bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 022: Assessing Attitudes and Treatment Preferences Among Patients With Hyperlipidemia: Patient Focus Groups
Authors: Barrett Amy M , DiBenedetti Dana B , Rane Pratik , Wade Sally , Qian Yi
Published: June 2021

Objective:
To better understand current and recent statin users’ perceptions, attitudes, experiences, and preferences related to hyperlipidemia (HLD) and its treatment.

Methods:
Four focus groups were conducted in 2 cities in the US with individuals (N = 28) ≥ 18 years old self-reporting a clinician diagnosis of HLD for ≥ 6 months and current or previous statin use for ≥ 3 months in the past year. Two of the focus groups included a total of 13 participants reporting a cardiovascular event or surgery (e.g., heart attack, stroke, stent placement) in the past 10 years (CV group). The other two groups included a total of 15 participants who had not had a CV event or surgery (non-CV group). Concern about HLD and treatment motivation, adherence, and preferences were explored.

Results:
Among the 28 participants, 15 (53.6%) were male. The mean age was 57.3 ± 10.1 years. At screening, 6 (21.4%) participants were not using a statin, and 3 of these 6 reported statin intolerance. The majority of the 28 participants (17; 60.7%) had switched statins. Including their current statin, 10 (35.7%) participants had used 2 statins, and 7 (25.0%) had used 3 statins. Twelve (42.9%) participants had experienced statin-related muscle aches. Participants reported high levels of statin adherence, but reasons for dissatisfaction were noted: adverse events (primarily muscle aches and gastrointestinal symptoms), insufficient lowering of cholesterol levels, and worry about potential liver damage with long-term use.

All participants identified having no/few side effects, lowering cholesterol levels, and preventing CV events as important attributes of cholesterol-lowering drugs (CLDs). Avoidance of drug-drug interactions was important for all 13 CV group participants but for only 4 of the 15 (26.7%) non-CV group participants. Although participants believed statins reduced cholesterol levels, they generally considered lifestyle changes, such as eating a healthy diet and exercising, to be more or as effective.

Overall, 60.7% (17 of 28) said they would be willing to try an injectable CLD in addition to their current treatment if cholesterol levels were not sufficiently lowered. Given the choice of a prefilled syringe, autoinjector, or on-body infusor (with no limit on the number of selections), the autoinjector was acceptable to the largest percentage of participants (22 of 28; 78.6%), followed by the on-body infusor (13 of 28; 46.4%). More participants in the CV group than the non-CV group were willing to try each type of injection.

Discussion:
The frequent switching and side effects highlight significant unmet need in patients with HLD and dissatisfaction with statins among current and recent users, with and without a history of CV events. Results also suggest that a sizeable portion of patients with HLD may be willing to try an injectable CLD.
Abstract 026: Development and Validation of an Electronic Health Record Model for Predicting 30-Day Readmissions in Acute Myocardial Infarction: the AMI READMITS Score
Authors: Nguyen Oanh K , Makam Anil N , Clark Christopher , Zhang Song , Das Sandeep R , Halm Ethan A
Published: June 2021

Background:
Readmissions after hospitalization for acute myocardial infarction (AMI) are common, but the few available risk prediction models have poor predictive ability and are not readily usable in real-time.

Objectives:
To develop and validate an AMI readmission risk prediction model from electronic health record (EHR) data available on the first day of hospitalization, and to compare model performance to the Centers for Medicare and Medicaid Services (CMS) AMI model and a validated multi-condition EHR model.

Methods:
EHR data from AMI readmissions from 6 diverse hospitals in north Texas from 2009-2010 were used to derive a model predicting all-cause non-elective 30-day readmissions to any of 75 hospitals in the region, which was then validated using five-fold cross-validation.

Results:
Of 826 consecutive index AMI admissions, 13% were followed by a 30-day readmission. The AMI READMITS score included seven predictors, all ascertainable within the first 24 hours of hospitalization (
Table 1A
). The AMI READMITS score was strongly associated with 30-day readmission in our cross-validation cohort: ≤13 points = extremely low risk (bottom quintile, mean predicted risk 3%); 14-15 points = low risk (4
th
quintile, predicted risk 7%); 16-17 points = moderate risk (3
rd
quintile, predicted risk 11%); 18-19 points = high risk (2
nd
quintile, predicted risk 16%); and ≥20 points = extremely high risk (top quintile, predicted risk 35%). The READMITS score had good discrimination with comparable performance to the CMS model in our cohort; it had improved discrimination, reclassification, and calibration compared to a multi-condition EHR model (
Table 1B
).

Conclusions:
The AMI READMITS score accurately stratifies patients hospitalized with AMI into groups at varying risk of 30-day readmission. Unlike claims-based models which require data not available until after discharge, READMITS is parsimonious, easy to implement, and leverages actionable real-time data available from the EHR within the first 24 hours of hospitalization to enable early prospective identification of high-risk AMI patients for targeted readmissions reduction interventions.
Abstract 027: Comparing Changes in Hospital Readmission Rates by Frequency and Total Financial Penalties Over the First Five Years
Authors: Thompson Michael P , Kaplan Cameron M , Bazzoli Gloria J , Waters Teresa M
Published: June 2021

Objective:
To compare changes in risk-standardized readmission rates (RSRRs) for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PN) between hospitals receiving more frequent or higher total penalties under the Hospital Readmission Reduction Program (HRRP) over the first five years (fiscal year [FY] 2013-2017).

