bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 292: Predictors Of Heart Failure Readmission Rates, A Stanford Experience.
Authors: Odera Gulnar P , Mahmud Nadim , Feroze Abdullah , Shaw Richard
Published: July 2021

Introduction:
The prevalence of heart failure (HF) is approximately 5.8 million, one in every five Medicare patients with HF are readmitted within 30 days. Heart failure readmissions cost 17.4 billion dollars annually. A major focus of health policy reform has been to contain costs by preventing readmission. Medicare has proposed criteria for HF reimbursement among which are readmissions within a 30-day period after the index hospitalization will not be reimbursed. The Medicare core measure aggregate has been sparsely validated in the literature and such validation of the core measures is essential. The aim of our study was to evaluate the predictive value of the Medicare core measure aggregate and if this aggregate is an effective proposed benchmark in reduction of HF readmission.

Methods:
A database was developed using RedCap (Research Electronic Data Capture), to study all patients admitted to Stanford Hospital and Clinics from September 2011 through January 2012. Inclusion criteria included those with a primary or secondary diagnosis of heart failure. Cardiac variables of interest beyond the core measures included among others, demographics, length of stay, and past medical history. Aggregate data from the Redcap database was analyzed by standard methods.

Results:
101 patients were indexed during the retrospective cohort analysis. 100 were discharged alive. The overall 30-day readmission rate was 14%. There was no difference in readmission rates between patients who had core measures completed versus those who did not (13.8% vs. 14.3%; p= 0.944). In univariate Chi-square analyses, a phone call to the patient by a nurse within 24-48 hours post discharge was associated with significant reduction in rehospitalization rates (7.1% vs. 22.7%; p=0.026). Patients who were readmitted were found to have significantly more prior hospital admissions (3.0 +/- 2 vs. 1.7 +/- 2; p = 0.011) and prior ED visits (1.6 +/- 2 vs. 3.1 +/- 2; p=0.008). In multivariate logistic regression analysis, the phone call was associated with a 75% reduction in readmission (adjusted odds ratio = 0.254, 95% CI 0.066-0.981; p= 0.047). The predictor variable, systolic dysfunction (EF < 55%) approached significance, with an adjusted odds ratio of 6.962, 95% CI 0.979-49.5; p 0.052.

Conclusions:
High readmission rates for HF are present despite advances in its management. The achievement of Medicare core measure variables was not associated with a reduction in 30-day HF readmission. The reasons for this finding are still unclear, perhaps hospitalizations are in need to meet Medicare core measure guidelines rather then tailor the discharge care of each patient. It is unexpected and noteworthy that a phone call made by a nurse to the patient post discharge was associated with a 75% reduction in 30-day readmission rates. Predictors of HF readmission remain complex and an ideal aggregate for predictors in readmission have yet to be defined.
Abstract 330: Hospital-Level Variation in One-Year Mortality and Angina Following Myocardial Infarction is Not Explained by In-Hospital Quality of Care in the TRIUMPH Registry
Authors: Vigen Rebecca , Ho P M , Jones Philip G , Spertus John A , Arnold Suzanne V , Bradley Steven M
Published: July 2021

Background:
Studies demonstrating variation in hospital quality of care using longitudinal outcomes have been limited in the amount of clinical data used to stratify patients’ risks and have not examined health status outcomes. We sought to describe hospital-level variation in risk-adjusted health status and mortality in the year following myocardial infarction (MI) and describe the extent to which hospital quality of care explains this variation.

Methods:
4,316 patients from the TRIUMPH registry, a prospective cohort study of MI patients at 24 hospitals, were included for analysis. Using hierarchical models, we described the hospital-level variation in angina (yes/no) and 1-year mortality rates. We then added hospital quality of care measures for MI applicable to the time period studied (ASA and beta blockers within 24 hours of arrival and at discharge, ACE/ARB at discharge, thrombolytics within 30 minutes, PCI within 90 minutes, and smoking cessation instructions at discharge) to these models to determine if hospital variation in one-year mortality and angina were explained by index MI quality of care.

Results:
The mortality rate at one year was 6.2% and the incidence of angina at one year was 23.0%. Unadjusted hospital-level 1-year mortality ranged from 0% to 10.8% and unadjusted presence of angina ranged from 9.3% to 66.7%. Statistically significant hospital-level variation in one-year mortality and angina was observed, with risk-adjusted mortality rates ranging from 5% to 8.3% (p<0.0001) and risk-adjusted angina rates ranging from 17.6% to 31.9% (p<0.0001). In-hospital quality of care measures did not attenuate hospital-level variation in mortality or angina (Figure 1).

