bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P60: Inclusion of Pregnancy History in Cardiovascular Risk Screening of Women
Authors: Morrone Doralisa , Bradley Elizabeth , Ehrenthal Deborah
Published: March 2022

Background:
Epidemiologic studies have demonstrated that women with a history of hypertensive disorders during pregnancy are at greater risk for cardiovascular disease later in life. Despite this, pregnancy history is not usually collected. Our purpose is to evaluate the association of a history of hypertension during pregnancy with hypertension later in life within a cohort of community women undergoing cardiovascular screening,

Methods:
We conducted a cross-sectional study of women who responded to an on-line cardiovascular risk factor assessment and then participated in on-site screening. Information about traditional risk factors, pregnancy history, and medication use, as well as physical examination and biologic testing were obtained at the on-site screening. Chi-square test of independence and multivariable logistic regression were used to test the association of pregnancy history with traditional cardiovascular risk factors and outcomes at the time of screening.

Results:
We identified 449 women age 35 years and older; 74% white and 21% black. The mean age was 56.6 years (SD=10.6), mean BMI 30.9 kg/m
2
(SD=7.3), and 32 (7.1%) reported a history of hypertension during pregnancy. At the time of the risk screening, 193(43%) were treated for hypertension, 156 (34.7%) for hyperlipidemia, and 12 (2.7%) for diabetes. Self-reported history of hypertension during pregnancy was associated with a significantly increased odds of current hypertension (aOR=2.4, 1.03, 5.5 95%CI) after adjusting for age, BMI, family history and race, but no increase in treatment for hyperlipidemia or diabetes. The odds of current cardiovascular disease associated with hypertension during pregnancy were increased, after adjusting for current hypertension, but this was not statistically significant due to a low frequency of cardiovascular events.

Conclusions:
History of hypertension during pregnancy was associated with hypertension later in life. Larger studies are needed to assess the utility of pregnancy history at improving risk factor assessment in women. Until then including pregnancy history in cardiovascular risk screening requires consideration.
Abstract P66: Can Euroscore Predict Intensive Care Unit Length of Stay After Cardiac Surgery? A Regression Model of Competing Risks Based on Pseudovalues of the Cumulative Incidence Function
Authors: Barili Fabio , Capo Antonio , Cheema Faisal H , Jiang Jeffrey , Ardemagni Enrico , Barzaghi Nicolette , Grossi Claudio
Published: March 2022

Background:
The perioperative period has been an increasingly noticed and salient issue for both clinicians and institutions and especially length of stay in the Intensive Care Unit (ICU-LOS) after cardiac surgery. The aim of this study was to design a specific ICU-LOS risk model based on the euroSCORE preoperative factors utilizing modeling strategies for time-to-event data.

Methods:
From Jan '04 to Jan '10 data on 3263 consecutive heart surgery patients were prospectively collected. ICU length of stay was analyzed as a time-to-event variable in a competing risks framework with death as the competing risk. Covariate effect on the cumulative incidence function was modeled using pseudo-values from a jackknife of the non-parametric estimate of the crude cumulative incidence.

Results:
Median ICU-LOS was one day and the 3rd quartile was 2 days. All euroSCORE factors were included in the final reduced model except gender, post-infarct septal rupture, unstable angina and recent myocardial infarction due to lack of significance in the initial model. The relative risk (RR) of discharge ranged from 0.35 to 0.90. In the final model, critical preoperative state (RR 0.33), emergent operation (RR 0.35), left ventricular dysfunction (RR 0.42) and serum creatinine >200 μMol/L (RR 0.49) had the largest weight on ICU discharge probability. Effect of predictor was often time-dependent and RR tended to increase towards 1.0, reflecting a progressive reduction of their weight on ICU-LOS (figure).

Conclusions:
Most of the euroSCORE variables were demonstrated to be independent predictors of ICU-LOS and were used to develop a dynamic ICU prediction model through competing risks analysis.
Abstract P67: Nonwhite Males Show Less Satisfaction with Atrial Fibrillation Care
Authors: Beru Yodit , Yarboro Elizabeth , Hall Laura Lee
Published: March 2022

As part of a performance improvement continuing medical education activity on atrial fibrillation (afib), cardiologists and other health care providers solicited baseline surveys to ascertain patient attitudes about quality of life and provider communication and behaviors. Using selected questions from the ambulatory CAHPS survey and internally developed afib-specific questions, surveys were collected from 1,385 patients. The sample included more males (n=757) than females (n=574) and was majority white (n=1207) and 55 or older (n=1200). A subset of the survey containing 7 CAHPS items (α = .88) assessed the extent to which their doctor explained things clearly, listened carefully, spent enough time with them, and other indicators of quality care. Items were scored using a 4-point Likert scale and responses were analyzed using ANOVA with two independent variables (sex and race/ethnicity) and their interaction term. For analysis purposes, race/ethnicity was re-coded into 2 groups: white and non-white. The main effects of sex, race/ethnicity, and their interaction term were significant (F (3,1327) = 23.77, p. = .00; F (3,1327) = 10.74, p. = .00; F (3,1327) = 28.66, p. = .00, respectively). Results indicated non-white males were least satisfied with care (see attached graph). While the results are preliminary and need further validation, reduced satisfaction with care among non-white males is consistent with recent results from focus groups conducted by Griffith and colleagues at the University of Michigan School of Public Health. As the project continues, educational interventions for physicians will highlight this disparity and potential changes over time will be examined.
Abstract P83: What Women Would Like to Know About Sexuality Following an MI
Authors: Decker Carole , Garavalia Linda , Abramsohn Emily , Garavalia Brian , Krumholz Harlan , Spertus John A , Chan Paul S , Spatz Erica , Lindau Stacy
Published: March 2022

Purpose:
Post-MI recovery requires major life adjustments, which may include a person's sex life. MI educational materials contain information on medications and activities, but often neglect sexual activity. A qualitative study of sexuality with post-MI women sought to identify what information would be helpful.