Methods:
Using publically available HRRP penalty data, we categorized hospitals as receiving penalties in all five years vs. fewer than five years. We also summed the penalty amounts over the first five years by hospital and hospitals based on their quartile of summed penalty amount vs. receiving no penalties. Using generalized linear regression, we estimated the average change in RSRRs for AMI, CHF, and PN by penalty frequency (all years vs. not all years) and amount (quartile of total penalty vs. no penalty) between FY 2013 and FY 2017, adjusting for hospital characteristics in the American Hospital Association Annual Survey and Medicare Impact File (both 2009-2011).

Results:
There were 3,346 hospitals eligible for HRRP penalties between FY 2013 and FY 2017. From this sample, 1,938 hospitals had RSRRs for AMI in both years, 2,821 hospitals had RSRRs for CHF, and 2,876 hospitals had RSRRs for PN. The average change in RSRRs for AMI, CHF, and PN was -2.8%, -2.8%, and -1.4%, respectively. Declines in RSRRs were greater for hospitals receiving penalties in all five years compared to hospitals penalized fewer than five years in AMI (-0.9%, p<0.001), CHF (-0.9%, p<0.001), and PN (-0.4%, p<0.001). Similarly, hospitals receiving the highest total penalties in the first five years of the HRRP had the largest decline in RSRRs compared to hospitals never receiving a penalty for AMI (-1.2%, p<0.001) and CHF (-0.9%, p<0.001), but not for PN (-0.2%, p = not significant).

Conclusions:
Hospitals receiving more frequent and higher total penalties had greater reductions in RSRRs for AMI and CHF, and to a lesser extent for PN. Our findings suggest that HRRP penalties did not limit hospitals’ ability to reduce readmissions.
Abstract 028: Electronic Health Record Meaningful Use Did Not Improve Pay-for-Performance Outcomes
Authors: Thompson Michael P , Graetz Ilana , Fareed Naleef , Bazzoli Gloria J , Waters Teresa M
Published: June 2021

Objective:
With the goal of improving healthcare quality, Medicare has implemented a series of pay-for-performance initiatives and allocated substantial financial resources to promote meaningful use of electronic health records (EHRs). The purpose of this study was to examine whether hospitals achieving EHR meaningful use improved hospital 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates used in Medicare pay-for-performance (P4P) initiatives.

Methods:
We used publically available data on Medicare EHR Incentive Program achievement (2014 to 2015) to categorize hospitals as achieving two years, one year, or no years of stage 2 meaningful use (i.e. comprehensive EHR) from 2014-2015. Using generalized linear models, we compared the change in publically reported 30-day RSMRs and RSRRs for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PN) from 2012 to 2016 by years of stage 2 meaningful use. Models were adjusted for hospital teaching status, system affiliation, ownership status, urban/rural location, bed size, and safety-net status obtained from the American Hospital Association Annual Survey and Medicare Impact File (both 2009-2011).

Results:
From the 4,755 hospitals participating in the Medicare EHR program, 19.8% and 46.0% had two years and one year of stage 2 meaningful use, while 34.2% never achieved stage 2 meaningful use. The Figure shows that from 2012 to 2016 thirty-day mortality for AMI decreased (-1.2% to -1.4%), increased modestly for CHF (+0.5), and increased for PN (+4.1 to +4.6%). All thirty-day readmission rates decreased during this time, with decreases greater in AMI and CHF (both -2.7% to -2.8%) than in PN (-1.3% to -1.4%). We found that there were no significant differences in risk-standardized mortality or readmission rate changes by years of stage 2 meaningful use, even after adjusting for hospital characteristics (all comparisons p>0.05).

Conclusions:
While RSMRs and RSRRs have changed substantially from 2012 to 2016 for most conditions, changes were similar for hospitals with two years, one year, or no years of stage 2 EHR meaningful use. Our findings suggest that adoption of more comprehensive EHRs did not improve hospital P4P outcomes.
Figure.
Change in RSMRs and RSRRs rates by years of stage 2 meaningful use.
Abstract 029: Design, Safety and Effectiveness of Exercise Interventions in Patients With ICDs and CRT: a Systematic Review
Authors: Steinhaus Daniel A , Lubitz Steven A , Noseworthy Peter A , Kramer Daniel B
Published: June 2021

Introduction:
Exercise improves outcomes across a broad spectrum of cardiovascular disease. The optimal design, safety, and effectiveness of exercise-based interventions in ICD and CRT patients remain poorly understood.

Methods:
We performed a Pubmed search for clinical studies using the following search terms: “implantable cardioverter-defibrillators”; “ICD”; “cardiac resynchronization therapy”; “CRT”; and any one of the following: “activity”; “exercise”; “training”; or “rehabilitation”; from 1/1/2000 - 10/1/2015. Eligible studies were evaluated for study design features, measured endpoints, and reports of ICD shock rates.

