bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P188: Comprehensive Center Metrics: A 2-Year and New Year Follow-up
Authors: Censullo Joan , Chiu David
Published: March 2022

Background and Purpose:
In 2005, the Brain Attack Coalition (BAC) published recommendations outlining elements of the highest level of stroke care and coined the term- Comprehensive Stroke Center. Six years later, international and national certifications are still not offered. Regional certifications are available in three U.S. states, based on affirmative responses to capability inquiries; with the quality assessment aspects identified by the Brain Attack Coalition being wholly disregarded.

Quantifying quality at this highest level has proven difficult. Only one center in Houston, Texas has published the successful delineation and operationalization of thirteen Comprehensive level quality measures (2008). In February 2011, Leifer and colleagues published an additional set of twenty-six potential Comprehensive metrics that iterated some of the previously published measures and added new ones. This is a two year review of the original 2008 Texas Medical Center publication and a review of the more recent February 2011 metrics.

Methods:
Quality metrics for both 2008 and 2011 publications were derived from the Brain Attack Coalition Comprehensive Stroke Center guidelines. Metrics fell into one of two categories of Donabedian's quality measures: process or outcomes. The 2008 publication defined all measures recommended by the BAC that had reliable/valid benchmark thresholds. Inclusion and exclusion criteria were specified and delineated using industry standard identifiers/codes. The 2011 publication included core, optional, inpatient, and outpatient measures. Standardized (replicable) definitions for numerator and denominator elements, and quality thresholds were not indicated.

Results:
The mandatory reporting elements of the Comprehensive Stroke Centers are still being debated by the stroke care industry. And, operationalization of developing Comprehensive Center metrics continues to be challenging.

Conclusions:
As purported Comprehensive Stroke Centers advertise the highest level of technological and practitioner capability, they are obliged to demonstrate outcomes assessment reflecting Comprehensive level care. This review shows that Comprehensive metric monitoring is achievable and replicable.
Abstract P191: Impact on Short- and Long-Term Mortality of Invasive Versus Conservative Strategy in Non–ST-Elevation Acute Coronary Syndromes: A Meta-analysis
Authors: Stavrakis Stavros , Stoner Julie A , Thadani Udho
Published: March 2022

Background:
Early invasive strategy is recommended for patients presenting with non-ST elevation acute coronary syndromes (NSTEACS). However, evidence for long-term benefit is lacking. We performed a meta-analysis to evaluate the impact of invasive vs. conservative (selective invasive) strategy on short- and long-term outcomes in patients with NSTEACS.

Methods:
We searched MEDLINE for randomized clinical trials comparing invasive vs. conservative approach in patients with NSTEACS. Pooled relative risk (RR) estimates with 95% confidence intervals (CI) were calculated using fixed and random effects models.

Results:
8 trials including 10,359 subjects (5,177 invasive and 5,182 conservative) were included. Based on the random effects model, invasive strategy was not associated with a significant reduction in 30-day, 6-month, 1-year and 5-year mortality compared to conservative treatment (2.2% vs. 2.0%, RR=0.96, 95% CI 0.54-1.69, p=0.88; 2.7% vs. 3.2%, RR=0.81, 95% CI 0.54-1.22, p=0.32; 4.4% vs. 4.4%, RR=0.93, 95% CI 0.63-1.36, p=0.70 and 10.6% vs. 11.5%, RR=0.92, 95% CI 0.77-1.11, p=0.40, respectively). Non-fatal myocardial infarction was significantly reduced with invasive approach at 6 months (RR=0.76, 95% CI 0.61-0.95, p=0.018), but not at later follow-up.

Conclusions:
Early invasive strategy does not lead to improved outcomes compared to conservative approach in patients with NSTEACS and its routine use cannot be justified at present. More studies are warranted to address this issue.
Abstract P196: Outcomes in Cocaine Chest Pain Patients Treated with β-Blockers
Authors: Finkel Jonathan , Foy Andrew , Patel Ankitkumar , Marhefka Gregary
Published: March 2022

Introduction:
Cocaine is the second most commonly used illicit drug in the US, and the most frequent illicit substance to precipitate an emergency room visit. Cocaine is associated with acute and chronic complications affecting the cardiovascular system. Although Beta blockers (BB) have been shown to improve outcomes in patients with ACS, current ACC/AHA guidelines call for avoidance of BB in patients presenting with chest pain and suspected MI with recent cocaine use due to concern for precipitating coronary vasoconstriction. Recently new data has emerged on beta blockade following cocaine intoxication, demonstrating improved cardiovascular hemodynamics and patient outcomes. In this study we looked at clinical outcomes of patients with cocaine chest pain that received BB therapy.

Methods:
All patients presenting to the Thomas Jefferson University Hospital Emergency Department (ED) with a chief complaint of chest pain from April 2007 to September 2008 were included (n=5432). Retrospective chart review was conducted on 37 individuals with cocaine positive urine drug screen that received BB. Data was collected on gender, previous history of MI, outpatient BB therapy, and cardiovascular outcomes (hypertensive emergency, MI, stroke, cardiac arrest or death).

Results:
Of the 37 patients that were cocaine positive and received BB therapy, 33 were male, 18 had a prior MI, and 24 were on outpatient BB therapy. There were no reports of hypertensive emergency, stroke, cardiac arrest or death following BB therapy. Four patients were diagnosed with MI, but in all cases the troponin assay was positive prior to BB administration. When compared with cocaine positive patients who did not receive a BB, there was no significant increase in negative cardiovascular outcomes following BB therapy.