Methods:
Women in the U.S. TRIUMPH MI registry who reported being sexually active before and 12 months after their MI were randomly selected. In-depth telephone interviews 18-24 months post-MI were conducted until thematic saturation occurred. Transcripts were coded and content analyzed by a multidisciplinary team of a nurse, psychologist, public health researcher, anthropologist, and gynecologist.

Results:
The 17 female subjects averaged 57.6 years of age (43-75 years). Twelve stated they had not received any information about sexual activity even though they felt sex was still an important aspect of their life. Three thematic categories emerged: initiating the discussion; criteria for readiness to resume sex; and education content. Several women mentioned that they were uncomfortable
initiating the discussion
of sex post-MI; a 48 y/o woman said, "I think definitely the doctor (cardiologist) has to initiate it because most women will not bring it up." The
criteria for when to resume sex
safely was not communicated clearly. Several women said that when they asked their physician and were told ‘when you feel like it,’ they remained fearful. One 49 y/o stated she got her information from a popular movie where "Jack Nicholson had a heart attack and the doctor told him that when he could walk up a flight of stairs, he could have sex. That’s kind of what I went by." The
specific content for sexuality education
was also missing. A 69 y/o described the lack of information: "I had cardiac rehab and there were lots of different classes I could go to. But there was nothing offered in the sexuality area. It was a missing link."

Conclusions:
Patients emphasized the importance of receiving guidance on timing and safety of resumption of sexual activity from their cardiologist, tailored to their specific cardiac condition and overall health. Initiating the discussion and providing information about sexual activity is an important opportunity for post-MI education.
Abstract P84: Antithrombotic Treatment Patterns, Hospitalizations, and Associated Costs in Acute Coronary Syndrome (ACS) Patients
Authors: Lefebvre Patrick , Laliberte Francois , Dea Katherine , Nelson Winnie , Crivera Concetta , Ellis Lorie , Schein Jeff R , Damaraju C V , Mody Samir , Duh Mei Sheng
Published: March 2022

Background:
We investigated real-world patterns of use of antithrombotic therapy among ACS patients to evaluate the level of undertreatment, nonadherence to medication use, recurrence of cardiovascular events, and associated costs.

Methods:
We analyzed the PharMetrics Integrated Claims database from 01/2004 through 12/2009. Patients ≥18 years old with ≥1 claim for ACS during a hospitalization or emergency department visit were included. Adherence to antiplatelet therapy was estimated using proportion of days covered (PDC) by drug available. Persistence was defined as continuous drug claims without a gap of ≥30 days between refills. Major outcomes were cardiovascular disease (CVD)-related hospitalization, readmission, and length of stay. We reported all-cause and CVD-related per-patient-per-month (PPPM) healthcare costs. Incidence rates of major outcomes were calculated as number of patients with an event divided by patient-years of observation, censored at the time of the first event.

Results:
Among the 173,573 ACS patients, mean age was 55.4 years; 36% (62,914 of 173,573) were female. During follow-up, 36.2% (62,774 of 173,573) and 5.0% (8685 of 173,573) had antiplatelet or anticoagulant prescriptions; 3.4% (5866 of 173,573) had both. Mean duration of antiplatelet therapy was 457 days. At 1.5, 6, and 12 months, mean PDCs were 0.93, 0.78, and 0.70. Kaplan-Meier rates of persistence after 6 and 12 months were 0.66 and 0.47. The incidence rate of CVD-related hospitalization was 0.22 events per patient-year of observation. The rates of CVD-related and all-cause hospital readmissions were 0.32 and 0.41 events per patient-year; mean length of stay was 7.1 and 6.8 days per rehospitalization. All-cause healthcare cost PPPM was $2419; 63% ($1518 of $2419) of total all-cause costs PPPM were associated with claims for CVD-related hospitalization.

Conclusions:
This observational study suggests undertreatment in secondary prevention of ACS. Persistence with antiplatelet therapy dropped dramatically by 6 months after the initial event. ACS patients have a high risk of repeated CVD-related hospitalizations that incur high costs to the healthcare system. Interventions to improve long-term use of evidence-based therapies may improve ACS management.
Abstract P87: Reduction of Appropriate Implantable Cardioverter-Defibrillator Shocks for Ventricular Arrhythmias with Statin Therapy in Ischemic Versus Nonischemic Cardiomyopathy
Authors: Contractor Tahmeed , Beri Abhimanyu , Gardiner Joseph , Ardhanari Sivakumar , Thakur Ranjan
Published: March 2022

Introduction:
Statins have been hypothesized to decrease ventricular tachycardia/ fibrillation (VT/VF) through a direct anti-arrhythmic effect. Clinical studies have demonstrated a reduction in VT/VF only in populations with underlying ischemic heart disease. There have been no conclusive studies in patients with non-ischemic cardiomyopathy.