Results:
From 649 articles, 75 abstracts met initial criteria from which 16 studies remained after full-text review: 56% randomized trials, 31% single-arm trials, 13% observational studies. A total of 2114 patients (median 52, range, 8 - 1053) were included. Exercise interventions varied widely in character and duration (mean days 82.6, range 23 - 168). VO2 max and other physiologic exercise performance measures were the most common primary endpoints (81%), with few studies evaluating clinical outcomes. Most studies (75%) showed statistically significant improvement in primary physiologic endpoints. ICD shocks were uncommon during active exercise intervention with only 7 shocks in 1248 patients. ICD shocks in follow-up were less common in patients receiving exercise intervention (16.9% v 25.6%, Figure).

Conclusion:
Exercise training in patients with ICDs and CRT appears safe and effective based on a small literature. Lack of consensus on design and both physiologic and clinical endpoints limit broader application to an important patient population.
Abstract 034: Rapid Response Activation and In-hospital Mortality
Authors: Kassar Kinan , Pusateri Dorothy , Kapetanos Anastasios
Published: June 2021

Introduction:
The institute for Healthcare Improvement (IHI) encouraged the implementation of rapid response teams (RRT) in hospitals with the aim of early detection of patient deterioration. The rapid response system (formerly Medical Emergency Team (MET)) has been in place at our institution since 2005; however, data regarding its utilization and outcomes are scarce.

Methods:
Data regarding patient characteristics and reasons for activating RRTs were collected from hospital telephone operator records and patient medical records. The study was IRB exempt.

Results:
During a 2 month period (08/09/16 to 10/09/16), the RRT was activated 96 times on 93 patients. Of those, 31 RRT activations (32%) took place within 24 hours of admission to the hospital. The average age of these patients was 64, and 59% were male. Fifty-four RRT activations (56%) were called during the daytime shift (from 7 am to 7 pm). The reason for calling the RRT was mentioned in the hospital operators paging message in 67/96 cases. The most common reasons for activating the system were: Respiratory distress 34/67 (51%), mental status changes 9/67 (13%), and tachycardia 9/67 (13%). Other less common causes were seizures 3/67 (4.5%), chest pain 3/67 (4.5%), hypotension 3/67 (4.5%), and falls 2/67 (3%). Twenty patients (22%) on whom an RRT was called, died during the same hospital admission. The mortality rate of those patients was 6 folds higher than the general In-hospital mortality rate. The average age of the patients who died was 63. Respiratory distress was the most common cause of RRT activation among patients who died 10/20 (50%).

Conclusion:
Patients admitted to the hospital who had an RRT activation had a six fold risk of dying during the same admission. The majority of RRT activations were for respiratory distress, mental status changes, and tachycardia, and one-third occurred within the first 24 hours of admission. Routine review of RRT data can help target areas for improvement, specifically, factors contributing to in-hospital mortality.
Abstract 040: Mineralocorticoid Receptor Antagonists After Hospitalization of Patients With Heart Failure With a Reduced Ejection Fraction
Authors: Durstenfeld Matthew S , Katz Stuart D , Park Hannah , Blecker Saul
Published: June 2021

Background:
Mineralocorticoid receptor antagonists (MRAs) are an important component of guideline-directed therapy for patients with heart failure with a reduced ejection fraction (HFrEF) but are underutilized in clinical practice. Hospitalization is a quality-improvement opportunity to increase appropriate use of MRAs, particularly as this therapy is associated with reduced readmission following both hospitalizations with a principal and secondary diagnosis of heart failure. We studied MRA prescription for heart failure patients before and after hospitalization.

Methods:
We performed a retrospective cohort study of adults hospitalized within an academic tertiary-care hospital system in 2013-2015 with a principal or secondary discharge diagnosis of heart failure. We included patients with ejection fraction ≤35%, systolic blood pressure ≥100 mm Hg, estimated glomerular filtration rate >30 ml/min/1.73 m
2
, and potassium <5.0 mEq/L. We recorded MRA prescription before and after hospitalization. We used McNemar’s test to compare MRA prescription before and after hospitalization, with pre-specified principal and secondary diagnosis subgroups. We used the chi-square test to compare prescriptions between groups.

Results:
Among 1176 hospitalizations of patients who met the inclusion criteria, the mean age was 72.7±13.4 years and 366 (31%) were female. Of these patients, 303 (25.8%) were prescribed MRAs prior to hospitalization and 331 (28.2%) were prescribed them at discharge, a small but statistically significant increase (p=0.02). Among patients previously prescribed MRAs, 241 (79.5%) continued them at discharge. Among 873 patients not previously prescribed MRAs, 90 (10.3%) had MRAs initiated at discharge.

Among 347 patients with a principal diagnosis of heart failure, 95 had MRAs continued, 27 had MRAs discontinued, and 39 had MRAs initiated, a non-significant increase of 12 patients (+3.6%, p=0.14). Among 829 patients with a secondary diagnosis, 146 had MRAs continued, 35 had MRAs discontinued, and 51 had MRAs initiated, a non-significant increase of 16 patients (+1.9%, p=0.08). More patients with a principal diagnosis received MRAs at discharge: 134/347 (38.6%) compared to 197/829 (23.7%) patients discharged with a secondary diagnosis of HFrEF, p<0.0001; similarly, patients with a principal diagnosis of HFrEF had higher rates of MRA initiation at discharge: 39/225 (17.3%) versus 51/648 (7.9%), p=0.0004.