Conclusions:
We found no increase in adverse events or negative cardiovascular outcomes following Beta blocker therapy in patients with cocaine associated chest pain. This study adds to the body of evidence showing BB may not be harmful in patients with cocaine associated chest pain and myocardial ischemia. Given the strong evidence supporting BB use in ACS, further study is warranted to investigate whether BB therapy may be beneficial in certain cocaine chest pain patients.
Abstract P201: Patient Demographics, Complications, and Hospital Utilization of Pacemaker Implantation in the Extreme Elderly
Authors: Stevenson Robert , Lugg David , Gray Robert , Hollis Douglas , Stoner Michelle , Williams Jeffrey L
Published: March 2022

Introduction:
There are scant data for pacemaker implant complications and readmission rates in the extreme elderly (age≥80 years) despite their common use in this population.

Methods:
This is a retrospective chart review of 149 consecutive patients (age≥80 years) who underwent pacemaker implantation at a community hospital Electrophysiology program from July 2008 through June 2010. Single-, dual-, and biventricular-chamber pacemakers and generator changes were included for analysis; cardioverter-defibrillator devices, temporary pacemakers, and loop recorders were excluded. Standard procedures for implantation were used. Major complications defined as death, cardiac arrest, cardiac perforation, cardiac valve injury, coronary venous dissection, hemothorax, pneumothorax, transient ischemic attack, stroke, myocardial infarction, pericardial tamponade, and arterial-venous fistula. Minor complications defined as drug reaction, conduction block, hematoma or lead dislodgement requiring reoperation, peripheral embolus, phlebitis, peripheral nerve injury, and device-related infection.

Results:
The baseline demographics, complication rates, and hospital utilization are shown in the Table below. There were no intraprocedural complications. There was one major in-hospital (0.7%) and one minor in-hospital complication (0.7%). Within 30 days of implant, there were 2 minor (1.3%) and 4 major (2.7%) complications. Eight of 149 patients (5.4%) were readmitted within 30days of implantation.

Conclusions:
This report of pacemaker implantations in the extreme elderly reveals rates of complications comparable to data from younger patient populations.
Abstract P224: Determinants of Quality of Life Following Myocardial Infarction
Authors: Arnold Suzanne V , Masoudi Frederick A , Rumsfeld John S , Li Yen , Jones Philip G , Spertus John A
Published: March 2022

Introduction:
Optimizing quality of life (QOL) after acute myocardial infarction (AMI) is a major goal of treatment. Unlike mortality, for which numerous prediction models are available, no risk stratification models predicting QOL after AMI exist.

Methods:
In the prospective 24-center US TRIUMPH registry, 2693 AMI patients were assessed at baseline and 1 year after AMI for disease-specific QOL with the Seattle Angina Questionnaire (SAQ). Median regression (to account for skewed outcome distribution) was used to build a prediction model for 1-year QOL. Using 60 candidate sociodemographic, economic, and clinical variables, a linear regression model was built that fit all covariates against the predicted value of SAQ QOL as the dependent variable. The least significant covariates were sequentially removed until 90% of the variance of the full model was explained. Models accounted for clustering within site. Non-linear spline terms were considered for all continuous variables.

Results:
After variable selection, poor QOL at 1 year was associated with younger age, female sex, prior heart failure, prior CABG, depressive symptoms, perceived stress, low monthly financial reserves, self-reported financial difficulty getting medical care, and poor baseline SAQ QOL (Table). The R
2
of the median regression model was 11.9%, and the median absolute prediction error (the expected value of the absolute difference between the future and predicted responses) was 8.44 (interquartile range: 3.81 to 16.28).

Conclusions:
This is the first predictive model for QOL after AMI ever reported and demonstrates that traditional demographics and medical comorbidities only partly predict QOL. This model identifies important patient factors associated with QOL that may be targets for further intervention (such as financial difficulties and stress), can be used to identify high-risk patients, and may permit comparisons among hospitals in risk-adjusted QOL outcomes.

Table

Predictors of Long-term Disease-Specific QOL After Myocardial Infarction

Predictor
Estimate (95% Confidence Interval) of 1-Year Change in Median SAQ QOL Scores
P-Value

Age (per 10 years)
3.10 (2.58, 3.62)
<0.001

Female sex
-2.61 (-4.03, -1.18)
<0.001

Prior heart failure
-2.48 (-5.15, 0.19)
0.069

Prior bypass surgery
-3.69 (-6.23, -1.14)
0.005

Baseline disease-specific QOL score (per 5 points)
0.43 (0.27, 0.60)
<0.001

Baseline Patient Health Questionnaire depression score (per 5 points)
-2.37 (-3.25, -1.48)
<0.001

Baseline Perceived Stress Score (per 4 points)
-1.15 (-2.02, -0.28)
0.010

Self-reported financial difficulty getting medical care
-7.99 (-10.99, -4.99)
<0.001

Monthly financial reserves

Just enough to make ends meet vs. Some money left over
-0.08 (-1.34, 1.18)
0.90

Not enough to make ends meet vs. Some money left over
-3.77 (-6.35, -1.19)
0.004
Abstract P228: Status and Awareness of Related Risk Factors Among Patients with Coronary Heart Disease: Results from a Survey of Patients and Their Attending Physicians in China
Authors: Gong Yanjun , Hong Tao , Jiang Jie , Han Xiaoning , Yu Yang , Chu Songyun , Fan Fangfang , Huo Yong ,   The 11th 5-Year National Key Technologies R&D Program for CHD--Secondary Prevention Rsch Group
Published: March 2022

Background:
CHD is product of multiple risk factors, such as dyslipidemias, hypertension, diabetes, smoking and obesity. Almost all of these risk factors are modifiable , so most of CHD are preventable. Patients’ awareness of these risk factors is very important to motivate preventive strategy.

