas R , Bahia Amit K , Hokanson John E , Peterson Pamela N , Heidenreich Paul A , Lindenfeld Joann , Allen Larry A , Masoudi Frederick A
Published: July 2021

Background:
Sudden Cardiac Death (SCD) is a leading cause of mortality in patients with left ventricular systolic dysfunction (LVSD). The renin-angiotensin-aldosterone pathway has been implicated in the pathogenesis of SCD. A meta-analysis of randomized controlled trials (RCTs) to assess the impact of aldosterone antagonists (AA) on SCD in patients with LVSD has been lacking.

Methods:
We systematically searched PubMed, EMBASE, Cochrane, US Food and Drug Administration and Clinical Trials databases through March 31, 2011 without language restrictions. We included trials that enrolled patients with LVSD (LV ejection fraction ≤ 45%), randomized subjects to an AA vs. placebo, and reported outcomes of SCD. Pooled odds ratios were calculated using DerSimonian and Laird random effects model. Heterogeneity was measured by Cochran’s
Q
test and

I
2

statistic. Sensitivity analysis was performed to evaluate the strength of our model. Publication bias was explored with a funnel plot and Eggers test. A two sided p-value of < 0.05 was considered statistically significant.

Results:
We identified six published trials, which enrolled 11,654 patients, and met inclusion criteria (Table 1). No significant heterogeneity was observed among the trials. Patients with LVSD treated with AA had 23% lower odds of experiencing SCD compared with controls. Similar results were observed with secondary outcomes of total and cardiovascular mortality. Sensitivity analysis did not significantly change the odds ratio. Significant publication bias was observed (asymmetrical funnel plot and Eggers test p = 0.01) due to the inclusion of small trials with less precision and large trials with high effect size in the final synthesis. We found a trivial shift in the effect size from 0.770 to 0.776 after a trim and fill test to account for hypothetically missed studies suggesting that the impact of the publication bias on these findings is probably insignificant.

Conclusions:
AA reduce the risk of SCD in patients with LVSD. Comparative effectiveness studies of AA on SCD in the usual care setting as well as other SCD-prevention strategies in the setting of AA use are needed.
Abstract 194: Pre-Operative Health Status is Only Weakly Associated With Mortality or Hospitalization Following Continuous-Flow Left Ventricular Assist Device Implantation
Authors: Flint Kelsey M , Matlock Daniel , Sundareswaran Kartik , Lindenfeld JoAnn , Morgan Jeffrey , Spertus John , Farrar David , Allen Larry
Published: July 2021

Background:
Health status predicts death and hospitalization in heart failure and cardiac surgery, but its prognostic value in the setting of left ventricular assist device (LVAD) placement is unknown. We hypothesized that baseline health status could help identify patients at risk for adverse post-operative outcomes and improve patient selection for LVAD therapy.

Methods:
We examined the association of pre-operative health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score (OSS), with overall mortality and hospitalization in 965 patients undergoing LVAD placement as part of two clinical trials of the HeartMate II device. Unadjusted statistical analyses were performed using Cox proportional hazard models and Kruskal-Wallis non-parametric tests.

Results:
Baseline OSS of survivors (median: 25.5, inter quartile range (IQR): 15.6-38.6) was similar to those who died (median: 23.4, IQR 12.9-39.2, p=0.06). Patients in the lowest quartile of KCCQ scores (OSS<14.8) had worse survival as compared with the upper 3 quartiles (unadjusted HR: 1.30. 95% CI 1.03-1.63, p=0.03). Patients in the lowest quartile of baseline OSS also spent more time in the hospital (median 25 days, IQR 19-42) as compared with the upper 3 quartiles (median 23 days, IQR 17-35, p=0.009). Outcomes for the 3 higher OSS quartiles were not significantly different. When comparing KCCQ sub-domain scores of patients who died during follow-up to those who did not, lower total symptom score was significantly associated with worse survival (p=0.009); all other KCCQ sub-domains were not.