Conclusions:
Over 70% of hospitalized HFrEF patients did not receive MRAs before or after hospitalization. Although more patients with a principal diagnosis than secondary diagnosis of heart failure received MRAs and had them initiated, over 80% of eligible patients not on MRAs were not initiated on them at discharge. Hospitalization remains an opportunity to identify patients indicated for MRAs and initiate guideline-directed heart failure pharmacotherapy.
Abstract 042: Association Between Preexisting Valvular Heart Disease and Takotsubo Cardiomyopathy Among Hospitalized Patients in the United States
Authors: Akinjero Akintunde , Adegbala Oluwole , Akinyemiju Tomi
Published: June 2021

Background:
The pathogenesis of Takotsubo Cardiomyopathy (TTCM) remains poorly understood. Several case reports have described the occurrence of TTCM in patients with preexisting valvular heart disease (VHD). We sought to examine the association between preexisting VHD and TTCM in hospitalized patients.

Methods:
Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), all hospitalizations between 2007 and 2011 with preexisting diagnosis of VHD and admitting diagnosis of TTCM were extracted using ICD-9 CM codes. We compared patients admitted for TTCM who had preexisting VHD to those without. We excluded patients below the age of 18 as well as those diagnosed with TTCM who later underwent percutaneous coronary intervention (PCI). Multivariate logistic regression was used to assess the independent effect of preexisting VHD on both occurrence of TTCM and clinical outcomes (length of stay (LOS), stroke and in-hospital mortality).

Results:
In our study, 613 (0.06%) out of the 1,084,719 hospitalized patients with preexisting VHD, had TTCM, compared to 13,381 (0.04%) out of the 31,460,000 with no preexisting VHD (p<0.0001). In adjusted models, patients with preexisting VHD had a lower risk of being hospitalized for TTCM in the index hospital admission (adjusted odds ratio (aOR) =0.83, 95% confidence interval (CI) =0.77-0.90), independent of potential demographic, comorbid and lifestyle confounders. However, preexisting VHD was significantly associated with longer LOS (aOR=2.59, 95% CI=1.95-3.23), increased stroke rate (aOR=2.49, 95% CI=1.75-3.54) and higher in-hospital mortality (aOR=1.48, 95% CI=1.05-2.09).

Conclusion:
In this large, nationwide study, preexisting VHD was associated with worse clinical outcomes in patients hospitalized for TTCM. Our results can guide future clinical decision-making regarding prompt risk factor identification for poor prognosis in TTCM patients. Future prospective studies are needed to further evaluate this association.
Abstract 046: PCSK9 Inhibitors in Familial Hypercholesterolemia: a Meta-analysis of 9 Randomized Controlled Trials
Authors: Singh Avinainder , Gaviria Simon C , Chada Lourdes , Abu Qamar Omar , Soliman Omar , Kharrazian Datis , Qamar Arman , Blankstein Ron , Dickerman Barbra , Hernan Miguel , Healy Brian
Published: June 2021

Background:
The prevalence of Familial Hypercholesterolemia (FH) is estimated to be 1 in 250 US adults. The advent of PCSK9 inhibitors has led a to a paradigm shift in the management of these patients. The purpose of this study was to analyze the efficacy of PCSK9 inhibitors in patients with heterozygous or homozygous FH.

Methods:
Pubmed, EMBASE and clinicaltrials.gov were searched for randomized controlled trials of PCSK9 inhibitors. Trials that exclusively recruited FH patients or those that reported data separately for FH patients were included. The primary outcome of this analysis was mean difference in LDL-C in patients treated with a PCSK9 inhibitor compared with placebo. Secondary endpoints were change in other lipids and incidence of adverse events. A random effects model was used to analyze the pooled estimates.

Results:
A pooled analysis of 9 trials with a total of 1361 patients was performed. Overall the mean difference in LDL-C reduction with PCSK9 inhibition was -48.6% (95% CI: -51.3 to -45.9; p<0.001), as compared with placebo. There was no significant difference in LDL-C reduction between trials using alirocumab vs. those using evolocumab. There was significant heterogeneity among the included trials I
2
=75.9%. The risk of bias in all included studies was low.

Conclusions:
Among patients with FH, PCSK9 inhibitors were highly effective and reduced LDL-C levels by nearly 50% compared with placebo. No differences in magnitude of reduction were observed between alirocumab and evolocumab.
Abstract 047: Variation by Provider in Echocardiographic Surveillance of Mitral Regurgitation
Authors: Tanguturi Varsha , Hidrue Michael , Picard Michael , Atlas Steven , Weilburg Jeffrey , Ferris Timothy , Armstrong Katrina , Wasfy Jason
Published: June 2021

Clinical outcomes after surgical treatment of mitral regurgitation (MR) are worse if intervention occurs after deterioration of left ventricular (LV) size and function. Echocardiographic surveillance of patients with MR is therefore indicated to avoid ventricular remodeling that could worsen patient outcomes. However, overly frequent trans-thoracic echocardiograms (TTEs) can impair access for other patients and reduce value in the delivery of care. Given the balance between timeliness of surveillance and possible over-utilization of TTE in valvular disease, we sought to investigate patient and provider factors contributing to variation in TTE utilization. We hypothesized that there was variation attributable to provider practice even after adjustment for patient characteristics.