Methods:
Patients with an ejection fraction <35% who received an implantable cardioverter defibrillator and had more than one month of follow up were included. The ischemic and non-ischemic cardiomyopathy patients were further separated into statin treatment and control groups. Occurrence and frequency of appropriate shocks were analyzed utilizing negative binomial models to account for over dispersion of the “count” data (number of appropriate shocks) and an adjusted intensity rate (IR) was calculated. Models were separately developed for the ischemic and non-ischemic groups and the IR was compared.

Results:
We included 676 patients whose mean age was 67.0 (±12.3) years, follow-up 3.32 (±2.43) years and ejection fraction 25.7 (±6.8) %. There were 65% (329/506) and 42% (72/170) patients on statin therapy in the ischemic and non-ischemic groups, respectively. Occurrence of appropriate shocks was significantly reduced with statins in the ischemic cardiomyopathy patients (13.4 % [44/329] versus 20.9% [37/177]; relative risk=0.64, p=0.028), but not in the non-ischemic group. The final negative binomial models for the two groups had adequate goodness of fit. The adjusted IR of shocks was significantly lowered in ischemic cardiomyopathy patients with statin therapy [IR ratio=0.23, 95% CI 0.12 to 0.47]. No such benefit was noted in the the non-ischemic cardiomyopathy patients [IR ratio=1.27, 95% CI 0.37 to 4.40].

Conclusions:
Statins reduced the occurrence and frequency of appropriate shocks for VT/VF in patients with ischemic but not in non-ischemic cardiomyopathy. Larger, prospective studies comparing these two groups are needed to confirm these findings.
Abstract 126: Massachusetts Health Reform Did Not Reduce 30-day Readmissions for Acute Myocardial Infarction among Massachusetts Residents Overall or among Racial/Ethnic Minorities
Authors: Lasser Karen E , Chu Chieh , McCormick Danny , Kressin Nancy , D'Amore Meredith , Cabral Howard , Kapoor Alok , Rose Adam , Hanchate Amresh
Published: March 2022

Introduction:
After Massachusetts (MA) health reform, the percent of uninsured residents fell, particularly among minorities. Studies have not examined the effect of this policy change on 30-day readmission rates, and disparities in such rates, following acute myocardial infarction (AMI).

Hypothesis
: 30-day readmission rates will decline in patients age 18-64 (affected by health reform) vs. patients age ≥ 65 (most unaffected)

Methods:
We used 2004-2009 MA discharge data. We compared all-cause 30-day readmission rates after a hospitalization for AMI overall, and among racial subgroups, for patients age 18-64 vs. age ≥ 65 in the period prior to and following reform. We used chi-square tests to compare unadjusted 30-day readmissions for AMI between groups. Treating patients age 18-64 as the intervention cohort, and those age ≥ 65 as the control cohort, we used logistic regression to conduct difference-in-difference analysis that estimates odds of readmission in the post-reform period vs. the pre-reform period in MA adjusted for secular changes. The model was also adjusted for age, gender, and medical comorbidity. To assess differences in white vs. minority disparities over time between the pre and post reform periods among patients age 18-64 vs. age ≥ 65, we used logistic regression to conduct difference-in-difference-in-differences analysis.

Results:
Among patients age 18-64, pre-reform and post reform readmission rates were 11.5% and 10.5%. Among patients age ≥ 65, they were 24.0% and 22.2%. The post-reform decrease among patients age 18-64 was not different than the decrease among patients age ≥ 65 (difference-in-difference adjusted OR (AOR) =1.0; 95% CI=0.9-1.2). Among patients age 18-64, blacks had higher readmission rates than whites pre and post-reform. Post-reform changes in readmission rates among non-elderly and elderly adults were not significantly different among whites, blacks, and Hispanics. There was no significant change in the presence of disparities between whites and blacks or between whites and Hispanics among non-elderly and elderly adults pre- and post-reform.

Conclusions:
A major coverage expansion in MA was not associated with a reduction in 30-day readmissions for AMI overall or a reduction in racial and ethnic disparities.
Abstract 14: Intensity of Vascular Care for PAD: More Spending, But Not Fewer Amputations.
Authors: Goodney Philip P , Travis Lori L , Brooke Benjamin S , Wallaert Jessica B , DeMartino Randall , Birkmeyer John D , Goodman David C , Fisher Elliott S
Published: March 2022

Introduction:
While significant disparities exist in the care of patients with severe PAD, the relationship between the intensity of vascular care, spending, and limb salvage remains unclear.

Methods:
We studied the vascular care provided to 20,058 Medicare patients in the year prior to amputation for critical limb ischemia, using the 306 hospital referral regions (HRRs) as defined in the Dartmouth Atlas of Healthcare. We examined associations between the intensity of vascular care (defined as the number of revascularization procedures or vascular-related admissions in the year prior to amputation), price-adjusted Medicare spending, and population-based amputation rates.

Results:
Overall, 54% of patients did not undergo any revascularization in the year prior to amputation. Of the 46% who underwent open or endovascular revascularization, 18% had one procedure, and 28% had more than one revascularization procedure. Among patients who underwent revascularization, the mean regional cost of vascular care in the year prior to amputation was $14,155, such as in Gainesville FL (Figure, Panel A). However, in HRRs where at least 25 patients underwent amputation, spending on vascular care in the year prior to amputation varied from $9,475 (Bismarck, North Dakota) to $26,787 (St. Paul, Minnesota). The intensity of vascular care, as measured by procedures and hospitalizations, was well correlated with spending (r=0.36), but higher spending was not associated with lower population-based amputation rates (r=0.07) (Figure, Panel B).