Conclusion:
Only patients with very low baseline health status (KCCQ <15) were at increased risk for mortality and hospitalization following LVAD implantation, with the absolute differences being very small. This weak association between baseline KCCQ and post-operative outcomes suggests that LVAD implantation, unlike chronic heart failure and other cardiac surgeries, represents a unique clinical situation in which the benefits of the intervention may outweigh the anticipated risks of worse health status.
Abstract 204: Who Funds “Evidence-Based Medicine” in our Guidelines: Government or Industry? Analysis of the AHA/ACC Class I Secondary Prevention Guidelines in 2011 vs. 2001
Authors: Kohli Payal , Murphy Sabina A , Cannon Christopher P
Published: July 2021

Background:
Heated debate on the “influence” of the pharmaceutical industry has led some to question whether trials sponsored by industry provide strong evidence for clinical practice. We sought to analyze this issue by looking at what the independent ACC/AHA Guideline committee cited as the evidence base for Class I (strongest) recommendations, and evaluated the funding source, as well as changes over time.

Methods:
After importing all citations from the AHA/ACC Secondary Prevention 2011 Update into EndNote citation manager, we excluded those that were not primary publications (e.g. consensus statements or summary guidelines). Funding source was determined from the PubMed database (or if not specified, the primary publication itself). Research support was divided by PubMed categories: U.S. governmental (gov’t), non-U.S. gov’t (typically industry), or mixed. (Note that further division of funding source into any (U.S and foreign) governmental source vs. exclusively industry, is ongoing.) All Class I recommendations were reviewed to determine what percentage of the supporting evidence was funded by U.S. gov’t vs. non-U.S. gov’t, weighting those in the mixed category equally between the other two categories. Chi-square tests were used to statistically compare these percentages.

Results:
Overall, 62% of studies cited to support Class I recommendations in 2011 were sponsored by non-US gov’t (e.g. industry) sources. Nine of 12 categories of Class I recommendations had the majority of the studies supported by non-gov’t/industry rather than from US gov’t funding (Table 1). This was true both for lifestyle interventions and pharmacological therapies, although the percentage of industry-funded trials for pharmacological therapies was significantly higher as compared to studies for lifestyle interventions (83% vs. 46%, p<0.001). Looking at trends over time, in the 2001 guideline, 51% of studies supporting Class I recommendations were funded by the US gov’t, while of the newer additions since 2001, 78% have been funded by non-gov’t/industry sources (p=0.005). Thus, the time trend for the overall % of recommendations that were sponsored by non-US gov’t/industry has risen from 49% in 2001 to 62% in the 2011 guidelines.

Conclusion:
Based on this initial categorization from PubMed, it appears that the majority of trials providing the evidence for the ACC/AHA Secondary Prevention guideline comes from non-government/industry-sponsored trials, and this percentage has increased over time. This finding suggests that industry-sponsored trials do provide a positive impact on clinical guidelines.
Abstract 209: The Quality of Life in Patients With Good Outcome After Anterior Circulation Aneurysm Surgery Using The WHOQOL Instrument-Korean Version
Authors: Jang Dong-Kyu , Jang Kyung-Sool , Han Young-Min , Park Sang-Kyu
Published: July 2021

Purpose:
This study was aimed to investigate the quality of life (QOL) for the patients who underwent anterior circulation aneurysm surgery and had good outcome by validating and using the World Health Organization Quality of Life (WHOQOL) instrument-Korean version and identify the contributing factors in the patient’s perception of health.

Materials and methods:
From January 2008 to October 2010, we treated 280 patients with 290 intracranial aneurysms. Questionnaire were taken in 99 patients whose Glasgow outcome scale (GOS) at 6 months after operation above 4, Global deterioration scale (GDS) less than 3, and informed consent were obtained from each of them. Eighty five hospital staffs and their relatives served as control subjects. Six domains and 24 facets were compared between two groups, and subgroup analysis was done about quality of life and hospital expenses in aneurysm patients according to type of craniotomy, type of approach, bleeding of aneurysm and brain injury.

Results:
Aneurysm patients showed the lower quality of life than that of the control patients in all domains except for physical and social domains. There was no difference in the quality of life between unruptured and ruptured aneurysms. In the environmental domain, there were significant intergroup differences according to type of craniotomy and surgical approach. (P<0.05) Hospital charges were significantly different according to type of craniotomy. (P<0.05)

Conclusion:
Quality of life in patients who experienced anterior circulation aneurysm surgery was low about all domains except for physical and social domains. Craniotomy size may affect the quality of life in patients who underwent anterior circulation aneurysm surgery with good outcome.
Abstract 211: A Comparison of Bleeding in Patients Treated with Clopidogrel or Prasugrel in a US Hospital Database
Authors: Ernst Frank , Bae Jay , Lipkin Craig , Faries Douglas , Zhao Zhenxiang , Moretz Chad
Published: July 2021

Background:
Newer, more potent antiplatelet therapy is commonly perceived as being associated with a higher incidence of bleeding complications. There are limited real-world data on bleeding among patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) with new antiplatelet therapy. The objective of this study was to compare “real-world” incidence of bleeding among patients on clopidogrel vs. prasugrel therapy in a large database from diverse US hospitals.

