bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 340: Improved Patterns for Advanced Non-Invasive Diagnostic Testing Using a Personalized Gene Expression Score among Patients Presenting to Primary Care Clinicians with Symptoms of Suspected Obstructive Coronary Artery Disease: Results from the IMPACT-PCP (Investigation of a Molecular Personalized Coronary Gene Expression Test on Primary Care Practice Pattern) Trial
Authors: Herman Lee , Conlin Michael , Watson Pamela , Froelich James , Kanelos Dino , St Amant Robert , Yau May , Rhees Brian , Monane Mark , McPherson John
Published: March 2022

Introduction:
Chest pain is the chief complaint in ~10,000 visits/day in the primary care provider (PCP) office and results in approximately $5 billion/yr in testing costs. Better methods are needed to more accurately assess the CAD risk of patients (pts) in an office-based, non-invasive fashion and to optimize referrals to advanced non-invasive testing for further evaluation and care planning.

Hypothesis:
We hypothesized that gene expression score (GES) results would lead to a change in the PCP’s diagnostic evaluation of stable pts presenting in the ambulatory setting with symptoms suggestive of obstructive CAD.

Methods:
The IMPACT-PCP Trial was a multi-center, prospective study which enrolled 251 consecutive pts with no history of CAD seen by nine clinicians for evaluation of chest pain and related symptoms. All patients underwent GES testing: the clinician’s diagnostic strategy was evaluated before and after the GES result was known. The GES is a blood-based molecular diagnostic test with a 96% NPV for excluding the diagnosis of obstructive CAD (defined as at least one vessel with ≥50% coronary artery stenosis by quantitative coronary angiography or core-lab CT-angiography) in symptomatic patients. The primary outcome of interest was the decision change in the diagnostic testing pattern pre/post GES testing as measured by McNemar’s test and logistic regression modeling.

Results:
Characteristics of the 251 pts eligible for primary endpoint analysis included 140 (56%) women, mean age of 56.2 years (SD± 13.0), average BMI of 29.7 (SD± 6.7), and mean GES of 16 (SD± 10). Following GES, a decision change in treatment plan (e.g. MPI, CTA, and cardiac catheterization) was noted in 145 pts (58% observed vs 10% expected change, p<0.001). More patients had a decreased (n=93, 37%) versus increased (n=52, 21%) intensity of testing (p<0.001). In particular, among the 127 low GES pts (51% of study pts), 60% (76/127) had decreased testing and only 2% (3/127) had increased testing. Follow-up is ongoing, with 233 (93%) pts having completed 30-day follow-up. There has been one MACE event (stroke) reported.

Conclusion:
The GES was associated with a statistically significant and clinically relevant change in clinical decision making among pts evaluated for suspected symptomatic CAD. In conclusion, the addition of the GES showed clinical utility above and beyond conventional decision-making by optimizing the pt’s diagnostic evaluation, particularly around the reduction in the intensity of diagnostic testing among low GES patients.
Abstract 351: Predictors of Delays to Antihypertensive Medication Initiation Among Young Adults with Regular Primary Care Use
Authors: Johnson Heather M , Thorpe Carolyn T , Bartels Christie M , Palta Mari , Pandhi Nancy , Sheehy Ann M , Smith Maureen A
Published: March 2022

Background:
In the U.S., young adults (18-39 years old) continue to have low rates of hypertension control (38%) compared to middle-aged and older adults (54%). Although lifestyle modification counseling is a critical step in hypertension treatment, antihypertensive medication initiation is crucial for young adults who remain hypertensive, especially with Stage 2 hypertension (≥160/100 mmHg). However, young adults have low rates of antihypertensive medication initiation and the factors driving delays in medication initiation among young adults who are regular users of primary care are not well understood. The purpose of this study is to compare the rates of antihypertensive medication initiation among age groups and determine predictors of delays in antihypertensive medication initiation among young adults.

Methods:
This is a retrospective analysis of 14,974 patients, ≥18 years old, receiving regular primary care in a large, Midwestern, academic group practice from 2008 - 2011. Patients were included upon meeting JNC7 clinical criteria for Stage 1 (≥140-159/90-99 mmHg) or Stage 2 hypertension and followed up to 4 years. Patients with a previous antihypertensive prescription were excluded. Cox proportional hazard models (HR; 95% CI) stratified by hypertension stage, were fit overall and separately for young adults 18-39 years old to identify predictors of delays in antihypertensive medication initiation.

Results:
After 4 years, 51% overall (4,149 of 8,125) were prescribed antihypertensive medication and 69% (1,650 of 2,403) among those with Stage 2 hypertension; 43% of hypertensive young adults (18-39 yrs; 846 of 1,988) were prescribed medication, 62% (339 of 547) among those with Stage 2. Among age groups, 43% of 18-39 year olds (846 of 1,988) received antihypertensive treatment within 4 years, compared to 53% (40-59 yrs; 2,223 of 4,216) and 56% (≥60 yrs; 1,080 of 1,921). Adjusting for patient factors, blood pressure lability (i.e., intermittently normal blood pressures), and provider factors, adults 18-24 years old had a 50% slower rate of medication initiation (HR 0.5; 0.4-0.7) than ≥60 year olds. Adults 25-31 years (HR 0.6; 0.5-0.7) and 32-39 years (HR 0.8; 0.7-0.9) also had slower rates of medication initiation. When analyses were limited to young adults, higher urgent care use, White race, labile blood pressures, and non-English primary language were associated with slower rates of medication initiation. Young adults with diabetes, Medicaid and more specialty visits had faster rates.