Methods:
A representative questionnaire survey was performed during 2007 and 2009 among patients definitely diagnosed as CHD and their attending physicians from cardiology departments in 26 hospitals in China. The survey was divided into two parts. One part contained questions for patients on awareness of their diagnosis of myocardial infarction, hypertension, hyperlipidemia and diabetes mellitus and status of smoking and physical activity. Another part contained questions for attending physicians on the patient's diagnosis of these diseases. Regarding the diagnosis of myocardial infarction, hypertension, hyperlipidemia and diabetes mellitus, we included the case only if both patient and physician answered the questions. Physician's diagnosis were defined as the correct answer.

Results:
4373 patients and their attending physicians completed the questionnaire and their answers were included in this survey. Patients were 61.2±11.2 years old, and 3199 patients (73.2%) were male. The percentage of myocardial infarction, hypertension, hyperlipidemia and diabetes mellitus in these patients diagnosed by physicians were 51.2%, 63.4%, 49.7%, and 27.7%. While most of the patients can correctly answer whether they have myocardial infarction (90.7%), hypertension (96.0%), or diabetes (97.3%). Only 81.2% patients can tell whether they have hyperlipidemia correctly, and 68.6% patients who was diagnosed as hyperlipidemia knew they had it. Among all the patients, 23.1% of them were current smokers and 48.7% of them exercised regularly.

Conclusions:
Many chinese CHD patients complicated with hypertension, hyperlipidemia and diabetes. The level of patients’self-identification of CHD related risk factors is unsatisfactory. To improve the quality of care of CHD patients, Chinese medical service provider should pay more attention to patients’ education.
Abstract P234: Discharge Medication Status Compares Poorly with Claims-Based Outpatient Medication Exposure Estimates
Authors: Lanfear David , Peterson Edward , Wells Karen , Williams L Keoki
Published: March 2022

Background:
Discharge medication status is used as a surrogate for chronic therapy, but how well this reflects drug exposure is not clear. Exposure metrics from claims data are widely available and may offer superior quantification. We compared beta-blocker (BB) discharge status (BBdis) to a claims-based BB exposure estimate (BBexp) in heart failure (HF) patients, and assessed the relationship to heart rate and outcomes.

Methods:
Retrospective study of patients receiving care from a large health system with a primary hospital discharge for HF between 1/2004 and 6/2008 and surviving at least 6 months. BBdis and heart rates were obtained from electronic medical record. BBexp was estimated over the six months after discharge using pharmacy claims; values ranging from 0 (no BB) to 1 (max dose available daily). BB dose was calculated as a proportion of goal dose. Cox regression was used to test the association of BB with death or hospitalization, adjusting for baseline factors. The correlation of BB with heart rate was compared using the Pearson coefficient (CC).

Results:
A total of 1254 patients were included; 1054 with BB at discharge (84%). There was wide variability in BBexp regardless of BBdis status (figure). BBexp was independently associated with a lower risk of death or hospitalization (HR 0.44, p<0.001), while BBdis showed no association (HR 1.1, p=0.34). BBexp also showed a negative correlation to HR (CC= -0.136) while BBdis showed a slight positive correlation (CC= 0.039).

Conclusion:
Discharge BB status correlates poorly with claims-based exposure and BB-related outcomes. Medication exposure methods using pharmacy claims data likely offer a more accurate characterization.
Abstract P239: Evaluation of SPECT Appropriateness Criteria Using Clinical Outcomes
Authors: Hernandez Marlow B , Toffts Ryu , Trivedi Naman , DeMuth Kaelin , Jacques Mirlene , Maric Leyla V , Raj Opal , Lawrence Ashik , Talwar Rishi , Ballesteros Salguero Paola , Shen Michael
Published: March 2022

The utilization of SPECT imaging has increased significantly over the last 2 decades. Appropriateness Criteria (AC) has been created to improve quality of care by guiding appropriate use since 2005. Although many studies have demonstrated that AC can improve appropriate use in clinical settings, the impact of AC on clinical outcomes has not been well studied. The objective of this study is to assess the AC and clinical outcomes.

Methods.
Consecutive outpatients in Cardiology and Internal Medicine over 12 months were included in the study. New SPECT AC (2009) was used as the standard to assess appropriateness. Outpatient visit notes, SPECT imaging results and cardiac events (Hospitalization, PCI, CABG, MI and death) were analyzed. Inferential statistics were applied to evaluate each specific AC indications and their associations with cardiac events.

Results.
Out of 32,961 consecutive pts, 327 (1%) pts had events. Seventy-nine of the pts (24%) were excluded due to uncertain or non-categorized. Pts met Appropriate Indications (A-I) had significantly higher event rates than those pts with Inappropriate Indications (I-I) (63% v. 29%; OR 2.17, p < 0.001), and 10 fold between the most predictive and least predictive indications (60% versus 6.4%). The most predictive A-I were criterions #5 (detection of CAD in patient with high pre-test probability of CAD) and #30 (known CAD with new/worsening symptoms). However, I-I #13 (intermediate CHD risk by ATP-III), and #27 (known CAD on coronary angiography or prior abnormal stress imaging study) were equivalent to A-I in predicting cardiac events(63 % v. 59%, p=NS).

