bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 075: Heterogeneity in Treatment Effect in Patients With Peripheral Artery Disease: Insights From the CLEVER Trial
Authors: Pokharel Yashashwi , Jones Phillip , Graham Garth , Spertus John , Smolderen Kim
Published: June 2021

Background:
The CLEVER trial (Claudication: Exercise versus Endoluminal Revascularization) showed significant improvement in peripheral artery disease (PAD)-specific health status (Peripheral Artery Questionnaire, PAQ) at 6 and 18 months for both supervised exercise (SE) and stent therapy (ST) compared with optimal medical care (OMC) in PAD patients. However, it is unknown whether there is variation in treatment by age, gender or race, or if recovery is similar across these groups over time.

Methods:
A total of 111 patients from 22 sites with hemodynamically significant aortoiliac arterial stenosis were randomized to SE, ST, or OMC. Using maximum likelihood methods for longitudinal analyses, we analyzed change from baseline in PAQ summary scores at 6 and 18 months and tested interactions between demographic factors (≥65 vs. <65 years; women vs. men; non-Caucasians vs. Caucasians) and treatment, time, and treatment by time. When significant, we further examined effects by different treatment modalities (OMC, SE and ST).

Results:
The mean age of the study population was 64.4 years (53.1% <65 years), 37.8% were women and 32.4% were non-Caucasians (26.1% African Americans and 6.3% other race). There was a significant interaction by race and treatment (p=0.006, overall difference in PAQ summary scores in non-Caucasians minus Caucasians -4.0 [-11.6, 3.6], p=0.30), but there was no significant interaction between other demographic factors and treatment, time, or treatment and time. In Caucasians, PAQ summary scores improved only with ST; in non-Caucasians, improvement was similar with ST or SE (Figure). Estimates of difference in PAQ scores between SE or ST and OMC showed similar results (Table).

Conclusion:
There was a significant interaction between treatment and race, with only ST showing significant improvement in PAQ scores in Caucasians, whereas both ST and SE showed significant improvements in PAQ among non-Caucasians. Further studies should validate and explore the mechanisms of different racial responses to PAD treatment.
Abstract 078: Implications of Patient-Reported Treatment Satisfaction for Discontinuation of Rivaroxaban versus Warfarin in ROCKET-AF
Authors: Rodriguez Fatima , Ungar Leo , Hellkamp Anne , Becker Richard C , Berkowitz Scott D , Breithardt Günter , Fox Keith A , Hacke Werner , Haperin Jonathan L , Hankey Graeme J , Nessel Christopher C , Piccini Jonathan P , Singer Daniel E , Patel Manesh , Mahaffey Kenneth
Published: June 2021

Background:
Patient-reported outcomes and satisfaction are important in both trials and clinical practice and may be associated with treatment adherence.

Methods:
ROCKET-AF was a randomized, double-blind trial of rivaroxaban versus warfarin for prevention of thromboembolism in patients with atrial fibrillation. In a substudy, we compared treatment satisfaction scores: Anti-Clot Treatment Scale (ACTS) and Treatment Satisfaction Questionnaire for Medication version II (TSQM II). Patient-driven discontinuation included stopping study drugs due to withdrawal of consent, non-compliance, or loss to follow-up. Rates of discontinuation were calculated for participants above and below the median scores for each scale.

Results:
Of 14,264 patients in ROCKET AF, 1,181 (8.3%; median age 75 years; 34% women) patients completed both the ACTS and TSQM II questionnaires 4 weeks after starting the study drug. Over a median follow-up of 1.6 years, 450 premature study drug discontinuations occurred, 116 (26%) patient-driven. Patients less satisfied with treatment by the ACTS Benefits and Burdens and TSQM II scales had higher rates of study drug discontinuation (
Table
).

Conclusions:
Patient-reported satisfaction was lower in patients with study drug discontinuation, suggesting that collecting patient-reported outcomes early in clinical trials may guide interventions that improve adherence and clinical outcomes.
Abstract 090: Armenian Ethnicity: An Independent Risk Factor for Positive Exercise Treadmill Tests
Authors: Rostomian Ara H , Sanchez Daniel , Soverow Jonathan
Published: June 2021

Background:
Several studies have examined the risk of cardiovascular disease (CVD) among larger racial and ethnic groups such as Hispanics and African-Americans in the United States, but limited information is available on smaller subgroups such as Armenians. According to the World Health Organization, Armenia ranks eighth in CVD rates among all countries however it is unclear if Armenian immigrants living in the US have the same high rates of disease. This study examined whether being of Armenian descent increased the risk of having a positive exercise treadmill test (ETT) among patients treated at a safety net hospital in Los Angeles County.

Methods:
Data on patients who received an ETT from 2008-2011 were used to conduct a retrospective analysis of the relationship between Armenian ethnicity and ETT result as a surrogate measure for CVD. A multivariate logistic regression analysis was used to estimate the odds ratios (OR) for having a positive ETT among Armenians relative to non-Armenians, adjusting for the following pre-specified covariates: gender, age, diabetes, hypertension, hyperlipidemia, smoking, family history of coronary artery disease (CAD), and patient history of CAD.

Results:
A total of 5,297 patients, ages 18 to 89, were included. Of these, 13% were Armenian and 46% were male, with an average age of 53 years. Armenians had higher odds of having a positive ETT than non-Armenians (Crude OR=1.30, p=0.037, CI:1.02,1.66). After adjusting for CV risk factors, Armenians were still significantly more likely to have a positive ETT than non-Armenians (OR=1.33, p=0.029, CI:1.03,1.71). CAD (OR 2.02, p<0.001, CI:1.38,2.96), and hyperlipidemia (OR=1.31, p=0.008, CI:1.07,1.60) were also significantly associated with a positive ETT.