Conclusions:
There are delays in antihypertensive medication initiation for young adults with multifactorial causes. Addressing poor hypertension control rates among young adults should target key factors related to delays, while continuing lifestyle modification counseling.
Abstract 39: Does Higher Use Of Non-invasive Testing Improve the Diagnostic Yield Of Coronary Angiography?
Authors: Chen Jersey , Wang Haiyan , Fazel Reza , Normand Sharon-Lise T , Bradford David , Al-Mallah Mouaz , Cohen David J , Spettell Claire , Fernandez Joaqium , Shaw Leslee , Krumholz Harlan M , Nallamothu Brahmajee N
Published: March 2022

Objective.
To examine whether higher use of non-invasive testing with stress testing or cardiac computed tomographic angiography increases the diagnostic yield of elective coronary angiography as assessed by subsequent revascularization.

Background.
Many patients who undergo elective coronary angiography are found not have obstructive coronary disease, yet prior non-invasive testing is often underused. Increasing the use of non-invasive testing prior to elective coronary angiography may improve its diagnostic yield through better selection of candidates for subsequent coronary revascularization.

Methods.
Using a complete sample of billing claims from a national health insurer, (Aetna) we identified adults≥35 years who underwent elective coronary angiography from January 1, 2008 to September 30, 2009. We first conducted a patient-level propensity-matched analysis to determine the relationship between non-invasive testing with revascularization. We also conducted a regional-level analysis examining geographic variation in non-invasive testing and revascularization rates across U.S. hospital referral regions (HRRs).

Results.
Overall, 33,429 out of 62,501 (53.5%) patients who underwent elective coronary angiography had non-invasive testing performed within 90 days, the majority undergoing myocardial perfusion imaging (n=29,634). In a matched propensity analysis that adjusted for patient characteristics, prior non-invasive testing was associated with a modestly lower likelihood of subsequent revascularization within 90 days (10.0% v 11.1%, p<0.0001). Across 241 HRRs, we observed substantial regional variation in the use of non-invasive testing prior to coronary angiography (median 52.5%, range 26.3-84.8%), and subsequent revascularization (median 10.8%, range 0-34.6%). However, regional variation in the non-invasive testing rate explained essentially none of the variation in revascularization rates (adjusted r-squared=0.04).

Conclusion.
Non-invasive testing prior to elective coronary angiography was not associated with increased revascularization in either patient-level or regional-level analyses. Efforts to improve the diagnostic yield of elective coronary angiography by increasing prior use of non-invasive testing may be limited in real-world settings.
Abstract 66: Cost Profile of Heart Failure Inpatient Admissions in the United States: Data from the Premier Hospital Database
Authors: Gunnarsson Candace , Rizzo John A , Burton Mark L , Mollenkopf Sarah A , Bril Sarah L , Tsintzos Stelios
Published: March 2022

OBJECTIVE:
Quantify the hospital cost of Heart Failure (HF) admissions and investigate differences among acute and chronic patients by disease severity.

METHODS:
2010 data from the Premier Hospital Database was used. Patients were included if (a) they had at least one inpatient admission with an International Classification of Diseases, Ninth Revision (ICD-9) primary diagnosis code of HF (both chronic or acute HF) and (b) had Diagnosis Related Group (DRG) Code of 291, 292 or 293. Patients were excluded if they had procedure codes indicating they were recipients of an implantable cardiac device (ICD) (e.g. Device Interrogation, Reprogramming, or Remote Monitoring) before or during the hospital stay. HF admissions meeting the inclusion criteria were categorized by ICD-9 Code (see table). Summary statistics were generated for the cost of care for each category and by DRG code.

RESULTS:
592,279 inpatient admissions had a primary or secondary ICD-9 Code for HF (11.72% of all inpatient admissions). Of those admissions, 446,145 were excluded for not having been assigned an HF DRGs (291-293). A further 37,125 admissions were excluded because of evidence of an implanted device and a final 27 were excluded for not having HF as primary code. 108,982 admissions (18.4% of the total) were included in the analysis - details are presented in the table. Within each category, admissions in DRG 291 (HF with Major Complications and Comorbidities) were the most costly. For all categories combined, the mean cost per visit was $8,184 (SD $8,015) median $6,140 (Q1 $3,989, Q3 $9,691). Fixed costs were 51% and variable costs were 49% of the total. Median Length-of-Stay (LoS) was 4 days. Further summary statistics for costs and LoS by category are given in the table.

CONCLUSION:
Heart Failure (HF) is highly prevalent and costly. It imposes a significant burden on US hospitals as the costs of a HF hospitalization typically exceed national Medicare reimbursement amounts ($8,245, $5,947 and $3,917 for DRGs 291, 292 and 293 respectively). Hospitals will benefit by identifying more efficient treatments for these patients.
Abstract 73: Use of an ED- Based Observation Unit Followed by Outpatient Stress Testing in Chest Pain Patients with Prior Coronary Artery Disease History: Evaluation of Safety and Prognostic Utility
Authors: Khalil Yasser , Pandey Prasant , Schwartz Mel , Abdul-Latif Maida , Matsumura Martin E
Published: March 2022

Objective:
Chest pain (CP) observation units are increasingly being used to efficiently triage patients with CP but without high-risk features such as positive biomarkers or pathologic ECG changes. However, little data is available regarding the use of a CP observation strategy in patients presenting with low-risk CP but with history of prior CAD events. The aim of the present study was to determine the outcomes of patients with CP and established CAD managed with observation followed by outpatient stress myocardial perfusion imaging (MPI) and to determine the prognostic value of this strategy.