Conclusion:
Some inappropriate indications of AC need to be reevaluated and might be considered for reclassified to reflect outcomes. Further research on the AC use is warranted before widely applied to clinical settings in the US from 1/1/2011 as a mandate for lab accreditation and reimbursement.

Risk of Cardiovascular Event within the Study Period

Performed
Not-Performed

Appropriate Indications
9/34(26.5%)
40/44(90.9%)

Inappropriate Indications
8/102(7.8%)
39/60(65.0%)

*Rate of events within any particular group vs. all other groups (p < 0.05)
Abstract P24: Clinical Strategies and Bleeding Outcomes in Octogenarians Undergoing Primary PCI: Results from the NCDR®
Authors: Dodson John A , Wang Yongfei , Krumholz Harlan M , Chaudhry Sarwat I , Curtis Jeptha P
Published: March 2022

Background:
Patients ≥80 years of age with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are at increased risk for bleeding. Specific clinical strategies may reduce the bleeding risk associated with PCI. However, the use and outcomes associated with these strategies in patients ≥80 have not been described.

Methods:
We analyzed data from the CathPCI Registry® between July 1, 2005 and June 30, 2009. Patients were included if they were ≥80, presented with STEMI, and underwent primary PCI. We evaluated trends in bleeding avoidance strategies (direct thrombin inhibitors, closure devices, radial access) and risk-adjusted bleeding (drop in hemoglobin >3 gm/dl, transfusion, or bleeding resulting in prolonged hospitalization) over time.

Results:
Among 10,469 patients age ≥80 undergoing primary PCI, 1002 (9.6%) experienced a bleeding complication. Only a minority of patients were treated with a direct thrombin inhibitor or vascular closure device, but the use of these strategies increased over time (p for trend <0.001) (Figure). Radial access was extremely uncommon and did not change over the course of the study. Risk-adjusted in-hospital bleeding decreased from 9.96% to 9.39% (absolute difference 0.57%) during the study period (p = 0.002).

Conclusions:
Despite significant increases in the use of bleeding avoidance strategies, patients ≥80 undergoing primary PCI remain at high risk of bleeding. These findings suggest the need to increase adoption of existing bleeding avoidance strategies and develop novel approaches to reducing bleeding risk in this vulnerable population.
Abstract P243: Depression Screening in Patients with Cardiovascular Disease in a Veterans Administration Hospital
Authors: Nadelson Jeffrey , McGowan Sarah Kate , Shankman Stewart A , Shroff Adhir R , Vidovich Mladen I
Published: March 2022

Background:
Depression is associated with less favorable outcomes in patients with cardiovascular disease (CVD). In the Veterans Administration System all patients are screened annually for depression using the Patient Health Questionnaire (PHQ9). We investigated whether PHQ9 scores were associated with CVD in order to provide optimal care to patients undergoing cardiac catheterization.

Methods:
1,088 unique patients underwent cardiac catheterization at Jesse Brown VA Medical Center from June 1
st
, 2008 to June 1
st
, 2010. Medical records were examined retrospectively for cardiac history, coronary angiography results, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical management, and PHQ9 scores. Depression was defined as a PHQ9 score ≥ 10. Differences between depressed and non-depressed patients were analyzed by chi-square and independent-samples t tests.

Results:
The prevalence of depression was 5.2% (n=57). Patients with depression were younger (M = 56) than those without depression (M = 64; p < .01) Patients were primarily male (97%) and African American (60%). Significant CVD (lesions > 50%) were present in 77% of total patients, 31.3% underwent PCI, 13.4% were referred for CABG, and 55.3% were continued on medical management. Of the 57 patients who screened positive for depression, 44 had abnormal coronaries. Revascularization occurred in 18 (41%) patients with depression compared to 362 (35%) without depression (
ns
). Patients with depression were more likely to have chronic obstructive pulmonary disease or asthma (35.7% with depression vs. 19.5% without, p<0.01), higher BMI (32.0 vs. 29.3, p<0.01), smoke cigarettes (48.2% vs. 28.6%, p<0.001), and use cocaine (31.7% vs. 16.2%, p<.05).

Conclusion:
Routine depression screening, as currently performed, inefficiently detects depression in the VA patients with CVD (prevalence in the VA system is 22%). Deficiencies in the processes of care in PHQ9 administration likely result in under-detection of depression and result in poor resource utilization. Additional efforts are required to optimize depression screening for patients with CVD in the VA system.
Abstract P248: Posttraumatic Stress Disorder Intrusions Are Associated with Prehospital Delay in Patients with Myocardial Infarction
Authors: Newman Jonathan D , Shimbo Daichi , Shaffer Jonathan A , Muntner Paul , Edmondson Donald
Published: March 2022

INTRODUCTION:
Increased pre-hospital delay prior to presentation for myocardial infarction (MI) is associated with poor outcomes. A history of post-traumatic stress disorder (PTSD), particularly intrusive reexperiencing of trauma, may also be associated with poor outcomes after MI. It is unknown, however, whether PTSD intrusions are associated with pre-hospital delay.

METHODS:
Patients (n=151) presenting to the emergency room with an MI in the Prescription Use, Lifestyle, Stress Evaluation (PULSE) study were included in this study. Patients reporting a traumatic event with intrusive reexperiencing prior to their MI, as recorded on a questionnaire administered by study staff, were considered to have PTSD intrusions. Pre-hospital delay was defined as the difference between patient-reported symptom onset and presentation time as documented in the medical record.