Conclusion:
Armenians have a higher likelihood of having a positive ETT than non-Armenians. This relationship appears to be independent of traditional CV risk factors and suggests a role for cultural and/or genetic influences.
Abstract 091: The Association of Invasive Treatment on Health Status Outcomes in Patients with Non-ST Elevation Myocardial Infarction and Pre-infarct Angina
Authors: Alturkmani Hani J , Qintar Mohammed , Patel Krishna , Jones Philip , Spertus John
Published: June 2021

Introduction:
Pre-infarct angina (PIA) in patients with non-ST elevation myocardial infarction (NSTEMI) is associated with better outcomes. However, the association of invasive strategy, as compared with ischemia-guided strategy, on health status outcomes for patients with PIA is not well studied.

Methods:
TRIUMPH and PREMIER are prospective myocardial infarction registries that collected the Seattle Angina Questionnaire (SAQ) at baseline, 1, 6 and 12 months. PIA was defined as a score of <100 on the SAQ Angina Frequency score at the time of patients’ acute myocardial infarction admission. Invasive strategy was defined as undergoing coronary angiography within 72 hours of admission without a preceding stress test. Propensity-adjusted mixed effect multivariable models were used to compare follow-up health status in patients with and without PIA based on treatment strategy.

Results:
Among 3,544 patients with NSTEMI, 1,839 (52%) had PIA, of whom 1,230 (67%) had an invasive strategy of whom 75% underwent revascularization. While patients who underwent invasive strategy had better health status at baseline than those who underwent ischemia-guided strategy, after propensity adjustment, patients’ comorbidities and characteristics were well balanced (all standardized differences <10%). An invasive strategy was associated with an improvement in SAQ angina frequency and SAQ summary score at 1 month only among patients with PIA (mean difference of 4 and 4.4 points, respectively,
p
<0.005), but this difference was not sustained at 6 or 12 months (Figure). However, among patients with no PIA, there was no significant difference in health status among patients who underwent an invasive or conservative strategy at all time points (mean difference at 1 month of 0.4 and 0.5 points on SAQ angina frequency and summary score, respectively,
p >0.5
).

Conclusion:
An invasive strategy for NSTEMI was associated with significantly better 30-day health status among patients with PIA, but not in those without. No health status benefits of an invasive strategy were observed at 6 or 12 months, regardless of PIA status.
Abstract 092: No Change in Peripartum Cardiomyopathy Outcomes or Risk Factors Over the Past Decade
Authors: Basu Nivedita , Mahowald Madeline , Kawamoto Kris , Davis Melinda
Published: June 2021

Background:
Few studies have evaluated temporal trends in outcomes and risk factors for peripartum cardiomyopathy (PPCM). Prior research using administrative data could only assess short-term in-hospital adverse events. It has also been hypothesized that the incidence of PPCM is rising due to advancing maternal age and increased risk factors. Therefore, we examined long-term outcomes and prognostic factors to determine if there has been any change over the past decade.

Methods:
Patients seen at a tertiary care center between 2000 and 2011 with a diagnosis of PPCM were identified by ICD9 code 674.5x and confirmed by manual chart review. Year of diagnosis, clinical and demographic variables, echocardiographic data, and outcomes including myocardial recovery (defined as EF>=55%), ICD placement, LVAD, transplant, and death were reviewed for follow-up through November 2016.

Results:
Of 60 patients, 31 (52%) were diagnosed recently (2006-2011) and 29 (48%) were diagnosed prior to 2006 (1996-2005). There were no significant differences in the recent group compared to the past group in initial EF (19% vs 22%), final EF (39% vs 39%), and final recovery status (52% vs 48%). Similarly, there were no differences in rates of ICD implantation, LVAD/transplant, mortality, and years of survival. There were no differences in age at diagnosis or in rates of hypertension, smoking, or diabetes. Few patients in either category underwent a subsequent pregnancy. Mean years of follow-up (through 2016) were longer for those diagnosed prior to 2006 (8.3 years vs 3.4 years, p<0.001).

Conclusions:
There has been no improvement in outcomes for patients diagnosed with PPCM in the past decade. Maternal age and risk factors do not appear to be increasing. Despite advances in heart failure treatment and increased awareness of PPCM, more research about the management and follow-up of young mothers with PPCM is needed.
Abstract 098: The Prevalence of Racial and Socioeconomic Disparities in an Outpatient Transitional Care Clinic
Authors: Hussain Khadijah , McMahon Colin , Krallman Rachel , Montgomery Daniel , Feldeisen Thane , Morgan Spencer , Koelling Todd , Rubenfire Melvyn , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: June 2021

Background:
Bridging the Discharge Gap Effectively (BRIDGE) is a cardiac transitional care clinic. BRIDGE has demonstrated improved patient outcomes for some populations. This study sought to determine if differences in outcomes (readmissions, ED visits, death) exist for Caucasian and non-Caucasian patients based on BRIDGE attendance and socioeconomic status (SES).

Methods:
Data on patients referred to BRIDGE from 2008-2014 were analyzed. Patients were split into two cohorts (Caucasian and non-Caucasian) and outcomes for each were independently compared by BRIDGE attendance and SES. Non-low SES was defined as income > $48,600 (200% poverty line for a family of 4) and low SES was income ≤ $48,600. Demographics and outcomes were compared between groups.