Methods:
Retrospective analysis of patients with CP managed with observation followed by outpatient stress MPI at a single community teaching hospital and followed up for 3 years for CV events (defined as death, MI, or need for urgent revascularization). Follow-up event rates were stratified by CAD history at the time of initial CP evaluation.

Results:
A total of 375 patients were included: 111 with and 264 without a CAD history. All patients safely completed outpatient stress MPI within 72 hours of observation. Stress MPI effectively identified patients at risk for CV events regardless of CAD history, although patients with CAD history had a significantly higher rate of +MPI (35/111 (31.5%) vs. 28/264 (10.6%) for patients with +CAD vs. [[Unable to Display Character: –]]CAD history, respectively, p=<0.001).

Patients managed in an observation unit followed by a non-ischemic outpatient stress MPI and without a CAD history had, as expected, very low rates of short- and long-term CAD events (2/264 (0.8%), and 3/264 (1.1%) at 1 year and 3 years, respectively). In contrast, follow-up event rates of those patients with a non-ischemic test but a +CAD history were significantly higher (6/111 (5.4%) and 7/111 (6.3%) at 1 year and 3 years, respectively; p=0.044 and p=0.034 compared to CAD- patients).

To determine if stress MPI testing contributed independent prognostic information regarding CP patients with a history of CAD, we developed a multivariable logistic regression model using patient demographic and risk factor data as well as MPI results: in this model a positive MPI proved to be a strong independent predictor of long-term CV events (OR=4.75 for CV events at 3yr follow-up, 95% CI 1.35-16.70, p=0.015).

Conclusion:
A strategy of observation followed by stress MPI can safely and effectively risk stratify CP patients with prior CAD for long-term CV events. However, our data suggests these patients are at increased risk of CV events even after a low-risk follow-up stress MPI study. Thus, patients presenting with CP and managed with a strategy of observation and a non-ischemic stress MPI still warrant close short and long term monitoring for recurrent events.
Abstract 82: Comparison of Outcomes by Type of Treatment for Patients with ST-Elevation Myocardial Infarction (STEMI) who presented to Hospitals without Percutaneous Coronary Intervention (PCI) Facilities in Quebec, Canada
Authors: Lambert Laurie J , Xiao Yongling , Kouz Simon , Rinfret Stéphane , Segal Eli , Ross Dave , L’Allier Philippe L , Vanasse Alain , Maire Sébastien , Nasmith Jim , Bogaty Peter
Published: March 2022

BACKGROUND:
Guidelines recommend that STEMI patients who present to non-PCI centers generally be treated with fibrinolysis instead of untimely transfer for primary PCI (i.e., first medical contact [FMC] to device ≥120 min). Little real-world evidence exists for this recommendation since transfer patients are often excluded from clinical registries. A provincial field evaluation of the whole system of STEMI care in Quebec (Canada) provided the opportunity to compare the effectiveness of different treatment modalities, including, importantly, inter-hospital transfer for primary PCI.

METHODS:
All STEMI patients who presented to non-PCI hospitals during two 6-month periods in 2006-7 and 2008-9 were identified (N=2623) and followed up to one year. Detailed information on patient risk factors and treatment delays was extracted from medical charts. We used a multivariate Cox proportional hazards model with time-dependent treatment modelling to assess the hazard ratio of death for 5 treatment modalities: on-site fibrinolysis without later transfer to a PCI center; on-site fibrinolysis with subsequent transfer; timely transfer for primary PCI; untimely transfer for primary PCI; no reperfusion therapy.

RESULTS:
Median FMC-to-device delay for transfer primary PCI patients was 131 min (interquartile range, IQR: 107-166) and only 29% had timely treatment. Median door-to-needle delay was 30 min (IQR: 20-48) with 70% being transferred, after fibrinolysis, to a PCI center (81% subsequently received PCI). Median time to transfer after fibrinolysis was 17.8 hours (IQR: 3.3-77.3). Compared with untimely transfer for primary PCI, the adjusted hazard ratio was 0.29 (95% CI: 0.15-0.56) for timely primary PCI transfer, 0.52 (95% CI: 0.29-0.95) for fibrinolysis with subsequent transfer, 1.18 (95% CI: 0.75-1.84) for fibrinolysis alone and 1.74 (95% CI: 1.31-2.31) for no reperfusion therapy.

CONCLUSION:
Timely treatment delay is associated with improved STEMI survival. These results also provide real-world evidence to support the guideline recommendation to prioritize on-site treatment with fibrinolysis (with consideration of subsequent transfer to a PCI center) over untimely transfer for primary PCI. Transfer to a PCI center after fibrinolysis mostly occurred the following day, suggesting that transfer need not necessarily be immediate.
Abstract 126: In-hospital Depression Predicts Early Hospital Readmission after an Acute Coronary Syndrome: Preliminary Data from TRACE-CORE
Authors: McManus David D , Saczynski Jane S , Waring Molly E , Anatchkova Milena , McManus Richard , Allison Jeroan , Goldberg Robert J , Parish David C , Awad Hamza H , Gurwitz Jerry , Ash Arlene , Kiefe Catarina I
Published: March 2022

Background:
Hospital systems, patients and providers seek to avert rehospitalizations within 30 days for patients admitted with an acute coronary syndrome (ACS). Rehospitalizations within 30 days of discharge are often considered preventable and to reflect poor in-hospital management or discharge practices. However, independent associations of psychosocial factors with early rehospitalization in patients admitted with an ACS have not been examined.