Methods:
We analyzed patient characteristics and the incidence of bleeding complications during the index (first) hospitalization among ACS-PCI patients treated with clopidogrel or prasugrel between July 2009 and June 2011. Bleeding was defined as the presence of bleeding ICD-9 codes and transfusion. Cohort differences in outcomes were assessed with unadjusted chi-square tests and adjusted for demographics and baseline clinical differences using logistic regression.

Results:
105,490 patients received clopidogrel and 10,544 received prasugrel. Among clopidogrel and prasugrel patients, respectively, 66% and 75% were men, 37% and 46% presented with STEMI, with median age of 64 and 57. During the index hospitalization, the unadjusted incidence of bleeding events was 7% in clopidogrel-treated patients and 4% in prasugrel-treated patients (P<0.0001). Similar patterns were reported in key subgroups (e.g. ACS types, heart failure, anemia, diabetes, renal insufficiency), as well as after a multivariate adjustment.

Conclusion:
It appears that observed bleeding complications among patients treated with prasugrel is not higher than those treated with clopidogrel, even after multivariate adjustments. However, the potential for unobserved confounders remains a limitation for such observational research. It is conceivable that appropriate patient selection helps to control bleeding complications, as shown here in this large, “real-world” database.
Abstract 219: “Real World” Characterization of Patients with a Cardiac Event: A Case-Control Study
Authors: Hume Andrea , Karas Richard H , Nair Radhika , Thakker Kamlesh M , Mukherjee Birswaroop
Published: July 2021

Background:
Recent clinical intervention trials with neutral outcomes, enrolled patients with relatively well controlled risk cardiovascular (CV) risk factor profiles. The extent to which these patients reflect risks in the general population is unknown.

Objective:
To determine the baseline characteristics of new cardiac patients, and compare these with the general population and subjects enrolled in recent clinical trials.

Methods:
This was a retrospective claims database analysis. Cases were selected as patients with first occurrence of at least one cardiac event/procedure (coronary or cerebral event or revascularization procedure) between January 2005 and December 2008. The date of the event was set as the index date. Patients 18-64 years old with a lipid panel who enrolled during the year prior to the index date were selected. The cases were matched 1:3 on age, gender, and length of enrollment with controls who had no cardiac event but who also a lipid panel during the year prior. NCEP ATP III guidelines were used to determine lipid goals. Descriptive analyses were conducted to understand the similarities and differences between the cases and controls. Logistic regression was used to identify the potential predictors of cardiac events.

Results:
A total of 78,596 patients with an event were matched to 235,788 individuals in the general population. Average age was 54 years (SD 8.4) and 53.2% were men. Only 37.9% of cases compared to 49.3% of the general population had all three lipid values at goal. Irrespective of LDL-C levels, cases had higher a prevalence of elevated TG and depressed HDL-C than controls. In logistic regression, hypertension (OR 1.86 CI 1.82-1.89), diabetes (OR 1.31 CI 1.28-1.34), depression (OR 1.43 CI 1.39-1.47), dyslipidemia (OR 1.31 CI 1.28-1.34) elevated LDL-C (OR 1.31 CI 1.29 1.33) and depressed HDL-C (OR 1.31 CI 1.28-1.34) significantly (p<0.05) increased the odds of having an event. Interpretation: Patients with a CV event had multiple lipid abnormalities and comorbidities known to increase CV risk. Patients with multiple cardiometabolic factors are at an increased risk for CV events and should be the focus of preventive strategies. Recent clinical intervention trials such as AIM-HIGH and ACCORD enrolled patients with significantly better controlled lipid variables than those observed in a ‘real world' population of patients who have cardiac events. These findings highlight the limited applicability of these recent trials to the general population at risk for cardiac events and encourage further study on the prevention of cardiac outcomes in cardiometabolic patients.
Abstract 234: Treatment Satisfaction Levels among Adults with Concomitant Conditions of Type 2 Diabetes Mellitus and Hypertension
Authors: Fox Kathleen M , Grandy Susan ,   SHIELD Study Group
Published: July 2021

Objective:
This investigation evaluated the satisfaction with therapy for adults with the concomitant conditions of type 2 diabetes mellitus (T2DM) and hypertension (HTN).