Results:
Of 2964 patients, 15.1% were non-Caucasian (n=448). Caucasians were significantly older than non-Caucasians (66.16±14.29 v 59.14±14.75, p<0.001), and were more likely to have primary diagnoses of acute coronary syndrome (28.2% v 23.5%, p=0.039) or atrial fibrillation (16.8% v 9.3%, p<0.001). Among Caucasian patients, BRIDGE attenders had significantly lower 30-day readmission rates (8.6% v 11.3%, p=0.038) and fewer ED visits within 6 months (1.80±1.3 v 2.10±2.0, p=0.049). Non-Caucasians, however, were more likely to have an ED visit within 6 months (40.9% v 33.7%, p=0.012; data not shown). Non-Caucasians of low SES were more likely to be readmitted within 6 months (40.5% v 29.5%, p=0.029) and less likely to attend BRIDGE (64.9% v 76.4%, p=0.016) than non-low SES non-Caucasians. There were no significant differences between non-low and low SES Caucasian patients. Among BRIDGE attenders, 6-month mortality rates were significantly lower for both groups (Caucasian: 5.2% v 10.8%, p<0.001; non -Caucasian: 4.3% v 10.7%, p=0.013).

Conclusions:
BRIDGE attendance was associated with improved outcomes in Caucasians that were not seen in non-Caucasians, with the exception of reduced mortality. Also, SES appears to impact non-Caucasians more than Caucasians, with low SES non-Caucasians having higher readmission rates and lower BRIDGE attendance than non-low SES non-Caucasians. Differences seen may be biased due to unevenly distributed groups (i.e. age and diagnosis). Efforts to target these vulnerable populations are warranted to reduce disparities.
Abstract 107: Cardiovascular Risk Predictors Among Black and African American Women: A Preliminary Analysis of the P4 Study
Authors: Egbuche Obiora E , Hall Meldra , Ojutalayo Folake , Alemah-Mensah Ernest , Lankford Brenda , Pemu Priscilla , Ofili Elizabeth
Published: June 2021

Objective:
To identify predictors that allow for early detection of cardiovascular disease in African American women

Background:
Cardiovascular (CV) mortality is high in African Americans in the United States. Cardiovascular disease (CVD) remains the leading cause of death in African American females. We hypothesize that certain cardiovascular risk factors are predictors of abnormal peripheral vascular compliance. We aim to identify determinants of abnormal vascular compliance by assessing the association between known CVD risk factors and the extent of vascular compliance

Methods:
This cross-sectional study utilized survey responses and results from a noninvasive screening tool. The study included only African American women. Traditional CV risk factors were independent variables (history of hypertension, high serum lipids, family or personal history of CVD). The instrument employed biomarkers that detect blood vessel elasticity. Outcome measures included small and large vessel compliance. Both survey responses and screening results were obtained from 70 consecutive participants. We conducted a univariate and bivariate descriptive analysis. A Chi-square or Fishers exact test was used to determine the significance as appropriate. We adjusted for potential confounders in our multivariable analysis. SAS 9.4 software was used for all the data analyses

Results:
Our study indicates that personal history of cardiovascular disease is strongly associated with abnormal small vessel compliance (Pvalue - 0.01). Family history of cardiovascular disease is strongly associated with abnormal large artery compliance (Pvalue - 0.02). History of cardiovascular disease in both parents is associated with abnormal large artery compliance (Pvalue - 0.04). Interestingly, Living Situation (Living alone) was associated with abnormal large artery compliance (Pvalue - 0.03)

Conclusion:
Family and personal history of CVD, and living alone have strong associations with abnormal vascular compliance. Cardiovascular mortality is high in Black and African American females. Identifying predictors of abnormal vascular compliance can allow for early disease detection and intervention.
Abstract 109: Transparent Plastic Medication Bag to Improve Medication Reconciliation and Transitional Care In Geriatric Patients With Heart Failure At the time of Discharge from Heart Failure Quality Improvement Prospective Cohort Study in Harlem, New York
Authors: Lee Hong Seok , Paladugu Keerthana , Cativo Hans , Oladejo Ayoola , Lin Sophi
Published: June 2021

Background:
Heart failure readmission has been national public health problems for many years. Medication reconciliation in elderly patients is important because the impact of medication intervention in elderly is critical to reduce readmission. There was no enough study to assess readmission or emergency room visit for elderly patients after resident physician level medication reconciliation at the time of discharge. The aim of this study is to determine whether providing a bag to hospitalized geriatric patients for heart failure exacerbation at the time of discharge will improve the rate of hospital readmission or visiting emergency department within 30 days after hospital discharge.

Method:
We conducted a randomized prospective cohort study with 265 patients with heart failure exacerbation above 65 years of age for one year. When patients were discharged to home, the family member or home attendants were called to bring all bottles to the hospital prior to discharge. Patients and their caregivers were educated by residents in charge about the discharge medications to bring the medications to their next clinic visits. We designed small transparent plastic bags for patients to recognize the medication easily through the bag. The interventional group was provided with a plastic bag to carry the newly reconciled medications along with teaching about the medications and the control group was only given information about their medications.

Results:
265 patients with heart failure exacerbation for admission were enrolled in our study. The mean age in our study population was 73.4±8.1 and 74.8±8.1 years old in the intervention and control groups, respectively (P=0.82). There was 66/141 (46.8%) and 63/124(54.8%) males in the intervention and control groups, respectively (P = 0.81). 3/141(2.12 %) of intervention patients and 7/124(5.64%) of control patients were readmitted (P = 0.11). And 2/124(1.61 %) of control patients and 0/141(0.0%) of intervention patients revisited walk-in clinic respectively (P = 0.13). There were no reported adverse medication events.