Methods:
A multi-racial cohort of 1,540 patients admitted with an ACS reported psychosocial factors via standardized questionnaires in an in-hospital interview. One month following discharge, patients were interviewed via phone and reported hospital readmissions. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the association between in-hospital psychosocial characteristics (depression, anxiety, and perceived stress), health literacy and numeracy, and cognitive status, with self-reported readmission within 30 days.

Results:
Participants were 34% female and 17% non-white, with a mean age of 62 years and a mean length of stay of 4.1 days. Rehospitalization was reported for 14% (n=208) of participants, 77% of which were due to CVD. In univariate analyses, in-hospital severe depression, anxiety, and high stress were associated with higher odds of early readmission, whereas low health numeracy was associated with lower odds of early readmission (Table 1). Severe depression remained associated with higher odds and low health numeracy remained associated with lower odds of early readmission in a multivariable model including covariates associated on univariate testing with rehospitalization.

Conclusions:
Early readmission after hospitalization for an ACS was common and associated with in-hospital depression and health numeracy. Notably, depression and health numeracy were the only predictors independently associated with readmission in multivariable analyses. We speculate that the lower likelihood of readmission for those with low numeracy may be related to less engagement with the healthcare system. In-hospital screening for depression and characterization of health numeracy may help stratify risk for early rehospitalization after an ACS.
Abstract 127: The Association Between Health Literacy And 90-day Re-hospitalization or Death: A Cohort Study of Patients Hospitalized for Heart Failure
Authors: McNaughton Candace D , Kripalani Sunil , Cawthon Courtney , Roumie Christianne L
Published: March 2022

Background:
More than 20% of patients hospitalized for heart failure are readmitted. Low health literacy, or the ability to read, understand, and use healthcare information to make decisions is associated with the reduced ability to participate in self-management.

Objective:
Examine the relationship between health literacy and a composite outcome of re-hospitalization or death within 90 days after index heart failure admission. Re-hospitalization or death were separate secondary outcomes.

Methods:
Patients discharged from a single referral institution between November 2010 and June 2013 with a primary diagnosis of heart failure and complete information on the nurse administered health literacy were included. The first eligible admission was included. At hospitalization, nurses administered the Brief Health Literacy Screen (BHLS). The BHLS (range 3-15) consists of three self-report questions and higher scores indicate higher health literacy. Low health literacy was defined as BHLS ≤9. Date of death was obtained from the Social Security Death Index and health record. Re-admissions within 90 days of discharge were tracked using standardized methods. Cox proportional hazards evaluated the association between low health literacy and the composite outcome adjusting for age, gender, race, and insurance.

Results:
For 1708 patients discharged for heart failure, mean age was 64.3 years (standard deviation, 15.1 years), 42.5% were female, 20.6% were African American, and 50.7% were covered only by Medicare Part A. Low health literacy was found in 18.6%. There were 601 (35.7%) composite events (129 deaths and 586 readmissions) within 90 days (35.4%, adequate health literacy vs. 35.1%, low health literacy). Adjusted hazard ratio (HR) for the composite outcome was 0.99 (95% CI 0.96, 1.01) per point increase in BHLS; adjusted HR for death within 90 days was 0.94 (95% CI 0.89, 0.99, p=0.02) per point increase in BHLS. Kaplan Meier failure plot for the composite outcome is below.

Conclusions:
In this single center cohort study of hospitalized heart failure patients, readmission within 90 days was common. Health literacy was not associated with the composite outcome of re-hospitalization or death within 90 days. However, higher health literacy was associated with lower risk of death within 90 days.
Abstract 142: Disparities in the Management of Acute Coronary Syndrome in Australian Aboriginal Patients
Authors: Tavella Rosanna , Zeitz Chris , Arstall Margaret , Chew Derek , Worthley Stephen , Worthley Matthew , Beltrame John F
Published: March 2022

Introduction:
It is well recognised that Aboriginal Australians have poorer cardiovascular outcomes compared to non-Aboriginal Australians. Evaluation of contemporary management practices may provide insights into potential service improvements that could promote better outcomes.

Objectives:
To compare the clinical features and hospital management of Aboriginal and non-Aboriginal Australian patients undergoing coronary angiography in public hospitals in South Australia (SA) following acute coronary syndrome (ACS).

Methods:
The Coronary Angiogram Database of South Australia (CADOSA) is a comprehensive registry of all public cardiac catheterization procedures performed in SA. Data for procedures undertaken in 2012 following an ACS, were used to detail the management of these patients. Comparisons between Aboriginal and Torres Strait Islander patients with non-Aboriginal patients were age adjusted where appropriate.