Methods:
Respondents to the US
S
tudy to
H
elp
I
mprove
E
arly evaluation and management of risk factors
L
eading to
D
iabetes (SHIELD) 2009 survey reported their disease conditions, current medications, and satisfaction with therapy. Respondents reporting T2DM with concomitant HTN were identified. Current medications were catalogued, as respondents referred to their prescription bottles to record the name of each medication. Therapy satisfaction was captured with 3 separate questions as satisfaction/dissatisfaction with: 1) ability of the medication to prevent or treat your condition, 2) side effects of the medication, and 3) the medication overall; and scored using a 0 (completely dissatisfied) to 5 (completely satisfied) scale for heart disease treatment and diabetes treatment, separately. Scores of 0-2 were categorized as dissatisfied, score of 3 was neutral and scores 4-5 were satisfied.

Results:
A total of 911 adults with T2DM and HTN reported their satisfaction with therapy. For those who were dissatisfied with their diabetes medication (n = 63), 52.6% were also dissatisfied with their heart disease medication's ability to treat their HTN, 64.5% were dissatisfied with the side effects of their heart medications, and 61.9% were dissatisfied with their heart medication overall. For those who were dissatisfied with their heart disease medication (n = 59), 74.5% were also dissatisfied with their diabetes medication's ability to treat their diabetes, 56.6% were dissatisfied with the side effects of their diabetes medication, and 66.1% were dissatisfied with their diabetes medication overall.

Conclusions:
Although most respondents with T2DM and HTN were satisfied with their treatment, dissatisfaction with treatment for one condition was associated with therapy dissatisfaction in the other condition. Approximately 53%-65% of respondents who were dissatisfied with their diabetes medication were also dissatisfied with their HTN medication overall and in the ability to treat the condition and medication side effects.
Abstract 235: Predictors of functional decline over time in an urban population: The Northern Manhattan Study
Authors: Dhamoon Mandip , Moon Yeseon P , Paik Myunghee C , Gervasi-Franklin Palma , Sacco Ralph L , Elkind Mitchell S
Published: July 2021

Background:
There is limited data on predictors of long-term functional status in population samples, and even less about the effect of vascular risk factors on function. We hypothesized that functional status would decline over time, and that vascular risk factors would affect function and mediate functional decline.

Methods:
The Northern Manhattan Study contains a prospective, population-based study of 3298 stroke-free individuals
>
40 years of age, followed for a median of 11 years for vascular events. The Barthel index (BI) was assessed annually and analyzed as a continuous variable on a 100-point scale. Generalized estimating equations models were adjusted for demographic, medical, and social risk factors assessed at baseline. Models were censored and uncensored for stroke and myocardial infarction (MI) occurring during follow-up. Secondarily, motor and non-motor domains of the BI were analyzed separately, and models were stratified by age.

Results:
Mean age (standard deviation) was 69.2 (10) years, 37% were male, 52% Hispanic, 22% had diabetes, and 74% hypertension. Among 3298 participants, there were 33556 BI assessments. There was an annual decline of 1.02 BI points (p<0.0001). Predictors of change in BI over time included: age (−0.08 BI points per year; p<0.0001), Hispanic ethnicity (−0.22 per year, compared to white; p=0.016), female sex (−0.30 per year, compared to male; p<0.0001), diabetes (−0.38 per year, compared to non-diabetics; p=0.0002), and depression (−0.26 per year, compared to no depression; p=0.046). Results did not change when stroke and MI were censored. Magnitude and significance of predictors of BI were similar for motor and non-motor domains. The following had a different effect on change in BI in those above the median age (68 years), compared to those less than or equal to the median: age (−0.15 per year vs. −0.03; p for difference <0.0001), female compared to male sex (−0.43 per year vs. −0.15; p=0.049), and depression compared to no depression (−0.64 per year vs. −0.008, p=0.023).