Conclusion:
In this study, the use of a bag to facilitate medication reconciliation at the level of medical resident physician was not associated with a significant difference in unplanned readmissions or in revisiting walk-in clinics within 30 days after discharge. We may conclude that patients with chronic medical condition might not be reversible only by medication reconciliation. It may need personalized discharge planning as well as medication reconciliation beyond only physician level because heart failure patients were basically at the high risk of readmission by themselves.
Abstract 110: Disparities in TTE Surveillance of Mitral Regurgitation
Authors: Tanguturi Varsha K , Bhambhani Vijeta , Picard Michael , Armstrong Katrina , Wasfy Jason
Published: June 2021

Valvular heart disease continues to be a significant burden to the U.S. population, and is likely to increase over the next several decades. While major technological advances have been made in repairing or replacing degenerating valves, improved outcomes have not affected all segments of society equally. The source of this disparity in outcomes after treatment of valvular disease is unknown. As clinical outcomes after surgical treatment of valvular disease, and especially mitral regurgitation (MR), are worse if intervention occurs after deterioration of left ventricular (LV) size and function, trans-thoracic echocardiographic (TTE) surveillance of patients with MR is indicated to avoid adverse ventricular remodeling. We hypothesized that patients at a lower socioeconomic status were less likely to receive TTE surveillance for MR within the appropriate guideline-indicated interval.

We obtained records of all TTEs from 2001-2016 ordered at a large echocardiography laboratory and linked each TTE to patient demographic data. The primary outcome was receipt of a TTE within guideline recommended intervals for MR surveillance. Intervals between TTEs were coded as appropriate or inappropriate, and logistic regression was used to assess the association of race and income level with appropriateness while controlling for demographic and clinical factors.

In total 31,058 patients with MR in 106,659 TTEs were assessed in the final cohort. Hispanic patients were less likely to receive appropriate TTEs (OR 0.89; p = 0.0440) than predicted by guidelines. Black race trended towards lower odds of receiving TTEs at appropriate intervals, but was not significant (OR 0.95; p = 0.2946). As patients aged, the odds of having a TTE within the appropriate time interval decreased across all races. Income level was not significantly associated with TTE appropriateness.

We conclude that there are disparities in receipt of timely TTE surveillance, especially associated with Hispanic ethnicity. This may contribute to disparities in clinical outcomes after treatment of valvular disease, and provides an opportunity for care improvement.
Abstract 111: Health Status Implications for Comorbid Diabetes in Patients with Symptomatic Peripheral Arterial Disease: Insights from PORTRAIT Registry
Authors: Alturkmani Hani J , Patel Krishna , Gosch Kensey L , Kosiborod Mikhail N , Spertus John , Smolderen Kim G
Published: June 2021

Introduction:
Patients with peripheral arterial disease (PAD) and coexisting diabetes mellitus (DM) have an increased rate of PAD progression and reduced walking performance as compared with non-diabetic PAD patients. It is unknown, however, whether patients with PAD and comorbid diabetes also experience worse PAD-specific health status (symptoms, functioning, quality of life) and what factors might mediate such a difference.

Methods:
PORTRAIT is a 16-center international registry that includes patients with exacerbated or new-onset symptomatic PAD presenting to specialty clinics. We measured PAD-specific health status at the time of PAD evaluation, 3, 6 and 12 months using the Peripheral Artery Questionnaire (PAQ). Hierarchical, multivariable, repeated measures analysis was used to assess the association between DM and health status at baseline and over time. Sequential adjustments for demographics, socioeconomic factors, PAD severity, comorbidities, psychosocial characteristics, primary treatment strategy and quality of care were made.

Results:
Of 1,204 patients, 398 patients had diabetes (33%, of whom 94% had Type II). Patients with PAD and DM had lower unadjusted PAQ summary scores at 0, 3, 6 and 12 months respectively (46.1 vs. 50.8,
p
< 0.001; 63.6 vs. 68.2,
p
< 0.01; 65.7 vs. 71.7,
p
< 0.001; 65.4 vs. 72.6,
p
<0.001). Patients with PAD and DM were more likely to be unemployed, depressed, of non-White race and to have more cardiovascular comorbidities, bilateral disease, non-healing ulcers and prior peripheral vascular interventions. When sequentially adjusting for relevant confounders, the effect for diabetes was mostly explained by comorbidities and psychosocial factors (Figure 1).

Conclusion:
Patients with PAD and co-existing DM have poorer health status upon PAD diagnosis and the year thereafter as compared with those who do not have DM, potentially explained by a higher burden of clinical comorbidities and psychosocial factors. Future work will need to further evaluate whether more emphasis on psychosocial aspects of care in these patients can improve their PAD-specific health status.
Abstract 113: Racial Comparisons in the Outcomes of SAVR and TAVR
Authors: McNeely Christian , Zajarias Alan , Fohtung Raymond , Robbs Randall , Markwell Stephen , Vassileva Christina
Published: June 2021

Background:
Racial disparities in the outcomes after intervention for aortic valve disease remain understudied.

Methods:
Data of patients who underwent surgical (SAVR) and transcatheter aortic valve replacement (TAVR) were obtained from the Medicare database from Nov 2011 through 2013. Comparisons were performed stratifying by race.