RESULTS:
Patients who had PTSD intrusions (
N
= 26, 17%) versus those without intrusions (
N
= 125; 83%) were younger (mean age: 58 vs. 63 years), more likely to be depressed (68% vs. 37%), and had a higher LVEF (53% vs. 46%). Pre-hospital delay was longer for participants with, compared to without, PTSD intrusions [geometric mean: 11.6 hours (95% CI 6.2-21.6) vs. 6.2 hours (95% CI 4.9-8.1)]
P
=0.05. After multivariable adjustment for age, sex, ethnicity, depression, LVEF, MI type (ST-elevation vs. non-ST-elevation) and history of prior MI, the mean pre-hospital delay was 136% (95% CI: 17% - 372%) longer for patients with versus without PTSD intrusions (Table).

CONCLUSION:
Among patients presenting with an MI, PTSD intrusions were associated with longer pre-hospital delays. Future studies should examine the behavioral mechanisms underlying longer pre-hospital delay for patients with PTSD intrusions.

Model
Covariate adjustment
Percent delay (95% CI) intrusions vs. no intrusions
p-value

1:
Unadjusted
85% longer (0% - 244%)
0.05

2:
Age, sex, ethnicity
97% longer (6% - 270%)
0.03

3:
Model 2 and depression MI type, LVEF, prior MI
136% longer (17% - 372%)
0.02
Abstract P249: Prospective Monitoring of Pediatric Cardiac Surgery Program Complications
Authors: Hancock-Friesen Camille L , Shanmugam Ganesh , Burton Hayley J , Warren Andrew E , O'Blenes Stacy B
Published: March 2022

Background:
The next horizon for improving pediatric cardiac surgery outcomes is the standardization and systematic tracking of complications.

Methods:
IWK REB approval was obtained. The Multisocietal Database Committee short list of complications (52) were captured prospectively for all pediatric cardiac operations at the IWK Oct 1 2009-Sept 30 2010. Morbidity burden was calculated by multiplying a severity coefficient (1-3) by frequency of complication in each surgical complexity strata using RACHS categories. Death was included as a complication (severity coefficient= 5). Indexed morbidity was calculated for each RACHS category by dividing morbidity burden by number of procedures.

Results:
A total of 110 procedures were performed on 86 patients. 83 of the 86 index procedures were open and 22 of the patients were neonates. The procedural mortality rate was 3.6%. Forty one (41/86, 47.7%) of the index procedures had a total of 89 complications. Sixty-four patients were in RACHS category 2 or 3. The most common complications were pulmonary (22) arrhythmias (16), or operative (16), accounting for 61%(54/89) of total complications. The indexed morbidity was 0 for RACHS1, 1.55 for RACHS 2, 2.63 for RACHS 3, 1.81for RACHS 4, and 2.81 for RACHS5/6. The CUSUM plots the occurrence of any complication in each case versus morbidity burden, illustrating the effect of complication severity on the slope of the curve.

Conclusions:
A high rate of perioperative complications are recorded when tracked prospectively using standardized definitions. Adjusting complications for severity may identify areas for improving patient outcomes that are missed by simply recording their occurrence.
Abstract P251: Cardiovascular Risk Perception in African Americans
Authors: Scobie Janice V , Collier Aliya , Weathers Benita , Hughes-Halbert Chanita
Published: March 2022

Substantial racial disparities exist in heart disease. African Americans have the highest rates of cardiovascular disease (CVD). The prevalence of cardiovascular risk factors is greatest among racial minorities. African Americans are more likely to be diabetic, physically inactive, and overweight compared to whites. Additionally, African Americans participate in cardiovascular risk reduction behaviors such as diet control, exercise, and weight management at lower rates compared to individuals from other racial groups. Primary prevention of CVD through the adoption of healthy diet and physical activity behaviors is recommended to reduce the risk of developing CVD. According to health behavior theories, people must perceive themselves as susceptible to disease to adopt a preventive behavior. Few studies have examined psychological and sociocultural factors that influence cardiovascular risk perception in African Americans. As part of a randomized trial comparing the effects of integrated versus disease specific risk education in a community-based sample of African Americans, we (1) evaluated perceived risk of developing CVD and (2) identified factors having significant independent association with risk perception. The sample consisted of 199 African American adults who were on average 45.0 years (± 9.9) old. The participants were 53% male and 47% female. Approximately 23% of the participants were at intermediate or high risk for CVD. Most (83%) participants received medical care in a doctor’s office, clinic, or community health center and had a recent visit (≤ 1 year) to a doctor (84%). More than half (62%) of participants did not perceive themselves to be at increased CVD risk. In the multivariate model that controlled for age, objective risk (β=1.85, p=0.03), a family history of CVD (β=0.47, p=0.006), a recent doctor visit (β=1.90, p=0.03), and usual source of health care (β=-2.24, p=0.008) had a significant association with risk perception. Our results suggest that usual source of health care is important to perceived risk of developing CVD. This could be because provider interaction is important in appropriate CVD risk perception. Future research is needed to evaluate the content of patient-provider discussions about CVD in different settings.
Abstract P256: Women Experience Significant Treatment Delays When Presenting with Acute Myocardial Infarction
Authors: Dreyer Rachel , Tavella Rosanna , Hoffmann Bernadette , Pati Purendra , Beltrame John , Arstall Margaret , Zeitz Christopher
Published: March 2022

Aim:
Delays in reperfusion therapy for ST-elevation myocardial infarction (STEMI) have been associated with an increased mortality. These delays are dependent upon both patient and health system factors. The objective of this study was to assess gender differences in door-to-balloon times, in patients undergoing percutaneous coronary intervention (PCI) for STEMI, with respect to its logistical components and evaluate its relationship to 30-day cardiac events (death and/or re-infarction).