Conclusion:
In this large, population-based, multi-ethnic study with long-term follow-up, we found a 1% mean decline in function per year that did not change when the effect of vascular events was excluded by censoring. Vascular risk factors predicted functional decline even in the absence of clinical events. The impact of gender sex and depression was stronger amongst the elderly.
Abstract 274: Patterns Of Statin Initiation, Intensification And Maximization Among Patients Hospitalized With An Acute Myocardial Infarction. Insights From The TRIUMPH Prospective Cohort Study.
Authors: Arnold Suzanne V , Jones Philip G , Tang Fengming , Zhao Zhenxiang , McCollam Patrick L , Decker Carole , Birt Julie , Maddox Thomas M , Spertus John A
Published: July 2021

Background:
Intensive statin therapy after an acute myocardial infarction (AMI) has been shown, in multiple trials, to be superior to less intensive treatment. Several studies have documented rates of statin prescription at discharge, in any dose, as a quality performance measure. However, variations in hospitals’ rates of initiating, intensifying and maximizing statin therapy after AMI are unknown.

Methods:
We assessed statin therapy at admission and discharge among 4340 AMI patients from 24 US hospitals (4/05-12/08). Initiation was defined as statin prescription at discharge in patients not admitted on them. Intensification reflected an increase in dose or change to a higher potency statin at discharge. The use of atorvastatin 80 mg or rosuvastatin 40 mg at discharge were considered maximal statin therapy. Hierarchical modified Poisson models estimated the association of site with initiation in naïve patients, intensification in those who arrived on submaximal therapy, and discharge on maximal therapy among all patients, after adjustment for patient factors including LDL level. Site variation was explored with a median rate ratio (MRR), which estimates the average relative difference in risk ratios of 2 hypothetically identical patients treated at 2 different sites.

Results:
On admission, 34.8% (1510/4340) of patients were taking a statin and 2.6% (112/4340) were on maximal therapy. 86.9% (2411/2776) of statin naïve patients without a contraindication were prescribed a statin at discharge, with no variability across sites after adjustment for patient factors (MRR 1.02). Among patients who arrived on submaximal statin therapy, 26.3% (323/1230) had their statin therapy intensified at discharge with modest site variability (MRR 1.47). Among all patients without a contraindication, 21.0% (899/4271) were discharged on maximal therapy with substantial site variability (MRR 2.79).

Conclusions:
In a large, multicenter AMI cohort, nearly all patients were started on statins during hospitalization, with no variability across sites. However, rates of statin intensification and maximization were lower and varied substantially across hospitals. Given that more intense statin therapy is important in optimizing outcomes, evolving the existing performance measures to include the intensity of statin therapy may be beneficial in improving care.
Abstract 292: Baseline characteristics of patients starting on Niacin extended-release
Authors: Nair Radhika , Karas Richard H , Thakker Kamlesh M , Simko Robert , Manthena Shivaji
Published: July 2021

Background:
The lack of CV benefit in the recent AIM-HIGH clinical trial, where niacin was given on a background of statin treatment in patients with baseline lipids that were already well-controlled, led us to ask the question as to what are the baseline characteristics of real-world patients that physicians were starting on prescription Niacin extended-release (NER).

Objectives:
To evaluate, using a real-world database, the baseline characteristics of real-world patients started on niacin monotherapy or combination therapy.

Methods:
This was a retrospective analysis using electronic medical records. Individuals receiving the first prescription for NER monotherapy or single pill statin-niacin combination (SPC) between July 2000-September 2011 were identified. The date of the first prescription was set as the index date. Patients were 18 years or older on index date, and during the six months prior to index date they had a lipid panel but had no prescription for NER or statin-niacin SPC. Patients were classified based on therapy: NER monotherapy, statin-niacin (includes SPC), and all other combinations of NER. NCEP guidelines were used to evaluate/classify risk-adjusted optimal lipid levels.

Results:
A total of 45,518 patients fulfilled all inclusion criteria. Overall, 58% of the patients had hypertension, 28% had diabetes, and 48% had CHD or CHD risk equivalent. Irrespective of LDL-C levels, 66% had low HDL-C. Among the remaining 34% of the patients with HDL-C at goal, 75.8% had LDL-C>100mg/dL and/or TG >200mg/dL. A total 17,042 patients (37%) were started on niacin extended release monotherapy, 18,782 (41%) were treated with statin-niacin (including SPC), and 9,696 (21%) were treated with all other combinations of niacin extended release. Among the high-risk patients treated with statin-niacin (excluding SPC) 64% had LDL-C<100mg/dL and 54% had non-HDL also at goal; 25% had LDL-C<70mg/dL and 16% had non-HDL also at goal. The baseline average LDL-C and HDL-C and median TG for statin-niacin patients were 93.1 mg/dL(33.5), 39.5mg/dL(11.3) and 165.0mg/dL, respectively.