Results:
In the TAVR group, there were 17,081 (95.0%) white patients and 706 (3.9%) African Americans (AAs). In SAVR, there were 89,265 (93.9%) whites and 4,562 (4.8%) AAs. Compared to whites, AAs were substantially younger in both TAVR and SAVR groups. Otherwise, most comorbidities were more common among AA (Table 1).

In TAVR, mortality at 30 days and 1 year was similar for AA patients and whites (6.1% and 6.3%, p=NS, and 20.5% vs. 22.3%, p=NS), respectively, while it remained higher in the SAVR cohort among AAs (6.2% vs. 4.7%, p=.0001, and 16.1% vs. 11.7%, p=.0001). Similarly, in TAVR, 30-day readmission was similar for AAs compared to whites (22.8% vs. 23.8%, p=NS) but remained higher for AAs after SAVR (25.2% vs. 20.1%, p=.0001). After adjustment for baseline characteristics, there was no statistically significant difference in 30-day mortality after SAVR between, races, however, AAs continued to have higher adjusted odds of readmission (OR 1.14, 95% CI 1.04-1.22). Compared to whites, AA patients were less likely to be discharged home after SAVR (52.1% vs. 57.7%, p=.0001), but not after TAVR.

Conclusions:
While AAs have worse outcomes in SAVR, it appears that race does not impact mortality, readmission, or discharge to home in TAVR. While these results may be influenced by patient selection and incomplete adjustment, they are representative of outcomes observed in current clinical practice.
Abstract 117: A Value-Based Assessment of a Mature Cardiology E-Consult Program
Authors: Kalwani Neil M , Rao Sandhya K , Chittle Melissa D , Isselbacher Eric M , Ferris Timothy G , Wasfy Jason H
Published: June 2021

Background:
Cardiology electronic consults (e-consults) are asynchronous communications between cardiologists and primary care providers that can replace some traditional in-person consults. We have previously evaluated the initial and intermediate-term impact of e-consults in cardiology. To improve clinical value, e-consults should substitute for traditional consults while avoiding excessive diagnostic testing. Little is known, however, about the rates of in-person follow up or diagnostic testing in a mature e-consult program.

Methods:
We conducted detailed medical record reviews of all patients with cardiology e-consults at the Massachusetts General Hospital from January 9, 2014 to September 11, 2015. Charts were reviewed to determine (1) the proportion of e-consults that were followed by in-person cardiology visits within 6 months and (2) the proportion of e-consults that recommended further cardiac testing.

Results:
From January 9, 2014 to September 11, 2015, 454 cardiology e-consults were performed. Of those, 304 had six months of follow-up available for review. In 254/304 (83.6%) cases, patients had no in-person visit with a cardiologist within six months of the e-consult (see Figure 1). In 37/304 (12.2%) cases, patients had an in-person visit that was recommended by the e-consult. Additional testing was recommended in 155/454 (34.1%) e-consults, including echocardiograms recommended in 98/454 (21.6%) e-consults, Holter/event recorders recommended in 58/454 (12.8%) e-consults, and stress tests recommended in 50/454 (11.0%) e-consults. Medication changes were recommended in 87/454 (19.2%) e-consults.

Conclusions:
In this cohort of patients receiving cardiology e-consults, only one sixth subsequently presented for traditional in-person cardiology visits within six months. E-consults therefore appear to replace traditional consults, rather than simply postponing them. Furthermore, e-consults do not appear to be associated with high rates of downstream testing. These results reflect nearly two years of experience with a mature e-consult program, and imply that e-consults may be an effective tool to improve value in cardiology care.
Abstract 118: Physician Specific Practice Patterns and 30-day Heart Failure Readmission Rates: Is One Way Better Than the Other?
Authors: Bhatt Anish B , Cheeran Daniel , Das Sandeep
Published: June 2021

Background:
Heart failure (HF) admissions place a significant burden on hospital resource utilization. Management of inpatient HF remains heterogeneous, from daily diuresis to discharge strategies. We sought to evaluate if specific physician practices were associated with two important contributors to resource utilization, readmission and length of stay (LOS).

Methods:
Physician-specific discharges, LOS, and 30-day readmission rates from 7/1/2015-6/30/2016 were extracted from the EHR. Patients with “shock” as the primary diagnostic code were excluded. We created a survey to assess HF management strategies that was administered to all cardiologists and hospitalists at our institution; physicians were blinded to LOS and readmission data. Many factors potentially impacting LOS and discharge decisions were queried, including physical examination, medication use and kidney function.

Results:
We received 62 of 69 (90%) survey responses – 26 cardiologists and 36 hospitalists. Overall, 52% (32 of 62) were male with a median 7 years in practice [IQR 3-13]. We tracked HF utilization metrics in 58 physicians, encompassing 753 patient discharges in the preceding year. Total 30-day readmission rate was 17.0% (128 of 753). No significant differences were seen in discharge practices between readmission rate tertiles. Median of the median LOS was 4.7 days (IQR 4.0-5.8), and physicians above median LOS were compared to physicians below median LOS. Point estimates suggest physicians with lower median LOS targeted a daily net diuresis goal greater than 3L (40% vs 11% for those above median LOS, p = 0.1), and were less likely to hold beta blockers (17% vs 37%, p = 0.1) or to consider 24 hours of inpatient oral diuretics prior to discharge to be “very important” (16% vs 56%, p < 0.01). The pooled readmission rate of physicians below median LOS was not significantly different than those above median LOS (14.5% vs 16.2%, p = 0.6).