Results:
In 2012, 3,014 coronary angiogram procedures were undertaken for ACS presentation and of these, 144 (5%) were undertaken on Aboriginal and Torres Strait Islander patients. Compared to non-Aboriginal ACS patients, these patients were significantly younger (50±11 vs 64±13 years, p<0.01) and more likely to be female (38% vs 30%, OR=2 (1.4-2.9) p<0.05). Despite their younger age, Aboriginal and Torres Strait Islander patients were more likely to present with acute myocardial infarction (AMI) (72% vs 60%, OR=1.6 (1.1-2.4), p=0.012), however they were less likely to undergo percutaneous coronary intervention (PCI) (34% vs 43%, OR=0.6 (0.4-0.8) p<0.01). CABG was observed in 13% of Aboriginal and Torres Strait Islander patients; similar to non-Aboriginal patients (10%, OR=1.4 (0.9-2.4) p=0.214). Discharge therapies are described in Table 1.

Conclusion:
Aboriginal ACS patients undergoing angiography are younger, more often female and more often present with AMI compared to non-Aboriginal ACS patients. Discharge medications are similar, however significantly less PCI procedures were undertaken in Aboriginal patients. Further investigation is required to evaluate the cause of this important disparity.
Abstract 150: Psychosocial Factors Predict Patient Ratings of Care Transition Quality: Results from Transitions, Risks, and Actions in Coronary Events - Center for Outcomes Research and Education (TRACE-CORE)
Authors: Anatchkova Milena D , Saczynski Jane S , Allison Jeroan J , Ash Arlene S , Kiefe Catarina I
Published: March 2022

Background:
Short hospital stays and fragmented care make the transition following hospitalization a high-risk period for ACS patients. Identified risks for rehospitalization and complications associated with transitions include demographic (e.g., older age), clinical (e.g., co-morbidities), and psychosocial (e.g., depression, lack of social support) factors. Thus, one might expect high-risk patients to receive better quality transitional care to minimize negative outcomes; alternatively, the quality of care may be yet another outcome influenced by the same risk factors. Little is known about the predictors of quality of care transitions from the patients’ perspective.

Methods:
We studied 1,545 TRACE-CORE patients (mean age = 62, 34% female, 78% non-Hispanic white) admitted with an ACS who completed in-hospital interviews and the Care Transition Measure (CTM) at 1 month after discharge. High quality transitions were indicated by a CTM-15 score >74. Using logistic regression models we examined the association between in-hospital demographic, clinical, and psychosocial characteristics, generic and disease specific quality of life, health literacy and numeracy, and cognitive status with high quality transitions (see Table for measures).

Results:
Over one-third (36%) of participants (n=552) reported high quality transitions after an ACS. Most variables or interest were associated (p < .20) with care transition quality in bivariate analyses (Table 1). After adjustment, in-hospital cognitive impairment (Odds Ratio (OR) 0.68; 95% CI 0.46, 0.98) and older age (OR 0.99; CI 0.98, 1.00) were negatively associated with reporting high care transition quality, while high levels of social support (OR 1.06; CI 1.03, 1.10) and patient activation (OR 1.46; CI 1.02, 2.09) increased the chance of reporting high care transition quality in a multivariable model.

Conclusions:
Older patients, those with cognitive impairment, low social support, or lower patient activation may be at risk for lower-quality transitions following hospitalization for ACS, and may benefit from extra attention and support during the transition from hospital to home.
Abstract 158: Patient Characteristics Associated with Appropriate Use of Aldosterone Antagonist in a National Cohort of Veterans Hospitalized with Heart Failure
Authors: Dev Sandesh , Lacy Mary B , Masoudi Frederick A , Wu Wen-Chih
Published: March 2022

Background:
Only 1 in 3 eligible Veterans receives an aldosterone antagonist (AA) after HF hospitalization. Our objective was to characterize the patient characteristics associated with appropriate AA prescription.

Methods:
From the VA External Peer Review Program, we identified a nationwide sample of Veterans with preexisting HF who were discharged from a VA hospital with a principal diagnosis of HF from 10/02 to 07/09. Patients were considered eligible for AA if they had LVEF ≤ 40%, serum creatinine ≤ 2.5 mg/dL for men/≤ 2.0 for women, serum potassium ≤ 5.0 meq/L, and were prescribed a beta-blocker or ACE-inhibitor or ARB at discharge. Patient demographics, vital signs, medications, labs, and coexisting illnesses were compared between patients who filled a prescription for an AA within 90 days of discharge versus those who did not. To examine patient-level predictors of aldosterone blocker fill among eligible patients, we used a generalized estimating equation adjusted for selected covariates to account for within hospital clustering. A backward selection procedure was used for covariate selection with a criterion of p<0.10 for model entry and termination.

Results:
Of the total cohort (n=14,534), 64% (n=9,355) were eligible for an AA (mean age 70 years, mean serum creatinine 1.4 mg/dL, 70% white, 1% female). Beta-blocker and ACE/ARB use were each > 90%. AA use was significantly associated (p<.05) with younger age, black ethnicity, lower systolic BP, higher body mass index, hospitalization prior to 2008, lower comorbidity score, DM, liver disease, electrolyte disorders, depression, discharge prescription of loop or thiazide diuretics, beta blocker, warfarin, lower serum sodium, lower serum creatinine, and with having no history of metastatic cancer or drug abuse. Age and BP accounted for the greatest percentage of total variability in AA use.