Conclusion:
Half the patients starting on NER have hypertension and/or CHD/CHD risk equivalents and the majority have low HDL-C. While the majority of high risk patients for whom niacin was added to baseline statin, or who were starting statin-niacin combinations had LDL-C<100mg/dL, fewer patients had LDL-C <70mg/dL goal, and even fewer had non-HDL <100mg/dL. In comparison to AIM-HIGH the average LDL-C and non-HDL levels were higher in the real-world, raising the question whether patients enrolled in AIM-HIGH were only the well-controlled patients, and that the sample size had to have been considerably higher for us to see any additional benefit of adding niacin to statin therapy.
Abstract 3: Declining Early And Late Mortality After Mitral Valve Surgery Among Medicare Patients
Authors: Dodson John A , Wang Yun , Desai Mayur , Hashim Sabit , Sugeng Lissa , Barreto-Filho Jose , Kim Nancy , Minges Karl , Krumholz Harlan M
Published: July 2021

Background:
Mitral valve surgery in older adults has substantial morbidity and mortality. While changes in operative techniques and post-operative care over time may lead to improved outcomes, there are currently a paucity of national surveillance data. The aims of our study were therefore to define trends in incidence, surgical technique, and mortality among patients undergoing mitral valve surgery.

Methods:
Inpatient Medicare standard analytic files were used to identify 100% of fee-for-service patients ≥65 years of age who underwent mitral valve surgery between 1999 and 2008. We constructed a denominator file from Medicare administrative data to report operative rates per 100,000 beneficiaries. Mortality (30-day and 1-year) was ascertained through corresponding vital status files. Surgery was classified as repair or replacement. Risk-standardized mortality rates were calculated using a multivariable model from Medicare claims data adjusting for medical comorbidities.

Results:
A total of 156,917 patients underwent mitral valve surgery during the study period. While the overall rate of mitral valve surgery per beneficiary remained relatively stable over time (1999: 136/100,000, 2008: 134/100,000), the proportion of patients ≥85 years of age increased (1999: 8.8%; 2008: 12.3%). The rate of mitral valve repair (vs. replacement) nearly doubled (1999: 24.7%; 2008: 46.8%). From 1999-2008, risk adjusted 30-day mortality decreased from 10.6% to 5.1% (OR 0.66; 95% CI, 0.60-0.71), a relative decline of 51.9%. Risk-adjusted one-year mortality decreased from 20.3% to 13.3% (OR 0.74; 95% CI, 0.69-0.78), a relative decline of 34.5%. Similar trends were seen across all age strata (Figure).

Conclusions:
From 1999-2008, despite an increase in the proportion of Medicare mitral valve surgery patients ≥85 years of age, postoperative risk-adjusted 30-day and one-year mortality decreased markedly across all age strata. Whether increasing rates of mitral valve repair or other management strategies are contributing factors deserves further investigation.
Abstract 312: Ten-year-trends In ST-elevation And Non-ST-elevation Myocardial Infarction Hospitalizations And Outcomes In The Us: Analysis Of Data From The Nationwide In-patient Sample 2000-2009
Authors: Mahankali Sridhar Arun Raghav , Jeevanantham Vinodh , Patel Dhavalkumar B , Gupta Kamal , Dawn Buddhadeb
Published: July 2021

Background.
The impact of advances in therapy and patient management on the trends in hospitalization, outcomes, costs and readmissions in patients with ST-elevation (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) remains unclear. Using a large database, we analyzed these trends over the course of 10 years.

Methods.
The 2000-2009 Nationwide In-patient Sample Database (the largest all-payer, in-patient database in the US) was used to identify patients with STEMI and NSTEMI, based on the ICD-9 discharge diagnosis codes. The trends for each diagnosis, the patient characteristics, hospital charges, and outcomes were analyzed.