Conclusions:
We identified three specific HF management patterns that may be associated with lower LOS without a concomitant increase in 30-day readmission: (1) more aggressive daily diuresis, (2) continuation of beta blockade, and (3) not delaying discharge to observe 24 hours of an oral diuretic regimen. Further studies are warranted to confirm and quantify the impact of these changes on resource utilization.
Abstract 121: Improvement in Functional Mitral Regurgitation After Isolated Aortic Valve Replacement for Aortic Insufficiency
Authors: Boll Griffin , Chen Frederick Y
Published: June 2021

Objective:
Aortic insufficiency (AI) can lead to left ventricular (LV) remodeling characterized by dilation and increased LV mass. This remodeling can cause altered mitral valve coaptation and functional mitral regurgitation (FMR). While there is growing evidence that aortic valve replacement (AVR) for aortic stenosis promotes sufficient ventricular reverse remodeling that FMR improves or resolves, this effect is not well characterized for patients with AI.

Methods:
All cases of AVR for AI that were performed at a single center between January 2003 and December 2015 were reviewed. Cases with any concomitant procedures, any degree of aortic stenosis, any evidence of ischemic etiology, absence of mitral regurgitation, or significant primary mitral pathology were excluded from analysis. The primary outcome was change in FMR after isolated AVR. Secondary outcomes included change in LV ejection fraction (EF), left atrial (LA) dimension, and change in end-diastolic and –systolic LV dimensions. Two-tailed paired t-test was used to evaluate for difference between the two time points.

Results:
Over the course of 13.4 years, 31 cases of isolated aortic valve replacement for pure aortic insufficiency with concurrent functional mitral regurgitation were identified. 54.8% (17/31) of cases had some evidence of bacteremia or aortic vegetations at time of surgery, with 41.9% (13/31) of cases completed urgently. Postoperatively, FMR was improved in 74.2% (23/31) of the patients, and decreased by a mean 1.0 ± 0.8 grades (1.6 ± 0.8 vs 0.6 ± 0.7, p < 0.001). There was no significant change in LV EF (50.5 ± 13.4 vs. 50.2 ± 12.9, p = 0.892) or LA dimension (42.5 ± 7.2 vs 40.7 ± 5.9, p = 0.341), but there were significant reductions in the dimension of the LV at end-diastole (56.7 ± 7.1 vs 47.7 ± 8.5, p < 0.001) and end-systole (38.5 ± 9.7 vs 34.0 ± 8.3, p = 0.011).

Conclusions:
Significant reduction in ventricular size and subsequent improvement in functional mitral regurgitation is expected after isolated aortic valve replacement for pure aortic insufficiency.
Abstract 123: Temporal Variation Affect Stroke Unit Admission Rates, Observations From the National Swedish Stroke Register
Authors: Darehed David , Blom Mathias , Glader Eva-Lotta , Niklasson Johan , Norrving Bo , Eriksson Marie
Published: June 2021

Introduction:
It is firmly established that management of acute stroke at dedicated stroke units (SU) improves functioning and survival. Although guidelines recommend SU admission as 1
st
level of care for all patients with acute stroke, quality registers show that many patients are treated at non-SU wards. Previous studies have shown that there are different patterns of time that impose an effect on a multitude of outcomes for acute stroke patients. The primary objective of this study was to investigate if there were any temporal variations on direct SU admissions as 1
st
destination from the emergency department (ED).

Patients and methods:
This register study comprised data on patients with acute stroke admitted to any of the 72 Swedish hospitals that register stroke patients in the Swedish stroke register. Patients with transitory ischemic attacks (TIA) were excluded. The study period lasted from January 1, 2011 to December 31, 2015. Unadjusted analyses were followed by logistic regression analyses where we adjusted for the effects of confounding factors (age, sex, consciousness level, hospital, stroke type, thrombolysis, previous stroke, ADL-dependency, diabetes, hypertension and smoking).

Results:
The study cohort comprised a total of 117 804 patients with acute stroke. In total, 76.0% (89 502 of 117 804) of the patients were directly admitted to a SU from the ED. Unadjusted analyses revealed differences in direct SU admission as a function of time of week; while 83.4% (4033 of 4833) of the patients admitted on Friday mornings were directly admitted to a SU, only 68.4% (483 of 706) of patients admitted Sunday night were directly admitted to a SU. Analyses also revealed a direct admission rate during office hours of 79.9% (41 796 of 52 340) compared to 74.4% (45 812 of 61 605) during off-hours. Finally, monthly variation in direct admission rates ranged from 74.4% (7 803 of 10 483) in January to 77.3% (7 323 of 9 473) in June. Results from the adjusted analyses showed an OR of 2.570 (95% CI 2.132-3.099) for direct admission on Friday morning versus Monday night. Off-hours exhibited an OR of 0.725 (95% CI 0.704-0.747) versus office-hours. June exhibited an OR for direct admission of 1.212 (95% CI 1.127-1.303) compared to January.

Discussion:
There are several patterns of time affecting admission rates to a SU from the ED. Some of the variation seen in this study could possibly be explained by healthcare organizational factors such as hospital crowding. More studies are however needed to elucidate the mechanisms behind temporal variations as well as the magnitude of these effects on the quality of stroke care. Finally, we believe quality improvement efforts should focus on reducing temporal variation.
Abstract 129: Clinical Predictive Models for Valvular Heart Disease: A Systematic Review of the Literature
Authors: Wessler Benjamin S , Ajlan Muhammad , Lundquist Christine , Natto Zuhair , Paulus Jessica , Lutz Jennifer , Kent David M
Published: June 2021

Objectives:
Pre-procedure risk assessment is central to clinical decision making for patients with advanced valvular heart disease (VHD) and treatments are increasingly being offered to patients with elevated pre-procedure risk. While there are numerous clinical predictive models (CPMs) available for patients with VHD, the relative performance of these CPMs is largely unknown. Here we describe the performance of CPMs available for patients with VHD with specific attention to whether CPMs have been externally validated.