Conclusion:
While Medicare spending is directly related to the intensity of vascular care, there is little evidence to suggest that higher spending is associated with lower population-based rates of amputation. Future health policy is needed to better direct Medicare spending for patients at risk for amputation.
Abstract 144B: Racial Differences in Physiological and Behavioral Response to School Based Wellness Program
Authors: Jamerson Taylor , Gurm Roopa , Smith Cydni A , Corriveau Nicole , Kline-Rogers Eva , Eagle Kim A , Jackson Elizabeth A
Published: March 2022

Background:
Racial differences in cardiovascular (CV) risk factors have been shown to exist in children. However, much of this data was obtained decades ago in a rural cohort of children in Bogalusa, LA. Given the growing epidemic of childhood obesity, we sought to examine CV risk factors in black and non-black 6
th
grade students prior to and seven months after implementation of a school-based wellness program targeting both inner city and suburban children in Southeast Michigan.

Methods:
Data from 1,979 middle-school students enrolled in Project Healthy Schools (PHS) were used to compare health behaviors and physiologic markers including lipids, blood pressure (BP), and BMI. PHS is designed to promote physical activity, consumption of fruits and vegetables, decrease consumption of fast/fatty foods and leisure screen time and encourage healthier beverage choices. Pre/post assessments included surveys of diet and physical activity. A Mann-Whitney, non-parametric test was used to compare the differences.

Results:
Among the 1,979, 504 (25.5%) were black. At baseline, % overweight/obese was significantly different between blacks and non-blacks (39.9% vs. 33.0%, p=0.003. Blacks had poorer diets and were less active than non-blacks (p< 0.001). BP and low-density lipoprotein (LDL) cholesterol were similar, while high-density lipoprotein (HDL) was higher in blacks (55 mg/dL vs. 52 in non-blacks) (p=0.004), and triglycerides were higher in non-blacks (92 vs.122 mg/dL) (p<0.001). Seven months after PHS was initiated, blacks improved their diets and physical activity more (p< 0.02). Blacks had a significant decrease in LDL cholesterol (10 mg/dL vs. 1) (p<0.001) whereas non-blacks had significant reduction in triglycerides (3 vs. 16 mg/dL) (p=0.041).

Conclusion:
Black 6
th
grade students show higher rates of obesity, poor dietary habits, and less physical activity at baseline. This data suggests that school-based wellness programs such as PHS can improve dietary, physical behavior and cholesterol profile. Early intervention for risk factor modification is not only possible but may be of great importance to the prevention of CV disease in adults, particularly in high risk groups like blacks.
Abstract 146: Healthcare Costs Among Nonvalvular Atrial Fibrillation Patients Experiencing A Major Bleeding Event In A Large Managed Care Population
Authors: Deitelzweig Steven B , Pinsky Brett , Buysman Erin , Lacey Michael , Makenbaeva Dinara , Wiederkehr Daniel , Graham John
Published: March 2022

Introduction
Bleeding among patients with nonvalvular atrial fibrillation (NVAF) may prevent subsequent anticoagulation, and consequent inadequate stroke prophylaxis could extend the economic impact of bleeding beyond the acute event.

Hypothesis
We hypothesized that costs for NVAF patients rise acutely following a major bleed and stay elevated through extended follow-up compared with costs for NVAF patients without a major bleed.

Methods
Adults with healthcare claims related to AF between Jan 2005 and Jun 2009 but no evidence of valvular disease were included. Follow-up lasted until the earliest of death, disenrollment from the health plan, or 30 Jun 2010. A bleeding event was considered major if it was associated with any of the following: inpatient care, blood transfusion, decreased hemoglobin or hematocrit, death, physician guided medical or surgical treatment, or intracranial bleed. Among patients with major bleeding events, average daily costs were calculated in the pre-bleed (from the index date until the event) and post-bleed (from the end of the event until the end of follow-up) periods, and during the event. Among patients without major bleeding events, the average daily cost during the entire follow-up period was calculated.

Results
Among 48,260 patients with NVAF (mean age 67±13 years; 62% male), 7908 (16%) had a major bleeding event during a mean (SD) follow-up of 802±540 days (median 673 days). Major bleeding events lasted a mean of 15±25 days and averaged $16,830 per event. Among patients who experienced a major event, average costs per patient increased from approximately $50 per day in the pre-bleed period to $63 per day in the post-bleed period, a difference of approximately $13 per day. Daily costs for NVAF patients who did not experience a major bleeding event averaged approximately $36 per day; thus, average daily costs for patients who had a major bleed were greater in both the pre- and post-bleed periods (by $14 per day and $27 per day, respectively) than for patients who did not have a major event. Cost differences persisted 2 years following incident major bleeding events.

Conclusions
Major bleeding events among NVAF patients are associated with substantial healthcare costs, both directly related to the event and in the post-event period.
Abstract 162: Rescue Carotid Stenting To Reestablish Flow In The Middle Cerebral Artery And Anterior Cerebral Artery In Patients Who Present With Acute Ischemic Stroke And Carotid Occlusion
Authors: Lodi Yahia M , Swarnkar Amar , Sethi Khalid , Bajwa Syed , Gaylon Dan
Published: March 2022

Introduction:
Acute ischemic stroke due to the occlusion of the internal carotid artery (ICA) is associated with malignant stroke and poor outcome. Without revascularization of ICA, perfusion to the middle cerebral artery (MCA) and anterior cerebral artery (ACA) is not possible.