We obtained records of all TTEs from 2001-2016 ordered at a large echocardiography laboratory. For each TTE, we linked to patient demographic data from hospital administrative records. To control for both clinical and demographic predictors of frequency of echocardiography, we constructed a hierarchical mixed-effects linear regression model with the individual physician as the random effect in the model. The outcome variable was time interval between TTEs. Intra-class correlation coefficient (ICC) was used to assess the proportion of total variation in the outcome variable due to provider practice, and shrinkage estimates were used to measure the contribution of individual providers.

After application of exclusion criteria, 79,194 TTEs corresponding to 55,663 TTE intervals remained. The mean interval between TTEs was 11.9 months for severe MR, 15.4 months for moderate MR, and 17.6 and 17.7 months for mild and trace MR respectively. After multivariate adjustment, male gender (Rate Ratio (RR) 0.96; 95% CI 0.94-0.98) was associated with shorter follow up, and Hispanic race (RR 1.11; 95% CI 1.01-1.21) was associated with longer follow-up intervals. Eight hundred and sixty-seven physicians were included in the analysis. After adjustment for patient factors, 31% of the variation in intervals was associated with provider practice and 19% of providers (161 of 867) were over-utilizers of TTEs and 24% (210 of 867) were under-utilizers.

We conclude that substantial variation exists in follow up intervals for TTE assessment of MR even after risk-adjustment for clinical and demographic variables, likely due to provider factors including specialty and experience. The association of TTE interval with race and gender warrants further investigation. Improving standardization of follow-up intervals may offer opportunity to reduce both overutilization and underutilization of echocardiography.
Abstract 048: Decision Regret in Patients With Durable Ventricular Assist Devices
Authors: Cooper Stephanie G , Whyte Sharon , Hansell Cole , Horvath Katelyn , Mokadam Nahush A , Mahr Claudius W , Kirkpatric James
Published: June 2021

Background:
Patients presented with the option of undergoing ventricular assist device (VAD) therapy are by definition very sick, and often in crisis. They are typically told that they have a high likelihood of dying in the next year without VAD. Though most patients have improved functional status and quality of life (QoL), repeated hospitalizations and potentially catastrophic complications in the post implant period can be burdensome.

Objective:
To assess for decisional regret or ambivalence about VAD implant.

Methods:
During a 3 year pilot program of outpatient palliative care embedded in a cardiology/CT surgery clinic, all post VAD implant patients were referred to palliative care as part of routine care. As part of their assessment, they were administered a survey consisting of a 5 question decision regret scale that has been validated for a wide range of treatment decision making, and has correlated well with decision satisfaction and decisional conflict. The results were entered into a QI database. On a scale of 0 (no regret) to 100 (regret), scores >25 were considered to reflect significant ambivalence about their decision to have VAD implant. Scores between 10-25 were defined as mild ambivalence. Patients were also administered the PHQ-9 depression inventory.

Results:
129 unique patients were seen as outpatients over a period of 49 months. 102 (79%) completed decision regret surveys. Of these, the majority (64/102, 63%) scored 0, 7/102 (7%) scored > 25, and another 29/102 (28%) scored between 10 and 25. The average age of the patients scoring > 25 on the scale was 46, compared with the average age of 55 of the whole cohort. Of those that expressed some degree of ambivalence (n=36) about their decision, 11/35 (31%) met criteria for at least moderate depression on the PHQ-9, compared with 18% for the whole cohort. Though 26% of the total cohort had VADs as BTT, 20/36 (44%) ambivalent patients and 3/7 (57%) very ambivalent patients were living with their VAD as BTT. The percent of patients expressing ambivalence < or > 6 months post implant was equivalent (33%).

Conclusions:
In this preliminary study, as expected, a majority of patients do not regret their decision. However a significant minority expressed some ambivalence about this decision, and a small number expressed significant ambivalence. Ambivalence was more common in those who are younger, those with VAD as BTT, and in patients with depression. Ambivalence is likely a marker for patients whose expectations for quality of life with VAD are not being met. It is important to recognize pre-implant that patients have different decision-making needs, and that managing their expectations may be a key component of helping them to adjust post VAD. It is also important to identify those patients who would benefit from more post implant support to optimize their quality of life.
Abstract 051: A Feasibility Study on 10-year CVD Risk Assessment as a Primary Prevention Tool for Cardiovascular Disease
Authors: Shi Ruizhi , Lan Yong , Lu Chunyang , Yu Wei
Published: June 2021

Background:
China National Center for Cardiovascular Disease launched a guideline-based 10-year risk assessment of cardiovascular disease (CVD) phone APP, and created a heart age index to visualize the CVD risk to public. This is the first time using totally Chinese local database which includes 40,000 people following up 10-15 years to assess CVD incidence risk. We assessed the self-test effect of the app in China and the feasibility of promoting risk assessment app as a primary prevention tool for CVD by government.

Methods:
The app was promoted through media and government projects by encouraging people spontaneously and randomly scanning two dimensional code and answering 8 questions about CVD risk factors, including age, sex, hyperlipidemia, hypertension, diabetes, weight, height, smoking. We analyzed the current status of cardiovascular risk in Chinese residents, the prevalence of hypertension, hyperlipidemia, diabetes, the distribution of heart-age and so on by SPSS 19.0. Spearman bivariate correlation analysis was used to get the correlation coefficient among different risk factors.