Methods:
To identify CPMs for patients with VHD, we conducted a systematic review of the Tufts PACE CPM Registry, a comprehensive database of cardiovascular CPMs. For each identified CPM for patients with VHD, we performed a complete citation search using Scopus to identify any external validations of these models published in other articles. We extracted information on CPM performance in both the original report and also the external validations. For external validations we calculated the relative percent decrease in discrimination.

Results:
We identified 41 CPMs predicting outcomes for patients with VHD. 33 (81%) predict outcomes following surgical intervention, 5 (12%) predict outcomes following percutaneous interventions, and 3 (7%) predict outcomes in the absence of intervention. Only 30/41 (73%) of the CPMs report a c-statistic. The median reported
c-
statistic was 0.77 [IQR, 0.04] for CPMs predicting outcomes following surgical interventions, 0.68 [IQR, 0.04] for CPMs for percutaneous interventions, and 0.83 [IQR, 0.07] for CPMs predicting outcomes in the absence of intervention. While a total of 69 external validations of these CPMs have been published, only 21 (51%) of the CPMs have ever been externally validated. For external validations that report
c-
statistics, we noted a median percent decrement in discrimination of -27.6% [IQR, -37.4] (
Figure)
.

Conclusion:
While there are numerous CPMs for patients with VHD, performance is often incompletely reported and half of these CPMs have never been externally validated. The CPMs that have been externally validated generally show substantially worse discrimination in external datasets compared to the derivation datasets.
Abstract 131: Association Between Limited Left Ventricle Ejection Fraction (LVEF) Transthoracic Echocardiograms (TTEs) and Overall TTE Utilization
Authors: Sandhu Alexander T , Heidenreich Paul A
Published: June 2021

Objectives:
To evaluate the change in utilization of TTEs associated with introduction of limited LVEF TTEs.

Methods:
We measured the number of total, full and limited TTEs before (2005) and after (2006-2015) implementation of limited LVEF TTEs at the Palo Alto VA Hospital (PAVA) and compared to other VA hospitals. We estimated the association between introduction of the LVEF TTEs at PAVA and TTEs volume using a linear regression model with other facilities as controls adjusted for facility, number of outpatients and average patient age.

Results:
There were 119 VA facilities that performed over 100 TTEs in 2005. Between PAVA and 118 control VA facilities, there was no significant difference in the number of outpatients (52,654 vs. 44,552 +/- 25,342[SD], p=0.37), average age (61.4 vs. 61.8 years +/- 2.5, p=0.44) total TTEs in 2005 (2,395 vs. 1,594.8 +/- 1,069.6, p=0.23) or limited TTEs (19 vs. 25.8 +/-101.5, p=0.48) in 2005. In 2005, limited TTEs were 0.8% of all TTEs at PAVA and 1.2% at controls. Between 2006-2010, limited TTEs were 8.3% of total at PAVA and 1.7% at controls. Between 2011-2015, limited TTEs were 19.5% of total at PAVA and 2.2% at controls. In 2005, total TTEs per outpatient were 4.5 per 100 at PAVA and 3.5 per 100 at other VA hospitals. Between 2006-2010, total TTEs were 4.5 per 100 patient-years at PAVA and 3.9 per 100 patient-years at controls. Between 2011-2015, total TTEs per capita were 4.6 per 100 patient-years at PAVA and 4.3 per 100 patient-years at controls. In an adjusted model, limited LVEF TTE introduction was associated with an average of -383 (CI: -554 to -211) annual full TTEs with no significant difference in total TTEs (-26.8; CI: -156 to 102). The decrease in full TTEs increased each year with an estimated -67.0 (CI: -97 to -37) full TTEs per year after 2006. This was equivalent to 683 fewer full TTEs (30.0% of total) in 2015.

Conclusion:
The introduction of limited LVEF TTEs at PAVA was associated with an increase in limited TTEs, a decrease in full TTEs, and no significant change in total TTEs when compared with control facilities. This suggests the introduction of LVEF studies was associated with substitution of limited TTEs for full studies. This could lead to substantial reductions in resource utilization and costs. We did not evaluate potential changes in outcomes associated with this change in TTE utilization.
Abstract 132: Association Between Perioperative Amiodarone and Postoperative Atrial Fibrillation Following Cardiac Surgery
Authors: Atreya Auras R , Priya Aruna , Stefan Mihaela S , Pack Quinn R , Lagu Tara , Lotfi Amir S , Lindenauer Peter K
Published: June 2021

Background:
Amiodarone effectively reduces the incidence of postoperative atrial fibrillation (POAF) in randomized trials and guidelines give a Class IIa recommendation for its use in high risk patients to improve outcomes; but little is known about its effectiveness to prevent POAF in routine clinical practice. Our aim was to determine the association between perioperative amiodarone use and clinical outcomes in a real-world cohort.

Methods:
We identified patients aged ≥18 years without atrial fibrillation at baseline, who underwent elective coronary artery bypass surgery ± heart valve surgery in a hospital that contributed to PREMIER, Inc. data warehouse during 2013-2014. We excluded patients to replicate patients enrolled in prior randomized controlled studies. Perioperative amiodarone use was defined as receipt of amiodarone on the day of surgery or prior to surgery within the same hospitalization. We used propensity scores to match patients who received perioperative amiodarone to patients who did not, and compared outcomes. Our primary outcome was POAF (not present on admission). Secondary outcomes included in-hospital mortality, 1 month-readmission among survivors, length of stay and cost.