Objective:
Objective of our study is to evaluate the technical feasibility of emergent extracranial carotid artery revascularization using stent and to evaluate the impact of stenting in distal cerebral perfusion.

Method:
From an established stroke database consecutive patients with acute ischemic stroke who underwent emergent extracranial carotid artery stenting and thrombolysis/clot retrieval of the MCA and ACA from July 2007 to December 2008 were enrolled. Patients’ demographics including presenting National Institute of Health Stroke Scale (NIHSS), degree of revascularization, hemorrhagic conversion and 30 days outcome data using Glasgow Outcome Scale (GOS) were collected.

Result:
Successful ICA stenting was possible in 20/21 (95%) patients. The mean age of patients was 62 plus-minus 15 years and mean NIHSS was 18 plus-minus 5. Carotid stenting facilitated successful revascularization of the MCA and ACA using TPA (tissue plasminogen activator) and MERCI (mechanical embolus removal in cerebral ischemia) clot retriever device in 18 patients (85.7%), 14 (67%) of which has achieved complete recanalization in the MCA and ACA. In complete recanalization group, a 4 point or higher NIHSS improvement was observed in 11/14 (78.5%) patients. Symptomatic intracranial hemorrhage was observed in 9.5% patients. Seven (50%) of 14 patients who achieved complete recanalization had a good outcome. Five (71%) of 7 patients who did not achieve complete recanalazation of the MCA and ACA died and had NIHSS 20 or higher. NIHSS 20 or higher was associated with incomplete recanalization of the MCA and ACA and poor outcome.

Conclusion:
Emergent extracranial carotid artery revascularization using stent is not only technically feasible in patients with acute ischemic stroke who present with acute carotid artery occlusion, but it also facilitates successful reestablishment of flow in the MCA and ACA with good outcome. Further study is necessary.
Abstract 172: Stroke Clinical Champions and Quality Improvement
Authors: Damush Teresa , Daggett Virginia , Plue Laurie , Myers Jennifer , Robinson Joshua , Mathias Marianne , Williams Linda
Published: March 2022

Objective:
Clinical champions may serve as important facilitators of clinical quality improvement. We sought to understand how stroke clinical champions communicate within and between clinical services among providers of acute stroke care which spans clinical services.

Methods:
We conducted semi-structured, in-person baseline interviews with clinical providers of acute stroke care services and related administrators and service managers across 11 VA Medical Centers across the US. We consented the responders and audiotaped the interviews. Closed ended question responses were entered into a database and open ended question responses were transcribed and qualitatively coded. For qualitative data, we assigned at least two coders per transcript for analysis. A priori, we operationalized key constructs of stroke quality improvement and utilized these constructs as an initial coding scheme. Additionally, we coded emerging themes from the qualitative responses using Nvivo software. Coders met regularly to review and consolidate when possible the emergent themes.

Results:
We completed 104 interviews of which the respondents included the following service lines: neurology, emergency department, inpatient care, education, social work, quality improvement, rehabilitation. Qualitative analyses indicated that 5 of the 12 facilities had unanimously identified stroke clinical champions. These sites reported more frequent communications within neurology service and stronger communications across service lines. Respondents external to the neurology service line were more likely to identify the presence of a stroke clinical champion at VA facilities that had established acute stroke care processes across the medical center compared to facilities where no systematic acute stroke care processes currently existed.

Conclusions:
A stroke clinical champion may be associated with the establishment of systematic clinical processes that span interdisciplinary services within an organization. The coordination of such interdisciplinary care and the brokering of interdisciplinary relationships may need a clinical champion to foster.

Impact:
Understanding the development of a stroke clinical champion is crucial for organizations that seek to improve their clinical processes.
Abstract 173: Use of Linked Datasets to Analyze Post-Stroke Outcomes in Massachusetts
Authors: Kulick Erin , Land Thomas , Schwamm Lee H
Published: March 2022

Introduction:
Stroke is the 4th leading cause of death in the United States and continues to be a leading cause of severe long-term disability. In Massachusetts (MA) there are over 18,000 inpatient hospitalizations attributed to stroke each year. Since 2004, the CDC-funded Paul Coverdell Acute Stroke Registry (MA-PCNASR) has collected detailed clinical and in-hospital data on stroke patients at 58/72 hospitals. Overall goals of the registry are to improve stroke care by tracking and evaluating adherence to evidence based stroke performance measures. While data has shown a significant improvement in adherence over time, to date there has been no method of examining post discharge patient outcomes of re-admissions and mortality. We sought to examine the feasibility of linking this dataset to statewide administrative datasets to analyze post-stroke outcomes.

Methods:
MA-PCNASR patients from 2005-2008 (n=31,113) were matched against stroke cases in the MA Hospital Discharge Database (HDD) (n=73,577). De-identified records were probabilistically linked (
LinkPlus, CDC
) on five points: patient admission date, discharge date, age, gender and hospital. Once linked, patient records were matched within the HDD by medical record number and encrypted social security number to examine re-admission rates as well as previous admissions before the stroke event. Taking a conservative approach, records with a probabilistic linking score of 9 or above (out of a possible 17.6) were accepted as true matches. Patient characteristics and co-morbidities were compared between the matched and un-matched groups.