Conclusions:
Patient characteristics associated with AA prescription were primarily clustered in the domains of age, ethnicity, HF severity-associated variables, potential contraindications, and comorbid conditions. It is unclear whether the association of increasing age with lower AA use is a disparity to be overcome or a safety concern. Certain patient characteristics, not previously reported, were found to be associated with AA use and may partially explain apparent gaps in appropriate use among Veterans.
Abstract 233: Physicians’ Perceptions of the Thrombolysis in Myocardial Infarction (TIMI) Risk Score in Older Adults with Acute Myocardial Infarction
Authors: Feder Shelli L , Schulman-Green Dena , Geda Mary , Dodson John A , Tinetti Mary E , Gill Thomas M , Chaudhry Sarwat I
Published: March 2022

Background:
Among patients presenting with acute myocardial infarction (AMI), 30% are age 75 years or older. The Thrombolysis In Myocardial Infarction (TIMI) Risk Score is a commonly used, well-validated instrument developed to estimate mortality risk for patients with AMI. However, the TIMI risk stratification model was not specifically developed for older adults (≥75 years). Little is known about physicians’ perceptions of the value of the TIMI risk score in older AMI patients.

Purpose:
To describe physicians’ perceptions regarding the strengths and weaknesses of the TIMI Risk Score in older adults hospitalized with AMI.

Methods:
This study was part of the “Comprehensive Evaluation of Risk Factors in Older Patients with AMI” (“SILVER-AMI”, R01HL115295-01, PI Chaudhry), a multi-center, observational study designed to develop and validate a risk stratification model for older adults with AMI. This qualitative study included semi-structured telephone interviews with cardiologists and hospitalist physicians who care for older adults with AMI. The constant comparative method was used for analysis with results grouped by emergent themes.

Results:
Twenty-two physicians completed interviews ranging from 10-30 minutes (mean = 18 minutes). The mean age of the sample was 41 years, with an average of 16 years of experience after medical school. Reported strengths of the TIMI Risk Score included its ubiquitous presence among medical professionals, ease of use, and utility in guiding clinical management for general AMI populations. Perceived weaknesses included a lack of specific risk factors relevant to older adults, limited capacity for influencing clinical management beyond initial AMI care, and the inability to predict outcomes important for clinical decision-making in older adults with AMI (See Table).

Conclusions & Implications:
Physician respondents perceive the TIMI Risk Score as ill-suited for older adults with AMI because it neither incorporates risk factors nor predicts outcomes important for clinical decision-making post-AMI in this population. These results suggest that a new risk stratification model is needed that is better targeted towards older adults with AMI and can more thoroughly assess risk to guide treatment after AMI in this population.
Abstract 237: Predictive role of thyroid in Takotsubo cardiomyopathy: A single center retrospective study
Authors: Aggarwal Sourabh , Papani Ravikanth , Gupta Vishal
Published: March 2022

Background:
Takotsubo cardiomyopathy (TC) is a transient systolic dysfunction of the apical and/or mid segments of the left ventricle that mimics myocardial infarction (MI) but in the absence of obstructive coronary artery disease. The exact etiology of TC is unclear. Few isolated case reports have described association of TC with hyperthyroid state. The exact association of thyroid status and TC has never been studied so far.

Method:
This was a single center retrospective study. All the patients diagnosed with TC between January 2006 and December 2012 at our hospital were identified retrospectively. Mayo’s revised criteria for TC was used to confirm the diagnosis. Baseline paramenters including demographic profile, cardiac markers, thyroid studies, angiographic and echocardiographic findings were extracted and analysed using SPSSv19.0

Results:
Seventy eight patient were identified as diagnosed with TC with 72 females (92.3%) and 6 males (7.6%) with mean age of 66.33 ± 13.37 years (range 23-91). Stressful event precipitating TC was identified only in 19 patients (24.36%) at the time of admission. Twenty seven patients (34.61%) had history of hypothyroidism and 25 patients (31.05%) were on levothyroxine replacement. Thyroid profile was available for 44 patients at the time of admission and 5 patients (11.36%) were found to be in a hyperthyroid state based on low TSH and/or high freeT4. During a mean follow up of 2.8 ± 1.5 years, 4 patients (5.13%) had episodes of recurrence.

Mean length of stay (mLOS) was 4.4 ± 3.9 days (Median 3 days, Range 1 - 23 days). Both TSH level and ejection fraction had significant independent negative correlation with mLOS (p <0.05).

Conclusion:
Thyroid status/thyroid hormone replacement may have a significant role in the pathogenesis of TC. In this first retrospective study describing the association of TC with thyroid status, precipitating stress was identifiable in only 24% patients whereas 35% of the patients had a history of hypothyroidism with majority on levothyroxine replacement. Additionally, TSH level had an independent negative correlation with mLOS.
Abstract 253: Bottom up Costing Ventricular Assist Device Therapy And Optimal Medical Management-first Steps To Establishing Cost Effectiveness.
Authors: Prichard Roslyn A , Kershaw Louise , Goodall Stephen , Davidson Patricia M , Macdonald Peter , Newton Phillip , Hayward Christopher
Published: March 2022

Background:
Since Left Ventricular Assist Devices were approved in the US for destination therapy, there has been a rapid increase in their use. Information on the cost of advanced heart failure management (AHF), transplant (HTX) and VAD programs is variable across health systems, as most cost data is derived from casemix costing, charges or claims against insurers. This weakens comparative studies as eligible AHF patients are cost outliers in the broader heart failure population.

We outline a cost effectiveness study of VAD therapy vs AHF as part of an HTX program, using Time Driven Activity Based Costing of identified models of care in an Australian setting.