Results:
Over 5 months, 18,214 people (39.7% of men, 60.3% of women) spontaneously used the app around the whole country. The mean age was 55.9 years, the mean heart-age was 64.8 years, and the mean 10-year CVD risk was 4.1%. For hypertension, hyperlipidemia and diabetes patients, the mean 10-year CVD risks were 8.7%, 7.1%, and 9.5% respectively. Prevalence of hypertension (SBP≥140 mmHg or DBP≥90 mmHg), hyperlipidemia (total cholesterol>6.2mmol/L) and diabetes mellitus were 15.8%, 14.4% and 8.5%, respectively. There were 11.2% people smoked. Among hypertensive patients, 33.4% had hyperlipidemia at the same time, and 10.5% of diabetes patients had hyperlipidemia. There were 0.54% people who had three diseases simultaneously. The correlation coefficient between hypertension and hyperlipidemia was 0.101 (P<0.001), between hyperlipidemia and diabetes was 0.022 (P=0.003), and between hypertension and diabetes was 0.038 (P<0.001).

Conclusions:
The 10-years CVD risk evaluation app can be a primary prevention tool for CVD in China, given its friendly design and visual risk. For the public, heart-age is 10 years older than actual age. Hyperlipidemia is highly associated with hypertension and diabetes, so it’s necessary for Chinese government to include blood lipid management in its national policy like hypertension and hyperglycemia management, though such policy is lacking in China
Abstract 055: Changes in Disease-specific versus Generic Health Status Measures After Left Ventricular Assist Device Implantation: Insights From INTERMACS
Authors: Nassif Michael E. , Spertus John A , Jones Philip G , Fendler Timothy J. , Allen Larry A. , Grady Kathleen L , Arnold Suzanne V
Published: June 2021

Background:
The effects of left ventricular assist device (LVAD) therapy on quality of life (QoL) are typically assessed with a combination of heart failure (HF)-specific and generic QoL measures. A generic QoL measure is believed to be necessary to fully capture the QoL effects of LVADs, as non-cardiac factors, such as comorbidities or LVAD complications, may limit generic QoL despite improvement in HF QoL after LVAD. However, the frequency and drivers of this expected discrepancy between HF-specific and generic QoL measures after LVAD implant are not known.

Methods:
Patients who underwent LVAD implantation as part of the INTERMACS registry from 2012-14 were assessed prior to and 6 months after LVAD with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EQ-5D Visual Analog Scale (VAS) to measure HF-specific and generic QoL, respectively. Scores range from 0-100, and ~5 points indicates a clinically relevant change for both measures. Changes in scores were standardized by dividing by the standard deviation of the corresponding baseline score and were categorized as: <0 (worsening), 0 to <0.5 (small improvement), 0.5 to <1 (moderate improvement), and ≥1 (large improvement). Discordance was defined as a ≥2-category difference in standardized changes. Among patients who reported improvement in HF-QoL, multivariable logistic regression was used to examine factors associated with KCCQ-VAS discordance.

Results:
Among 1888 patients, the majority reported improvement in both HF-specific and generic QoL after LVAD, with mean changes in the KCCQ of 32.7 ± 25.0 and in the VAS of 27.6 ± 27.4. Among the 1539 patients (81.5%) with moderate/large improvement in KCCQ, 334 (21.7%) had discordant changes in generic QoL (i.e., VAS did not substantially increase despite improvement in KCCQ). In multivariable modeling, baseline VAS scores were the strongest predictor of future KCCQ-VAS discordance (OR 2.17 per +10 VAS, 95% CI 1.98-2.38). Post-LVAD complications were not associated with discordance.

Conclusion:
In a multicenter cohort of patients undergoing LVAD implant, most patients had substantial improvements in both CHF-specific and generic QoL. Discordance occurred in only ~1/5 of patients and was primarily observed among patients who reported good generic QoL prior to their LVAD (despite low KCCQ). Contrary to our expectations, non-cardiac comorbidities and LVAD complications were not associated with discordance. These results support the continued use of the KCCQ to monitor QoL before and after LVAD implantation but also highlight potential limitations of the VAS in fully capturing the QoL effects from LVADs.
Abstract 057: Understanding of Treatment Strategies Among Patients Newly Diagnosed With Atrial Fibrillation: Findings From SATELITTE
Authors: Kaufman Brystana G , Kim Sunghee , Pieper Karen , Ezekowitz Michael D , Fonarow Gregg C , Naccarelli Gerald V , Mahaffey Kenneth W , Ansell Jack , Berger Peter B , Reiffel James A , Chan Paul S , Singer Daniel E , Allen Larry A , Freeman James V , Kowey Peter R , Gersh Bernard , Piccini Jonathan P , Peterson Eric D , O’Brien Emily C
Published: June 2021

Introduction:
Patient understanding of available therapies for atrial fibrillation (AF) is foundational to shared medical decision making and long term medication adherence. Yet, there is a paucity of data regarding the extent to which patients newly diagnosed with AF in routine community practice understand their options.

Hypotheses:
1) Understanding of warfarin, novel oral anticoagulants (NOAC), rhythm control therapy, cardioversion and radio frequency ablation changes little from baseline to 6 months and 2) treatment rates at 6 months are associated with patient understanding of therapies at baseline.

Methods:
We analyzed survey data from SATELLITE, a substudy of new-onset AF patients enrolled at 56 US sites participating in the ORBIT-AF registry. Patients were surveyed at the baseline and 6 month follow up clinic visit using Likert scales. Agreement between time points was assessed with the McNemar test, and the relationship between understanding and treatment was assessed only for the subset not on treatment at baseline.