Results.
During 2000-2009, 2.9 million patients were diagnosed with STEMI and 3.9 million with NSTEMI. The analyses of yearly data revealed a progressive and significant decline in the number of patients with STEMI over the decade (
P
<0.001), and a significant increase in the number of patients with NSTEMI (
P
=0.046) (Figure, Panel A) During the same time, the in-hospital mortality for STEMI decreased from 11.3% in 2000 to 8.6% in 2009, and for NSTEMI from 5.5% in 2000 to 4.0% in 2009 (
P
<0.001 for both) (Figure, Panel B). The average length of stay decreased from 5.3 days in 2000 to 4.7 days in patients with STEMI (
P
=0.003) and from 5.8 days in 2000 to 5.1 days in 2009 in patients with NSTEMI (
P
<0.001). However, the mean charges for the index hospitalization increased significantly for both STEMI and NSTEMI (
P
<0.001) (Figure, Panel C). Moreover, the readmission rates within 8 weeks after discharge increased from 13% to 16% for patients with STEMI (
P
<0.001), while the readmission rate increased from 10% to 11% for patients with NSTEMI (
P
=0.05) (Figure, Panel D). Although the incidence of STEMI decreased across all age groups, the proportions of each age group accounting for either STEMI or NSTEMI did not change significantly over the years. The age-group 64-84 years accounted for the highest number of MI-related hospitalizations accounting for 46% and 53% of STEMIs and NSTEMIs, respectively. Gender-stratified analysis revealed that on average 58% STEMIs and 52% NSTEMIs occur in males and this distribution did not change significantly over the decade.

Conclusions.
During the 2000-2009 period, the incidence of STEMI has decreased progressively and significantly in the US, while the incidence of NSTEMI has increased. Although the decrease in mortality rates for patients with STEMI and NSTEMI is encouraging, the worrisome increase in costs associated with the index hospitalization, and the increase in rates of rehospitalization deserve further attention.
Abstract 320: Cardiovascular Outcomes Associated with Combination of Renin Angiotensin System Drugs and Amlodipine
Authors: Panjabi Sumeet , Swindle Jason , Buzinec Paul , Iorga Serban , Ferrario Carlos M
Published: July 2021

To examine cardiovascular outcomes for patients medicated with renin angiotensin system (RAS) drugs/amlodipine in fixed (FDC)- and loose-dose (LDC) combinations. Retrospective claims from a large health plan (data from 01 Mar ‘07 to 31 Dec ’09) were used to identify commercial enrollees aged ≥ 18 yrs with hypertension and index claim for FDC olmesartan/amlodipine (FDC-OA), FDC benazepril/amlodipine (FDC-BA), or LDC angiotensin receptor blocker and amlodipine (LDC-AA). Absence of study drug 6 months prior to index claim, and continuous enrollment for ≥12 months post-index were required. The primary outcome of interest was a cardiovascular event (CVE) composite indicative of heart failure, stroke, myocardial infarction (MI), acute ischemic heart disease excluding MI, and MI/IHD-related surgery. Outcomes were identified on the basis of a primary or secondary ICD-9 diagnosis or procedure codes or CPT codes. To ensure cohort comparability, propensity scores assessing likelihood of assignment to FDC-OA were estimated separately, relative to FDC-BA and LDC-AA, and propensity score quintiles (PSQ) were generated. Cox proportional hazards model of time to first CVE controlling for demographics and baseline characteristics were estimated for each PSQ and results aggregated to compare time to first follow-up event between FDC-OA separately with FDC-BA and LDC-AA. A total of 4,864 individuals were identified on FDC-OA, 12,051 on FDC-BA, and 7,748 on LDC-AA. Mean follow-up duration was 543, 625, and 585 days, respectively. Mean proportion of day covered with therapy was higher in FDC-OA (0.63) cohort compared to FDC-BA (0.55,
P
<0.001) and LDC-AA cohorts (0.34,
P
<0.001). The proportion of patients who experienced an incident CVE in the follow-up was lower in the FDC-OA cohort versus FDC-BA and LDC-AA cohorts (5.94% vs 7.85%, and 16.85%, respectively). Adjusted Cox models suggested that patients initiated on LDC-AA (Hazard ratio [HR] =1.35, p<.001) but not FDC-BA (HR=1.14, p=0.085) were at greater risk of having a CVE compared to FDC-OA. Hazard ratios for first CVE in every quintile were greater for the LDC-AA compared to FDC-OA. In this large, managed care population, patients initiated with FDC-OA had a lower risk of cardiovascular events versus those initiated on LDC-AA, which may be attributed to the greater adherence associated with FDC therapy.