Results:
Overall, 82% (n=25,480) of PCNASR cases were matched to inpatient cases. There was no significant change in match percentage per year. It is expected that the presence of patients treated with t-PA and then transferred to another hospital within the un-linked cohort accounts for much of the difference seen between the groups (Table 1). Secondary matching will aim to identify these patients and link them to the final site of their inpatient care.

Conclusions:
Results indicate the feasibility of linking MA-PCNASR and HDD data. Preliminary linking has begun between the linked database and mortality data from vital records in order to assign 30 d, 90 d and 1 year mortality. The resulting dataset will be a valuable resource which will allow, for the first time in MA, stroke surveillance across the entire continuum of care - from the emergence of risk factors, to the index stroke event, and post-discharge outcomes- and targeted efforts at increasing adherence to measure4s that demonstrate an impact on health outcomes.
Abstract 175: Efficacy and Safety of Extra-Cranial Carotid Stent Placement - a Nation-Wide Case-Series Report
Authors: Lin Jou Wei , Chang Chia-Hsuin , Lai Mei-Shu
Published: March 2022

Background:
Carotid angioplasty and stent (CAS) placement has been applied to the patients with internal carotid artery stenosis in the symptomatic and asymptomatic patients with significant carotid atherosclerosis. However, the efficacy and safety of extra-cranial CAS were not fully evaluated.

Methods:
We analyzed the data from the patients who received CAS in the Taiwan National Health Insurance claims database from 2005 to 2008. The incidence of ischemic stroke in the periods after CAS (0-30 days, 31-90 days, 91-180 days, and 181-365 days) was compared with that in the year prior to the procedure as a self-controlled case series approach. A conditional Poisson regression model was applied to estimate the incidence ratio and 95% confidence intervals relative to the patient’s baseline risk.

Results:
A total of 1193 patients who had 70% stenosis in at least unilateral internal carotid artery underwent CAS. Among them, 93 had experienced ischemic stroke in the year prior to the procedure. In the first 365 days following CAS, 237 incident ischemic events occurred and the incidence ratio was 2.45 (95% CI: 1.95-3.13). There was a significantly increased risk for ischemic stroke in the first 30 days after CAS (incidence ratio: 26.27, 95% CI: 20.68-33.37). However, the incidence ratio of ischemic stroke decreased to 0.50 (95% CI: 0.24-1.03) in 31-90 days, 0.31 (95% CI: 0.08-0.51) in 91-180 days, and 0.20 (95% CI: 0.07-0.39) in 181-365 days.

Conclusions:
The results of this study have demonstrated that the risk of ischemic stroke was extremely high in the first 30 days after CAS. The protective effect against ischemic stroke gradually developed after the first month. Future work should be focused on exploring the factors that might predispose to peri- and post-procedural stroke in the early phase following CAS.
Abstract 176: Regional Stroke Networks May Fill Gaps for Community and Quality Improvement
Authors: Janjua Nazli , Melluzzo Shannon , Wira Charles R , Magdon-Ismail Zainab , Day David , McCullough Louise D , Stein Joel , Lichtman Judith H , Gropen Toby
Published: March 2022

Introduction:
State departments of health (DOH) and professional organizations such as the American Heart Association (AHA) create guidelines that influence many aspects of the stroke systems of care (SSC); however, they do not directly address ongoing quality improvement (QI) efforts and community/professional education (CE) activities. Regional networks such as The NorthEast Cerebrovascular Consortium (NECC) may better liaise with hospitals to fill this gap. We assessed current adherence with recommended stroke improvement activities in the NECC and the attributed source (Joint Commission (JC), hospital QI, AHA, The NECC, and Get With the Guidelines-Stroke [GWTG-S®]) on performing these activities.

Methods:
Surveys were completed by 37% (172/471) of acute care hospitals in the Northeast region and 100% (8/8) DOH regarding hospital capacity, stroke center designation (SCD), and SSC programs. Respondents used a Likert scale of 1-5 (5=strongly agree) to rate influence of state SC mandates; Joint Commission (JC), hospital QI, AHA, The NECC, and GWTG-S® recommendations on their practices.

Results:
Over 80% of hospitals offer smoking cessation counseling, blood pressure screening, and rehabilitation, attributing AHA guidelines as most influential for these programs (mean=4.2). Less than 2/3rds of hospitals sponsor outreach programs to community organizations, whereas 83% target emergency medical services. Hospitals with an increase in thrombolytic use over the past 5 years attribute this largely to attending level acute stroke team coverage, again influenced by the AHA (mean=4.0). Among 167 reported SSC areas needing improvement, 56 (34%) identified gaps in QI (compliance, provider education and feedback) and 29 (17%) in CE.

Conclusions:
Though AHA and DOH guidelines are well incorporated into hospital practice, enforcement of standards, CE and QI processes are needed. Regional organizations such as the NECC are well poised to fill this gap through in-person collaboration and meetings of local stakeholders.
Abstract 183: Psychosocial Risk Profiles in Patients with Acute Coronary Syndrome: First Findings from TRACE-CORE
Authors: Anatchkova Milena , Allison Jeroan , Fang Hua , Kiefe Catarina
Published: March 2022

Background:
Psychological distress variables (depression, anxiety, stress) and social support are associated with health outcomes in patients with acute coronary syndrome (ACS), as are low quality of life (QoL) and socioeconomic status (SES). Distress variables are often correlated and, together with social support, may generate categories of psychosocial vulnerability that could be useful in predicting cardiovascular outcomes. We examined the feasibility of generating psychosocial risk profiles based on these factors and, as an initial test of validity, hypothesized that high psychosocial risk would be associated with low SES and low QoL.