Results:
Of 1000 patients enrolled in SATELLITE, 506 had 6-month survey data (data collection is continuing). Among these, the median age was 69.0 years (IQR 63.0 - 76.0) and 93.7% (474 of 506) were white. There was evidence of improvement in the self-reported understanding of warfarin and NOACs from baseline to 6 months, but not for rhythm control, ablation or cardioversion. The proportion reporting high understanding improved significantly for warfarin (p<.0001) and NOACs (p<.0001) from 47% (223 of 474) and 51% (245 of 481) at baseline to 60% (284 of 474) and 69% (332 of 481) at 6 months respectively (Figure 1). Patients with high understanding of the benefits of ablation (p=0.0005) and options for ablation (p=0.0093) at baseline were more likely to have this therapy at the 6 month follow up (N=590), but improved understanding was not associated with increased use of warfarin/NOACs (N=83) or rhythm control (N=444).

Conclusions:
Patients with new-onset AF had improved self-reported understanding of some treatment options over the first 6-months from diagnosis; however, factors other than patient understanding may influence AF treatments received at 6 months. Patient understanding of AF treatments remains suboptimal at 6 months, and our results suggest a need for ongoing patient education.
Abstract 059: Developing a Mobile Application for Cardiac Rehabilitation
Authors: Beatty Alexis L , Fortney John C , Ho P M , Sayre George G , Whooley Mary A
Published: June 2021

Introduction:
Cardiac rehabilitation improves outcomes for patients with ischemic heart disease or heart failure, but is underused. New strategies to improve delivery of cardiac rehabilitation are needed. We developed a mobile application for technology-facilitated home cardiac rehabilitation and sought to determine its usability.

Methods:
We recruited patients eligible for cardiac rehabilitation who had access to a smartphone, tablet, or computer with internet access to participate in usability testing of the mobile application. The mobile application includes physical activity goal setting, logs for physical activity and health measures, health education, reminders, and feedback (Figure). Participants were introduced to the mobile application and then observed while completing pre-specified tasks with the mobile application. Participants completed the System Usability Scale (0-100), rated likelihood to use the mobile application (0-100), and participated in a semi-structured interview. Based on participant feedback, we made iterative revisions to the mobile application.

Results:
We conducted usability testing in 13 participants. The first version of the mobile application was used by the first 5 participants, and revised versions were used by the final 8 participants. From the first version to revised versions, task completion success rate improved from 44% to 78% (p=0.05), System Usability Scale improved from 54% to 76% (p=0.04), and rated likelihood of using the mobile application remained high at 76% and 87% (p = 0.30). Interview responses revealed a need for introductory training (
“Initially, training with a technical person, instead of me relying on myself”)
and on-demand help (“
If I had problems I’d try to find out how to fix it on this or call you”
). Additionally, many participants were interested in sharing data with providers (“
I can show my doctor what I’ve been working on
”).

Conclusions:
With participant feedback and iterative revisions, we significantly improved the usability of a mobile application for cardiac rehabilitation. Patient expectations for using a mobile application for cardiac rehabilitation include introductory training, on-demand help, and sharing data with providers. Iterative mixed-method evaluation may be useful for improving the usability of health technology.
Abstract 060: Association of Body Mass Index With Risk Factor Optimization and Guideline Directed Medical Therapy in Veterans With Cardiovascular Disease
Authors: Hira Ravi S , Akeroyd Julia M , Ramsey David J , Pokharel Yashashwi , Jneid Hani , Ballantyne Christie M , Petersen Laura A , Virani Salim S
Published: June 2021

Background:
Obesity is an epidemic in the United States and has been linked to the development of cardiovascular diseases (CVD) including atherosclerosis, heart failure and hypertension. However, obesity has been associated with better survival once CVD is established and has been referred to as the “obesity paradox”. Medical management and risk factor optimization are recommended for patients with all forms of CVD. The association of body mass index (BMI) with performance measure compliance is not known.

Methods:
In a large national cohort, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities between 10/1/2013 and 9/30/2014. CVD was defined as the presence of ischemic heart disease, peripheral artery disease, or ischemic cerebrovascular disease. We assessed the frequency of compliance with performance measures in patients divided into 5 groups: underweight (BMI <18.5 Kg/m
2
), normal BMI (18.5-24.9 Kg/m
2
), overweight (25-29.9 Kg/m
2
), obese (30-39.9 Kg/m
2
), and extremely obese (>=40 Kg/m
2
). We compared compliance with hypertension control (BP <140/90 mmHg), diabetes control (HbA1C <=9% among diabetics), use of statin, and use of antiplatelet therapy among the 5 groups. A composite of all 4 measures (BP control, statin use, antiplatelet use, HbA1C <=9% among diabetics) termed optimal medical therapy (OMT) was also compared among the groups. Multivariable logistic regression was performed with normal BMI as the referent category.

Results (Table):
Underweight comprised 12,623 (1.1%), normal BMI 230,471 (20.5%), overweight 413,590 (36.8%), obese 404,105 (36%), and extremely obese 61,778 (5.5%). Compliance with risk factor control (hypertension and diabetes control) was higher in the underweight and normal BMI group and lowest in the extremely obese group. However, statin and antiplatelet use was lowest in the underweight group and highest in the obese and extremely obese groups. Overall, only 32.7%-45.5% received OMT (i.e. met the composite measure) and was highest in the overweight group.