Methods:
Clinical and logistic parameters were prospectively collected between 2005-10 for 735 STEMI patients undergoing primary PCI at two South Australian teaching hospitals. Particular attention was given to the time of patient hospital arrival to the STEMI team notification (Door-Code time), the time from STEMI notification to first balloon inflation (Code-Balloon time), and conventional Door-to-balloon time. Infarct size was estimated by extent of ST elevation on admission and peak creatine kinase levels.

Results:
Women were significantly older than men (66±14 vs. 60±12years, P<0.001) thus parametric variables were age-adjusted and summarized in the table below (*p < 0.05, **p<0.001 compared with men). Multivariate logistic regression analysis revealed that female gender was the strongest predictor of 30-day death and re-infarction (Odds Ratio for Female = 3.06 (95% CI = 1.45 - 6.42, p = 0.003)

Conclusion:
Women with STEMI undergoing primary PCI have poorer cardiac outcomes, for which a prolonged door-to-balloon time may contribute. This delay is attributable not only in the recognition of the STEMI in women (Door-to-Code time) but also in attaining mechanical reperfusion (Code-to-Balloon time). Further studies are required to identify the source of these delays.
Abstract P258: Gender, Race, Age and Insurance Status in Patients Treated with tPA
Authors: Cochran John W , Patel Tejas H , Kitsantas Panagiota , Cheema Jehanzeb , Dugan Nicholas M , Callahan Christa , Krzywicki Karen , Mancini Barbara , Munoz Rosalyn , Whitson Maurie , O'Mara Susan
Published: March 2022

BACKGROUND AND PURPOSE:
At a large Stroke Certified Hospital serving a diverse population we analyzed Tissue Plasminogen Activator treatment (tPA) administration for ischemic stroke patients. tPA treatment is time dependent and we wanted to determine whether insurance type, race, age and/or gender affected the time frame of tPA treatment.

METHODS:
We used data from our Stroke database which covered patients treated at Fairfax INOVA hospital from February 2004 to April 2010. A total of 144 patients were treated within this time for ischemic stroke. Of these 144 patients, 99 were White, 19 were Asian, 16 were Black, and 10 belonged to other races. In order to avoid computational and estimation problems associated with small cell sizes, all non-White races were combined into a single category (n = 45). We used time between last known well and treatment as our dependent variable. Our predictors were demographic controls including age, gender, and sex and other dummy variables and an ANOVA model was run to produce the results.

RESULTS:
The factorial ANOVA results are presented in Table 1. As the p values indicate, no significant group differences were observed for race, gender, age or insurance type.

CONCLUSIONS:
We found that ischemic stroke patients receiving tPA treatment did so in a timely manner and factors such as insurance type, race, gender or age had no significant effect on the likelihood of receiving treatment. There appeared to be no disparity based on the variables examined in our sample. In the future we recommend this study be replicated with a larger sample size.
Abstract P269: Comparison of Usefulness of Apache II and SAPS II in Stroke Patients
Authors: Jang Kyung-Sool , Park Sang-Kyu , Han Young-Min , Jang Dong-Kyu , Yoon Wan-Soo , Shin Yea-Kyung , Park Young-Sup
Published: March 2022

Objective:
APACHE II and SAPS II are widely used for grading the derangement in the physiological homeostasis of individual patients as well as for prognostic calculations. But these mortality prediction systems are not made for specific patients group but for general ICU group. We studied the applicability of SAPS II and APACHE II in patients admitted to neurosurgical intensive care unit with high proportion of typical cerebral stroke and compared the accuracy of prediction between hemorrhagic and ischemic stroke.

Methods:
From January 2008 to December 2008, ischemic or hemorrhagic stroke patients, who admitted to neurosurgical ICU, were included into the study. Data collection was done during first 24 hrs of the stay. These data calculated as described in the original articles and predicted mortality was obtained. APACHE II and SAPS II predicted mortalities were compared each other by Calibration curve, Lemeshow-Hosmer goodness for fit test, ROC curve. We compared the results of APACHE II and SAPS II between hemorrhagic and ischemic stroke.

Results:
During January 2008 to December 2008, 672 patients were admitted to neurosurgical ICU. Observed mortality was 15.7% whereas APACHE II and SAPS II predicted mortalities were 27% and 30.2%. Calibration curve was close to the line of perfect prediction. SAPS II was not statistically significant in Lemeshow-Hosmer test, but slightly favor in area under ROC curve.

Conclusion:
ICU scoring systems are becoming increasingly important tools to improve resource allocation and to assist in clinical decision making. The ideal scoring system should be able to predict outcome upon admission to the ICU. The severity scores, however, are not accurate enough to be used in the routine management of these patients. In our study APACHE II and SAPS II systems can be used to measure performance in the neurosurgical ICU setting, but not in individual patient.
Abstract P270: Systolic Pulmonary Artery Pressure Predicts Hospital Readmission in Patients with Congestive Heart Failure
Authors: Njeim Mario , Ambulgekar Nikhil , Abas Mustafa , Alaali Yathreb , Assaad Mahmoud , Bou Malham Sarah , Hudson Michael
Published: March 2022

Background:
Left atrial hypertension results in pulmonary hypertension which is a frequent finding in the setting of left ventricular failure. We hypothesized that noninvasive measurement of systolic pulmonary artery pressure (SPAP) by echocardiography could be used to estimate the risk of hospital readmission in patients with congestive heart failure (CHF).