Methods:
Adults (n = 793 to date) in Worcester, MA and Macon, GA were interviewed during hospitalization for ACS in an ongoing longitudinal study within the Transitions, Risk, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE). Patients completed assessments of depression (PHQ-9), perceived stress (PSS), anxiety (GAD-7), social support (MOS), social network (LSNS), and generic (SF-36), and condition-specific (SAQ), QoL measures. K-means cluster analysis identified groups with different risk profiles using standardized summary scores of distress (PHQ-9, PSS and GAD-7) and social support (LSNS and MOS). We tested relationships of these clusters with demographic characteristics and QoL.

Results:
Average patient age was 61 years, 35% were women, 76% non-Hispanic White, 13% African American. We identified 3 clusters designated low, moderate and high risk (Table 1). The low-risk cluster had low distress and high social support scores; moderate-risk group had average distress and low social support; high-risk group had high distress and average social support. Moving from low to high cluster risk, we found increasing proportions of women and patients with lower SES. In contrast age and QoL decreased as cluster risk increased.

Conclusions:
Data-driven psychosocial risk stratification correlates as predicted with QoL and socioeconomic indicators If these clusters remain stable over time and are related to short- and long-term ACS outcomes as well (a testable hypothesis as TRACE-CORE progresses) they may facilitate developing tailored interventions to improve ACS patient outcomes.
Abstract 186: Decision Making Experiences of Patients With Implantable Cardioverter-Defibrillators (ICDs)
Authors: Matlock Daniel D , Jenkins Amy R , Masoudi Frederick A , Magid David J , Sepucha Karen A , Kutner Jean S
Published: March 2022

Introduction:
Decision making surrounding ICDs is complicated, involving balancing benefits of prolonging life with potential harms. As such, it is essential to include patients’ perspectives and values in ICD decision making. Research on other interventions suggests that some patients regret medical decisions that they make (or that were made for them). The objective of this study was to describe the decision-making experiences of patients who reported that they did not want an ICD at the time of implantation.

Methods:
We conducted a mailed survey of 412 patients in the Kaiser Colorado health system with ICDs about their experience in ICD decision making. The survey included a question: “Did you want an ICD?” The survey also asked questions about participation in their decision making and the validated decision regret scale (scored 0-100). Those responding “yes” or “no” to wanting an ICD were compared using Pearson’s Chi-squared test of association for dichotomous outcomes and t-tests for continuous outcomes.

Results:
A total of 295 patients with ICDs responded to this survey (response rate 72%, 295 out of 410). Of these, 19% (56 of 295) reported not wanting their ICD at the time of implantation. Patients who stated that they did not want the ICD were younger (<65 years-old; 74% vs. 43%, p <0.01, 36 vs. 91 of 127, respectively), had higher decision regret (31/100 vs. 11/100, p<0.01), and reported less participation in their decision making (See Table). Patients wanting and not wanting their ICD were equally likely to have experienced a shock (43% vs. 53%, 88 vs. 26 of 114, respectively, p = .19).

Conclusions:
Patients who reported not wanting their ICD also reported less participation in their decision making and higher decision regret. On one hand, these results are limited by recall bias and patients may be expressing frustrations with experiences that occurred after the ICD was implanted. On the other hand, they may suggest potential opportunities for improvement in decision making at the time of implantation. Future research should test whether a better decision-making process at the time of implantation could improve outcomes such as decision regret, decision participation, and decision quality.
Abstract 19: Ability to Perform Supine Bicycle Exercise Predicts Short-Term Mortality in Patients Undergoing Dobutamine Stress Testing
Authors: Rastogi Ashish , Yager Neil , Bindra Amarinder , Fein Steven A , Torosoff Mikhail
Published: March 2022

Background:
We studied outcomes associated with ability to perform supine bicycle exercise in patients referred for dobutamine stress testing.

Material and Methods:
Consecutive unselected patients referred for dobutamine stress echocardiographic testing were grouped by ability to perform supine bicycle exercise (n=85, 37 females, 61+/-12 years old) or not (n=107, 53 females, 57+/-12 years old). Demographic data and medical history were collected. Survival was ascertained through hospital records and Social Security Death index. Follow-up (mean 22+/-7 months) was available in 192 patients Analysis of variance (ANOVA), chi-square, and logistic regression analyses were used.

Results:
Target heart rate (THR) was achieved in 90% (76 of 85) with supine bicycle dobutamine (SBD) vs. 80% (85 of 107) with standard dobutamine tests (DT), p=0.046. During follow-up, 9% (17 of 192) of patients expired. Abnormal, ischemic response to stress testing was predictive of mortality (18% (6 of 33) in ischemic response vs. 7% (11 of 159) in normal response, p=0.038). When analyzed by ability to perform supine bicycling, there was a trend towards decreased mortality in patients able to exercise (SBD 7% (6 of 85) vs. DT 10% (11 of 107), p=0.435) or reach target heart rate (THR reached - 8% (14 of 171) vs. THR not reached - 15% (3 of 20), p=0.311). Longer exercise time was predictive of decreased mortality (HR 1.1 per minute, 95%CI 1-1.3, p=0.048), but not age (p=0.926) or maximal bicycle resistance (p=0.222). In addition to that, ischemia during test was not predictive of mortality in exercise-capable group (HR 2, 95%CI 0.4-13, p=0.406). On the contrary, in patients unable to exercise, ischemia by echo (HR 4, 95%CI 1-16, p=0.047) and age (HR 1.9 per decade, 95%CI 1-3.5, p=0.043) were associated with increased mortality. Gender, history of CAD, CHF, HTN, DM, PAD, smoking, beta-blocker treatment, or time to heart rate recovery had no effect on mortality in either groups.