Conclusions:
Compliance with OMT was low in all patients. Patients that were underweight and extremely obese were least likely to receive OMT. Our results suggest potential for improvement in OMT for all CVD patients especially those that are underweight and extremely obese.
Abstract 064: Improving Aortic Valve Replacement Risk Prediction: The Role of Geographically Derived Socioeconomic Factors
Authors: McCarthy Fenton H , Zhang Lingjao , Che Jingbo , Graves Desmond , Hargrove W. Clark , Szeto Wilson Y , Desai Nimesh D , Groeneveld Peter W , Williams Matthew L
Published: June 2021

Objective:
Low socioeconomic status (SES) is associated with worse surgical outcomes. Current risk adjustment models for aortic valve replacement (AVR) surgery do not include (SES), and therefore centers that treat large numbers of low-SES patients may be disadvantaged in hospital outcomes comparisons. This study evaluates whether inclusion of SES improves AVR risk prediction models.

Methods:
All patients undergoing isolated aortic valve replacement (AVR) at a single institution from 2005-2015 were evaluated. We estimated patients’ SES using census-tract-level data, which are more precise than ZIP-code-level data. We excluded patients (~5%) with addresses that could not be geolocated to census tracts. SES covariates were available for 95% of the study population. SES measures included mean rates of unemployment, poverty, household income, home value, educational attainment, and housing density. The risk scores for mortality, complications and increased length of stay were generated using models published by the Society for Thoracic Surgeons. Univariate models were fitted for each SE covariate with a cut-off of p <0.2 for inclusion in the multivariable models for (a) mortality, (b) any complication, and (c) prolonged length of stay (PLOS) in addition to the expected risk. We evaluated the incremental value of SES covariates using area under the curve (AUC).

Results:
Amongst the 1,386 patients undergoing AVR included in the study, the overall mortality was 2.8%, any complication rate was 15.1% and PLOS was 9.7%. In univariate models, higher education quartile was associated with decreased mortality (OR 0.96, p = 0.04) and complications (OR 0.97, p <0.01). Poverty was associated with increased length of stay (LOS) (OR 1.02, p =0.02). In the multivariable models, the inclusion of SES covariates increased the area under the curve (AUC) for mortality (0.735 to 0.750, p=0.14), for any complications (0.663 to 0.680, p<0.01), and for PLOS (0.749 to 0.751, p=.12)

Conclusions:
The inclusion of census-tract-level socioeconomic factors into the STS risk predication models is new and shows potential to improve risk prediction for outcomes following AVR, particularly for predictions of any complications following AVR. With the possibility of reimbursement and institutional ranking based on these outcomes, this study represents an improvement in risk predication model even when limited to census tracts and a single institution’s experience.
Abstract 071: The Association Between Comorbid Atrial Fibrillation and the Type of Coronary Stent Implanted in Acute Coronary Syndrome Patients
Authors: Annapureddy Amarnath , Weeda Erin R , Nguyen Elaine , Coleman Craig I
Published: June 2021

Background:
The presence of comorbid atrial fibrillation (AF) in patients hospitalized for acute coronary syndrome (ACS) and undergoing stent placement may necessitate the need for triple anti- thrombotic therapy including an anticoagulant plus dual antiplatelet therapy. We sought to determine the prevalence of comorbid AF in patients hospitalized for ACS and receiving a coronary stent and comorbid AF’s association with the type of stent implanted.

Methods:
We performed a retrospective analysis in the 2012 United States Agency for Healthcare Research and Quality National Inpatient Sample dataset. We included adult patients (age ≥18 years) hospitalized for ACS (International Classification of Diseases-Ninth Revision [ICD-9] diagnostic codes=410.x or 411.x in the primary position) who received either a bare-metal stent (BMS)(ICD-9 procedure code=36.06) or drug-eluting stent (DES)(ICD-9 procedure code=36.07). Patients were stratified into 2 cohorts based on the presence or absence of an ICD-9 diagnosis code in any position signifying comorbid AF (427.31 or 427.32). Multivariable logistic regression was performed to determine the association between comorbid AF and the odds of receiving a DES after adjustment for patient- and hospital-level covariates. Results are reported as adjusted odds ratios with accompanying 95% confidence intervals.

Results:
During the year 2012, there were 66,287 ACS patient admissions, of which, 24.7% received a BMS and 75.3% a DES. Of these admissions, 7,109 (10.9%) were for patients with comorbid AF (median [25%, 75% range] for CHA2DS2-VASc and ATRIA scores =3 [2, 4] and 1 [1, 3]). Following multivariable adjustment, the odds of receiving a DES were lower for ACS patients with comorbid AF (adjusted odds ratio=0.63, 95% confidence interval=0.59-0.67).

Conclusions:
Comorbid AF is not an uncommon condition in patients hospitalized for ACS and receiving a coronary stent. Our study suggests comorbid AF is associated with a significant 27% decreased odds of receiving a DES versus a BMS. This decreased utilization of DES may be secondary to concerns of increased bleeding from prolonged triple therapy and is not inconsistent with current guidelines.