Methods:
All patients activated to the HTX waitlist between 07/2009 and 06/2012 (n=101) were screened and 86 included (62 AHF, 24 VAD). Models of care were defined through 13/86 file reviews, clinician interviews and analysis of activity. Detailed costing was undertaken for 5 VAD and 8 AHF patients for 12 months pre and post HTX listing or VAD implant and included medical, allied health, nursing activities, inpatient care and clinic visits (ClinV), consumables, drugs, pathology, medical imaging, and prosthetics.

Results:
Mortality at 1 yr was 12% (3/24) for VADs post implant and 11% (7/62) for AHF post HTX activation. 148 service activities were identified in 13 file reviews ranging from basic documentation to ECMO insertion. The two groups were matched for age, AHF etiology and gender.

In house database interrogation yielded a median pathology cost per patient of $4811 in 17/24 Pre VAD, and $12,294 in 20/24 Post VAD patients,.

Median allied Health cost for 19/24 Pre VAD patients was $545 and in 23/24 Post VAD was $2938 ($AUD)

Hospitalisations and costs borne beyond the transplant center made comparison between VAD therapy and AHF incomplete.

Conclusion:
The BTT VADs were sicker, with more days hospitalized pre and post VAD.

From an institutional and health system perspective, correct identification of, and reimbursement for activities related to best practice models of care is crucial. Cost effectiveness, capturing costs borne at other hospitals as well as federal, drug and GP reimbursements should be addressed in this cohort.
Abstract 268: Evaluating Pre-Hospital Response When Stroke Symptoms are Present Though Hospital Arrival Mode and Last Known Well to Arrival Times
Authors: Pittenger Jeanne , Fuhrman Sue , Hansen Anne , Etter Cathy , Polum Kathy , Watkins Katie , Gardner Michelle
Published: March 2022

Background:
Delay in hospital arrival for stroke patients continues to be a persistent problem in Wisconsin (WI). Research shows outcomes are better with earlier arrival and treatment with IV tPA. The proportion of patients activating 911 and arriving quickly after a stroke has not improved over time. Arrival via EMS versus private transport has seen a slight decrease.

Purpose:
Evaluate the trends of patient arrival mode and trends of last known well to arrival time in order to work collaboratively with state partners on public awareness of stroke signs,symptoms and importance of calling 911.

Methods:
Two benchmarking groups were established in WI through the Get With The Guidelines Patient Management tool: the All WI hospital benchmark and the WI PSC benchmark. The benchmarks include 65 WI hospitals and 27,197 stroke records between 2009 and 2012. We evaluated trends in onset-to-arrival times and use of EMS among stroke patients in both benchmark groups.

Results:
During the study period, approximately 22% of stroke patients arrive to hospital within 120 minutes of time last known well with no change over time despite stroke systems work throughout the state. Onset-to-arrival times were similar at Wisconsin PSCs versus any Wisconsin hospital. Arrival by EMS has decreased over time at both PSCs (44% in 2009 to 30.1% in 2012) and all hospitals (35.6% in 2009 to 32% in 2012).

Conclusions:
Many stroke patients do not activate 911 or arrive to a hospital in a timely manner. Collaborative attempts by state partners to provide education to the public has not made much difference in arrival mode and arrival from time last known well. Structured outreach activities utilizing initiatives such as the American Heart Association’s signs and symptoms materials can continue to be utilized, but a more comprehensive plan among state stakeholders, EMS, hospitals and the AHA will need to be developed to improve patient awareness and subsequently patient arrival times, resulting in better outcomes.
Abstract 271: Anti-coagulation and Ischemic Stroke Risk in Patients with Chronic Kidney Disease and Atrial Fibrillation: Insights from the Kaiser Permanente Colorado Atrial Fibrillation Registry
Authors: Schneider Preston M , Tavel Heather M , Witt Daniel M , Kauffman Yardlee S , Shetterly Susan M , Go Alan S , Ho P M , Magid David J
Published: March 2022

Background:
There is uncertainty about the benefits of anticoagulation therapy for stroke reduction in CKD patients with atrial fibrillation. Accordingly, we assessed the association between anticoagulation use and stroke risk in CKD patients with atrial fibrillation.

Methods:
The Kaiser Permanente Colorado Atrial Fibrillation Registry is comprised of patients with incident atrial fibrillation between January 1, 2006 and June 30, 2012 from Kaiser Permanente Colorado. Incident atrial fibrillation was defined by ICD-9 codes 427.31 (Atrial Fibrillation) or 427.32 (Atrial Flutter) and without a diagnosis in the prior year. Patients with mitral valve replacement, renal transplant, or use of anticoagulants other than warfarin were excluded. CKD status was determined by ICD-9 codes or by two consecutive outpatient laboratory results with estimated glomerular filtration rate < 60 ml/min/1.73m2 by the CKD-EPI equation. The primary outcome was ischemic stroke identified by ICD-9 codes and validated by chart review. We assessed the association between warfarin use and ischemic stroke in patients with and without CKD using Cox proportional hazards models adjusted for CHA2DS2-VASc score and an interaction for warfarin use and CKD.