Methods:
We conducted a retrospective cohort study on patients discharged from a major urban hospital between June 2009 and October 2009 with a primary diagnosis of CHF. Noninvasive assessment of SPAP by 2D echocardiography performed within 6 months preceding hospital discharge was among the inclusion criteria. A SPAP of 40 mmHg or greater in addition to other factors potentially predictive of re-hospitalization were included in a univariable cox-regression analysis for predicting all-cause readmission. Variables with p-values less than 0.25 were allowed to participate in a stepwise cox-regression model which identified all statistically significant predictors within a mutlivariable setting.

Results:
145 patients participated in the stepwise cox-regression analysis. The mean SPAP (mmHg) was 47 with a median of 46. The following statistically significant predictors were identified: hemoglobin nadir < 10 g/dl (HR 1.63; 95% CI 1.07-2.48; P = 0.02), requirement of skilled nursing care after discharge (HR 1.73; 95% CI 1.14-2.63; P = 0.011), diagnosis of COPD (HR 1.62; 95% CI 1.04-2.51; P = 0.03), diagnosis of ESRD (HR 2.05; 95% CI 1.18-3.55; P = 0.01), use of cardiac resynchronization therapy (HR 4.71; 95% CI 1.95-11.35; P < 0.001) and SPAP of 40 or above (HR 2.03; 95% CI 1.30-3.18; P = 0.002).

Conclusions:
Previous limited studies have suggested that pulmonary hypertension is a prognostic marker in patients with cardiomyopathy. Our data suggests that noninvasive measurement of SPAP by echocardiography can help to predict the risk of hospital readmission in patients hospitalized for CHF. A systolic PAP of 40 mmHg or above appears to be a stronger predictor of re-hospitalization when compared to traditional risk factors including COPD, ESRD and anemia.
Abstract P273: The Underuse of Carotid Imaging Among Patients Admitted with Ischemic Stroke to the Veterans Health Administration
Authors: Keyhani Salomeh , Cheng Eric , Ofner Susan , Williams Linda , Halm Ethan , Bravata Dawn
Published: March 2022

Patients with symptomatic carotid disease who have greater than >70% stenosis may greatly benefit from a carotid procedure. We examined whether patients with ischemic stroke are receiving carotid artery imaging. Data were obtained from a retrospective study of 3965 persons admitted with ischemic stroke to the Veterans Health Administration (VA) in 2007. We applied extensive exclusion criteria to identify a sample who should definitely receive imaging. We excluded patients with a Charlson Comorbidity Index greater than 4, those who were non ambulatory on admission, patients who left against medical advice or transferred from another VA Medical Center (VAMC), and those who had dementia or died in the hospital. We determined whether any carotid artery imaging procedures were performed from 12 months prior to 2 months after stroke admission. Multivariate modeling was used to identify predictors of carotid imaging. The proportion of patients admitted to a hospital who received carotid imaging was calculated for VAMCs with at least 12 patients. We identified VAMCs with an imaging rate and associated confidence interval below the median of the sample which we established as a threshold for poor quality. There were 2379 patients across 127 VAMCs without any contraindications to carotid imaging. Among these patients, 86.6% (95% confidence interval [84%- 87%]) received imaging. In multivariate models, patients who were black (odds ratio (OR) 0.67 [0.47-0.90]) and who had a higher Charlson Index (OR 0.84 [0.73-0.97) were less likely to receive imaging. The median imaging rate was 91.7% across all VAMCs and ranged from 37.6% to 100%. Among the 93 VAMCs with at least 12 patients, 20 VAMC failed to meet the 91.7% threshold in carotid imaging. About 13.4% of stroke patients in the VA did not receive carotid imaging. Most VAMCs achieved the 91.7% imaging rate which was a reasonable target because of the extensive exclusion criteria we applied. Our analyses suggest that underuse of imaging is a quality problem for at least 20 VAMCs. Given the potential mortality benefit of intervention in a patient with symptomatic carotid stenosis, an effort by these VAMCs to identify and address reason for underuse of carotid imaging is warranted.
Abstract P289: African-American and Hispanic Patients with Neurologic Worsening after Intravenous Thrombolysis for Acute Ischemic Stroke Have Increased Length of Hospitalization and Poor Discharge Outcomes
Authors: Ifejika-Jones Nneka , Harun Nusrat , Noser Elizabeth , Francisco Gerard , Grotta James
Published: March 2022

Introduction:
Six percent of patients who receive IV rt-PA for cerebral ischemia experience a combination of neurologic worsening (NW) with intraparechymal hemorrhage (PH2). Also known as symptomatic intracerebral hemorrhage (sICH), PH2+NW is a good predictor of stroke mortality. There is growing clinical evidence that NW, defined as a two point increase in NIHSS, should be evaluated independently when predicting clinical metrics and outcomes.

Hypothesis:
To test the strength of NW as a predictor of clinical metrics in acute ischemic stroke patients receiving rt-PA.

Methods:
Patients with ischemic stroke who received IV rt-PA admitted to the UT Stroke Service between July 2004 and October 2010 were included (n=1083). No PH2/NW served as the control. We assessed differences in demographics and clinical metrics with respect to PH2, NW, PH2+NW and No PH2/NW using Chi-square or Fisher's Exact test when appropriate.