Conclusion:
Similarly to upright exercise, supine bicycle exercise capacity is associated with improved short-term mortality and appears to be more important than age or ischemia during stress testing. In patients unable to perform supine exercise, age and ischemia during stress testing remain significant predictors of poor outcomes.
Abstract 200: Self-Reported Patient Characteristics Among Atrial Fibrillation Patients Naïve to Warfarin Therapy, Lapsed on Warfarin Therapy, or Currently Receiving Warfarin Therapy
Authors: Vanderpoel Julie , Ruiz Juan , Galitsky Alex , Nelson Winnie , Mody Samir
Published: March 2022

Background:
Atrial fibrillation (AF) is the most common form of cardiac dysrhythmia and a risk factor for stroke. Guidelines recommend antithrombotic therapy among AF patients for stroke prevention. Warfarin, an oral vitamin K antagonist, is currently the most commonly used medication for stroke prevention among patients with AF. The purpose of this study was to describe patient-reported characteristics of atrial fibrillation patients treated with or without warfarin therapy.

Methods:
A survey of patients with AF in the United States was administered. Patients ≥55 years of age with a current diagnosis of AF qualified for survey participation. Participants completed an approximately 50-minute online survey during 12/10-12/28/2010. Survey questions addressed a variety of topics including, but not limited to, patient demographics, health status, and AF treatment. The data were weighted on demographic characteristics to represent the real world population of AF patients. Weighted results percentages are reported.

Results:
The survey was administered to 803 patients with AF. Fifty-six percent of the patients were male, mean age was 71 years, and 88% were Caucasian. Approximately 42% of patients were currently receiving warfarin, 20% were lapsed users, and 38% were naïve to warfarin. Time since AF diagnosis, as well as CHA2DS2VASc scores, were similar across the 3 patient groups, regardless of warfarin treatment status. Specifically, approximately two-thirds of patients in each group had a CHA2DS2VASc score of ≥3, indicating strong candidacy for anticoagulant therapy. Approximately 61% of the patients lapsed on warfarin and 57% of the patients naïve to warfarin reported currently using aspirin alone for AF treatment.

Conclusions:
Despite similar stroke risk among the surveyed AF patients, their stroke prevention therapies were vastly different. The high proportion of patients using aspirin alone is worrisome, as findings in a recent large registry indicated that the net clinical benefit for aspirin is not positive at any level of stroke risk. The patient-reported data from this survey highlight the need for consistent stroke risk assessment and effective anticoagulant prophylaxis among AF patients.
Abstract 221: The Impact of Using Mobile-enabled Devices on Patient Engagement in a Blood Pressure Remote Monitoring Program
Authors: Agboola Stephen , Havasy Rob , Henry Kurleigh , Myint-U Khinlei , Kvedar Joseph , Jethwani Kamal
Published: March 2022

Objectives:
Home monitoring of blood pressure has been shown to improve care as opposed to only the traditional office BP monitoring. The blood pressure connect program is a remote blood pressure monitoring program on a secured web-based platform where patients upload their blood pressure readings which are automatically shared with their providers, thereby facilitating timely feedback and intervention, like medications changes. Different data transfer technologies enable the uploading of the blood pressure readings from the blood pressure meters to the secure website: modem connection through a home phone line (iMetrikus) and more recently, wireless blood pressure devices (MedApps). Patients exhibit different engagement patterns with these linking technologies. This study aimed to compare how patients in the program engage using the 2 types of linking technologies, and its potential impact program design and outcomes.

Methods:
Thirty patients, aged 23-84 years (62 ± 14years), currently enrolled in the blood pressure connect program, who had completed at least 2 months in the program and not participating in any other clinical trial were included in the analysis. Half of these patients used MedApps while the other half used iMetrikus. The patients were matched by practice and age. Indices used to assess how device type affects engagement include number of days to first BP reading (measurement) and upload, total number of measurements and uploads/day. These indices were compared in both groups using the Wilcoxon-Mann-Whitney two-sample rank-sum test.

Results:
Measurements/day and uploads/day were significantly higher in the MedApps group vs. iMetrikus group (Median = 0.66 vs. 0.2 measurements/day; p-value= 0.0136 and 0.46 vs. 0.01 uploads/day; p-value = 0.0001 respectively). Number of days to first upload was significantly lower in the MedApps group (median = 4 vs.7days; p-value= 0.017). Number of days to first measurement did not differ between the groups (median= 2 vs. 1day p-value=0.9827).

Conclusions:
Wireless transmission made possible by the MedApps devices ensures that readings taken are transmitted to the web instantaneously, as seen from the significantly lower time to first upload. As a program design measure, this is extremely critical, as it provides clinicians timely data to intervene on. We hypothesize that the increased feedback resulting from this instantaneous upload leads to better engagement in the program, as demonstrated by the significantly higher number of measurements in the MedApps group. There is now overwhelming evidence that more frequent testing results in better clinical outcomes. The study is extremely significant in demonstrating the impact of mobile enabled wireless technologies on patient engagement and outcomes in remote patient monitoring programs.