Results:
Of 5,728 patients with incident atrial fibrillation, 2,070 (36.1%) had CKD. Patients with CKD were older, more likely to be female, had a higher CHA2DS2-VASc score, and were more likely to receive warfarin than those without CKD (see Table). During a mean follow up of 2.6 years (SD 1.8 years), stroke occurred in 49 (2.4%) patients with CKD and 83 (2.3%) patients without CKD. In multivariable analysis adjusting for CHA2DS2-VASc score, warfarin use was associated with lower hazard of stroke (HR 0.36; 95% CI 0.24 - 0.53). When stratified by CKD status, warfarin use remained associated with lower hazard of stroke in CKD (HR 0.35; 95% CI 0.18 - 0.66) and non CKD (HR 0.36; 95% CI 0.22 - 0.60) patients.

Conclusion:
1 in 3 patients with atrial fibrillation have CKD. There were similar reductions in the risk of stroke associated with warfarin use for CKD and non-CKD patients. These findings reinforce current clinical practice guidelines, which recommend warfarin use based on thromboembolic risk without consideration for CKD status.
Abstract 277: Conveying Risks and Benefits of rt-PA: the Eyes Have It
Authors: Decker Carole , Poirier Mark W , Chhatriwalla Emily , Gialde Elizabeth , Spertus John A , Mayhugh Tara M , Schleicher Karly M , McDowd Joan M
Published: March 2022

Background:
During the early phase of ischemic stroke (IS), thrombolytic (recombinant tissue plasminogen activator; rt-PA) therapy has been shown to effectively reverse symptoms and improve outcomes. However, serious bleeding can occur, which has discouraged both patients and physicians from using rt-PA. The purpose of the overall study is to create a decision-making tool that accurately depicts the risk and benefits of rt-PA in a graphical format that effectively engages physicians, patients and their families.

Methods:
To better understand the most effective method for presenting the probabilities of outcomes we used eye-tracking technology (Applied Science Laboratories D-6 optics) to assess the manner in which participants studied graphs of varying formats. We recorded which components of the graphs that participants looked at, and how long they looked at these graph components. The graphs were developed from a series of qualitative studies and showed 3 representations rt-PA benefits drawn from the NINDS data: bar; stacked bar; and iconic (person outline figures) graphs. Each presented probabilities for outcomes ranging from little/no disability to severe disability/death and risk of bleeding with or without rt-PA use. Stroke survivors or family members were randomly presented with one of the graphs and asked to imagine they were consulting with a physician about using rt-PA for a family member who had just had a stroke. Comprehension was tested with questions assessing knowledge of the risk and outcome percentages presented in the graphs.

Results:
Participants (n=12) spent a longer time studying the iconic and bar graphs (mean = 64 seconds and 63 seconds, respectively) than the stacked bar graph (mean = 46 seconds). Study time in different graph regions varied by graph type. Participants spent 16%, 7.5 %, and 1.4 % of their study time looking at the key risk information in the stacked bar, bar, and iconic graphs, respectively. In addition, 4 out of 5 subjects who incorrectly identified the risk of bleeding on the comprehension test had studied the iconic graph. When shown all three formats, participants indicated the iconic graph to be confusing and the stacked bar to be most informative.

Conclusions:
Our preliminary data suggest that stacked bar graphs facilitate better understanding of the risks and benefits of rt-PA in acute IS. Presenting data in this format could better engage patients and families in making treatment decisions in the setting of IS.
Abstract 303: The Association Between Change in Hospital-Level Use of Transradial PCI and Periprocedural Outcomes: Insights from the NCDR®
Authors: Bradley Steven M , Rao Sunil V , Curtis Jeptha P , Parzynski Craig S , Messenger John C , Daugherty Stacie L , Subherwal Sumeet , Rumsfeld John S , Gurm Hitinder S
Published: March 2022

Background:
Although radial artery access reduces access site bleeding, increasing use of transradial PCI (TRI) may compromise facility-level outcomes due to patient selection, procedural learning curve, and unintended consequences on femoral PCI management. We sought to determine the relationship between increasing facility-level use of TRI and change in rates of access site bleeding.

Methods:
Within the National Cardiovascular Data Registry CathPCI Registry®, we restricted our analyses to hospitals reporting at least 50 PCI procedures annually and with less than 10% TRI use in the first year of observation. We evaluated 1,438,516 patients undergoing PCI at 818 facilities participating in NCDR CathPCI between 2009 and 2012. We identified categories of hospital change in TRI use from latent class growth analysis with time modeled continuously across quarters. Controlling for bleeding risk calculated from prior CathPCI bleeding risk models, we estimated the association between hospital category of change in TRI use and access site bleeding rates using generalizing estimating equations accounting for clustering within hospitals and time.

Results:
Latent growth curve analysis identified four classes of hospital-level change in TRI use with widely divergent patterns (Figure 1a). Patients’ predicted bleeding risk was similar across hospital categories of change in TRI use (predicted bleeding from lowest to highest hospital category of TRI increase, 6.0% vs 5.8% vs 6.1% vs 5.7%). Risk-adjusted bleeding decreased over time for all hospitals, regardless of change in TRI use (Figure 1b). The decreasing rate of access site bleeding (determined from the relative risk [RR] of access site bleeding in the last quarter of study compared to the first quarter) was greater for hospitals with moderate or high increases in TRI use (RR 0.45; 95% confidence interval [CI] 0.36-0.56) compared with hospitals with very low or low increases in TRI use (RR 0.65; 95% CI 0.58-0.74; p for comparison=.002).

Conclusions:
In a national sample of hospitals performing PCI, access site bleeding decreased over time for all hospitals. The trajectory of decline in access site bleeding was greatest at hospitals with the largest increases in TRI use.