Results:
We examined 12,758 patients free of AF admitted at 235 hospitals, of which 2191 (17%) were treated with perioperative amiodarone. Baseline characteristics were well matched after propensity scoring. (Table 1) After adjustment, receipt of amiodarone was associated with reduction in POAF in the matched cohort (ARR 5.6%; RR 0.83, 95% CI 0.75-0.92) but was associated with greater risk of ventricular arrhythmias (OR: 1.66, 95% CI: 1.20 - 2.29), cardiogenic shock (OR: 1.66, 95% CI: 1.13 - 2.42) and higher hospitalization costs ($1,159, 95% CI: $373 - $1,946). There were no differences in in-hospital mortality, length of stay, 1 month readmission.

Conclusions:
In this large cohort of propensity matched patients undergoing elective cardiac surgery, perioperative amiodarone use was associated with a modest reduction in POAF, but there was no significant relationship with mortality, length of stay, or 1 month readmission. However, we found a small increase in risk of ventricular arrhythmias, cardiogenic shock and costs; findings that have not previously been described and require further evaluation.
Abstract 137: Clinical Outcomes After Cardiac Stress Testing Among U.S. Patients Younger Than 65, 2006-2012
Authors: Kini Vinay , Dayoub Elias , Marzec Lucas , Dickinson Miriam , Wynia Matthew , Masoudi Frederick , Ho Michael , Groeneveld Peter
Published: June 2021

Background:
Recent studies of national practice patterns suggest that there is inconsistency in the appropriateness of referrals for cardiac stress testing. However, little is known about the prevalence of relevant clinical outcomes such as coronary revascularization or acute myocardial infarction (AMI) after stress testing.

Methods:
Using administrative claims from a large national private insurer, we conducted an observational cohort study of patients aged 25-64 who underwent de novo stress testing from 2006-2012. We excluded patients with a prior diagnosis of coronary artery disease, heart failure, or stroke. We calculated rates of AMI and coronary angiography with or without revascularization in the year following stress testing. We estimated logistic regression models that included demographic characteristics (age, sex, and race) and relevant comorbidities (diabetes, hypertension, and dyslipidemia). Finally, we stratified the cohort into quintiles based on their risk of having an AMI or revascularization event in order to describe the characteristics of patients at lowest and highest risk.

Results:
We identified 564,313 patients (mean age 50, 49% women, 73% white) who underwent stress testing during the study period. Among these patients, 15% had diabetes, 37% had hypertension, and 42% had dyslipidemia. Within one year, 2.5% of the cohort underwent coronary revascularization or were hospitalized for AMI, and 2.7% underwent coronary angiography without revascularization. In the risk-stratified analysis, 0.5% of patients in the lowest risk quintile had an AMI or revascularization event, compared to 6.2% in the highest risk quintile (p<.001). Compared to the highest risk quintile, patients in the lowest risk quintile were younger (mean age 40 versus 58 years; p<.001), more likely to be female (85% versus 0%; p<.001), more likely to be non-white (36% versus 16%; p<.001), and less likely to have comorbidities (Table).

Conclusion:
The percentage of commercially insured U.S. patients who had an AMI or revascularization event within 1 year of stress testing was small. In the lowest risk quintile, the a priori prevalence of coronary disease risk factors was low, and the rates of subsequent AMI and revascularization was extremely low, raising questions about the value of stress testing in this subgroup.
Abstract 147: Subtle Degrees of Frailty Result in Adverse Cardiac Surgery Outcomes
Authors: Wilson-Pease Emma , Kephart George , Gainer Ryan , Begum Jahanara , Hirsch Greg M
Published: June 2021

Background:
In North America, octogenarians are the fastest growing demographic. Chronological age of a patient is not always the same as their biological age, and their biological status can vary from robust to frail. Frail patients are predisposed to falls, institutionalization, hospitalization, and mortality. In the realm of cardiac surgery, there is little research examining frailty as a risk factor for cardiac surgical intervention.

Purpose:
The objective of the current study is to explore the relationship between more subtle degrees of frailty and cardiac surgical outcomes in more detail.

Methods:
This non-interventional study subjects all consented participants fitting inclusion criteria to the same questionnaires. The assessment is comprised of the Frailty Assessment for Care-Planning Tool (FACT) for both patient and their collateral, and the EQ-5D-3L. A similar interview process is repeated 5-7 months after surgery, with the addition of a qualitative interview.

Results:
Pilot study results (n=57) show that 52% of the participants were positive for at least one category of frailty at a level of 4/7 (vulnerable). Results also demonstrated that 3.8% of participants who scored zero deficits on the FACT were discharged to an institution for follow up care compared to 19.3% of participants with one or more deficits.

Conclusions:
Overall, participants were much frailer than expected, with over half being considered vulnerable or worse on the FACT scale. This signifies an increase in frailty in the elderly population, which supplies rationale for the current study. This study will analyze a larger sample of elderly cardiac surgery patients in the Atlantic provinces to more thoroughly investigate this relationship.

Implications:
This study will assist in educating future heart surgery patients about their possible risks. It is hoped that patients who possess more knowledge about their personal risks will be able to make more informed decisions about their surgery. Strategies to address and reduce frailty by increasing mobility and cognitive function and reducing nutritional deficiencies could use this information to inform future work.