Results:
Demographics: There were no differences in age or gender across all groups. PH2+NW had the highest NIHSS (P=0.0005) and mortality (P=<0.0001). African-American and Hispanic patients were more likely to have NW (P=0.0321). Clinical Metrics: PH2+NW had the longest ICU course, followed by NW (P=<0.0001); NW had the highest duration of stay (P=<0.0001). NW required subacute care, custodial/hospice care or transfer to another service for continued management (P=<0.0001).

Conclusions:
Neurologic worsening in patients who received IV rt-PA for acute ischemic stroke is associated with increased days in the ICU and prolonged hospital length of stay. These patients are more likely to be members of minority groups and require treatment in a subacute facility, custodial/hospice care or a medical transfer of care. This study is limited by undetermined psychosocial factors and the size of the PH2 and PH2+NW groups. More research is needed on neurologic worsening in minority populations and the impact of transfer of care on a further increase in length of stay.
Abstract P291: Factors Affecting Physician Behavior When Managing Cardiovascular Risk
Authors: Memon Nabeel A , Kashem Abul , Homko Carol , Afari-Armah Nana , Reed Ashley , Rakita Val , Santamore William P , Bove Alfred A
Published: March 2022

Background:
Comprehensive management of the patient at increased risk for cardiovascular disease (CVD) should include counseling regarding life-style behaviors (weight loss/nutrition and increased exercise) in addition to testing and pharmacotherapy. This study sought to examine the patient factors that influence physicians’ provision of nutrition and exercising counseling among individuals at increased risk for CVD.

Methods:
This was a secondary analysis of a telemedicine trial among underserved inner city and rural subjects (n=388) with a 10% or greater CVD risk (Framingham 10 year risk score). Subjects were followed for one year and were seen for quarterly assessments, which included evaluation of weight, blood pressure (BP), lipid and glucose status. At each of the four quarterly visits, subjects were asked if their physician had discussed or made recommendations regarding life-style behaviors specifically diet/weight loss and exercise.

Results:
The average age of subjects was 60.9± 9.7 years and mean body mass index (BMI) was 31.6 ± 7.0 kg/m2. CVD risk decreased by 2.5% over the one year of follow-up (17.5 ± 10.3% at baseline vs. 15.0 ± 9.3% at 1-year; p<0.001). 79% of subjects indicated that their physician routinely provided nutrition and exercise counseling. Individuals who received counseling were significantly (p< 0.001) heavier than those who did not (204 ± 38.5 vs. 186.7± 40.3 pounds; 32.5± 5.9 vs. 29.0± 7.1 kg/m2 respectively). Logistic regression modeling utilizing BP, lipid and glucose levels, sex, urban vs. rural location and risk score as the independent variables revealed that only BMI at study entry predicted the provision of nutrition (p<0.001) and exercise (p=0.003) counseling.

Conclusion:
These data indicate that patient weight/BMI is a major factor determining whether or not physicians provide patient counseling regarding weight loss and physical activity. Physicians maybe missing important opportunities in patients at high risk for CVD to influence behavior by limiting their focus to obese subjects.
Abstract P38: The BRIDGE Transitional Care Model Demonstrates Cost-Effectiveness
Authors: Bumpus Sherry , Kline-Rogers Eva , Wheeler Jack , Montgomery Daniel , Norville Janice , Eagle Kim A , Froehlich James B , Rubenfire Melvyn
Published: March 2022

Background:
Readmission rates following discharge for a cardiac condition are common and costly. Compared to usual care (UC) the NP transitional care model (BRIDGE) reduced hospital readmissions in the pilot study. To determine if there is also a cost savings, we compared the costs of BRIDGE against avoided readmission and hypothesized that participation would reduce overall costs.

Methods:
Demographic, clinical, and f/u data were collected retrospectively on all pts referred to BRIDGE June 2008 to Aug 2009. Pts readmitted before their BRIDGE appt were excluded. Incremental costs were obtained from the institution's finance dept. MEDPAR charge data were obtained from the American Hospital Directory for the MS-DRG of cardiology.

Results:
Of 426 patients referred to BRIDGE, 284 (69.8%) attended, the rest received UC. Most were male (56.6%), mean age 63.4, without significant baseline differences between groups. BRIDGE participants were readmitted less frequently and were less costly (17.4% vs. 19.6%, p=.65). The incremental cost for a BRIDGE visit was $43.85 per pt compared to the avg Medicare charge for a cardiology admission of $27,558. The reduction in expected readmissions for BRIDGE pts, compared to incremental BRIDGE costs, translates into a $562 per patient savings, or a $145,106 program savings in readmission costs over UC. Because this is a marginal cost analysis, a conservative adjustment was made to account for nonproductive time. Using a multiplier of 2.63%, there was still a per pt savings of $502 and a program savings of $129,618 in readmission costs over UC. Cost savings varied by readmission rates for primary diagnosis. ACS pts have an unadjusted per pt savings of $5,412 ($357,234 program savings) and CHF pts $149 per pt savings ($225,722 program savings) while afib pts increase cost by $3,599 per pt ($179,942 program cost).

Conclusions:
This analysis demonstrates that the BRIDGE model reduces health care costs associated with readmissions that are in excess of program costs despite the diverse population. Hospital revenue is not addressed because our perspective assumes that lower health care costs benefit all. Further, proposed legislation to reduce hospital reimbursement for readmissions may make this a mute issue.