Conclusions:
Hospital-level variation in 1-year mortality and angina was observed among the 24 hospitals participating in this MI registry. However, this variation was not explained by in-hospital MI performance measures. Future studies should assess care delivery factors that impact longitudinal outcomes following MI.
Abstract 343: Cardiovascular Device Recalls in 2012
Authors: Buckles Roberta A
Published: July 2021

Background:
For the fiscal year 2012, the Food and Drug Administration (FDA) classified 1,190 medical device recalls. Of these, 132 (11%) were for cardiovascular (CV) devices. Class I recalls, representing the greatest health risk, result from finding a reasonable probability that device use will cause serious adverse health consequences or death. FDA approves or clears devices for the US market through either the Pre-Market Approval (PMA) pathway or, more commonly, through a substantial equivalence determination known as 510(k) clearance.

Methods:
Recalled devices were categorized into nine broad CV device groups. Recall data was included on class, marketing path, and the number of distributed devices.

Results:
PMA devices represented 14% of the CV device recalls and 510(k) devices represented 82%. There were four Class I recalls -- two PMA and two 510(k). Circulatory support and surgical (CS) was the device group with highest number of recalls (43, 33%). Physiologic monitors (PM) had the second highest (28, 21%) and Vascular catheters (VC) the third highest (17, 13%). The remaining recalls (44, 33%) were included in these device groups: Implanted pacemakers, defibrillators and leads (ID), Non-implantable EP devices (EP), External defibrillators (ED), Vascular access (VA), Stents/grafts/valves (SG), and Others (OT).

Over 16 million distributed devices were recalled in the year, with the highest average number per recall seen in the CS group and the lowest in the EP group. Class I recalls varied based both on market pathway and the number of distributed devices.

Thoratec’s Heartmate II - PMA - 3,852

St Jude Medical’s Riata - PMA -128,000

Draeger’s Infinity System - 510(k) -1

Cardiac Science Powerheart - 510(k) -12,782

Conclusion:
Most of the CV recalls in 2012 were 510(k) devices that were in the CS, PM, or VC device group. Failures in medical devices pose risk to the public and FDA strives to mitigate risk to the public health through the promotion of safe and effective devices, and the removal from the US market of those determined to be unsafe or ineffective.
Abstract 346: Use of Aldosterone Antagonists at Discharge in Eligible Heart Failure Patients With a Comprehensive Heart Failure Program: Trends in Compliance With Get With the Guidelines-Heart Failure
Authors: Maybrook Ryan J , Afzal Muhammad R , Rankin Audra , Russell Christy , Vacek James
Published: July 2021

Background:
Use of aldosterone antagonist (AA) therapy is a class I recommendation in moderate to severe heart failure (HF). Multiple studies have reported the underutilization of AA in eligible patients. We wished to analyze determining factors for this ongoing underutilization using the AHA’s Get With the Guidelines (GWTG) HF database from American Heart Association (AHA). We hypothesized that elevated creatinine is a major barrier to use of AA.

Methods:
A comprehensive HF program utilizing the GWTG measures was recently established at our institution. Outcome data utilizing the GWTG registry from January 2009 to June 2012 was analyzed. Given ACC/AHA guidelines that creatinine should be
<
2.5 mg/dL in men or
<
2.0 mg/dL in women, we chose to analyze genders separately. To analyze effect of degree of creatinine elevation on AA therapy at discharge, two subcategories of creatinine levels were analyzed. Creatinine levels above 2.0 mg/dL in women and 2.5 mg/dL in men were excluded, as AAs are contraindicated in these patients. Categorical variables were compared using the chi-square test.

Results:
Our total compliance rate with AA therapy at discharge during the study period was 26% (149 of 565) for females and 31% (199 of 640) for males. There was no significant decline in compliance when creatinine levels were >1 mg/dL. Additionally, when comparing rates of compliance according to creatinine level across gender, there was no statistically significant difference in the use of AAs (see Table).

Conclusion:
Overall, AA therapy compliance at discharge at our center, as well as a majority of nationally recognized HF center participating in GWTG-HF registry remains suboptimal, irrespective of gender. This is despite known data that has clearly shown AAs significantly reduce mortality, cardiovascular death, HF hospitalizations and the composite endpoints. In contrast to prior studies, mild creatinine elevation does not seem to be a significant barrier to presciption of AAs. It is possible that other variables such as polypharmacy, hyperkalemia and effects of dual blockade of the renin-angiotensin-aldosterone system and the possibility of endocrine side effects associated with the non-selective AAs may be playing a role. More aggressive and consistent use of AA therapy for HF is warranted.
Abstract 38: Bayesian Meta-analysis of Percutaneous Coronary Intervention Compared to Optimal Medical Therapy in Patients With Stable Ischemic Heart Disease or Post-Acute Myocardial Infarction
Authors: Malebranche Lionel J , Horne Aaron , Morrone Doralisa , Aguiar Ruth T , Kolm Paul , Zhang Wei , Resar Jon , Riesenberg Lee Ann , Jurkovitz Claudine , Weintraub William S
Published: July 2021

Background:
The role of Percutaneous Coronary Intervention (PCI) in acute coronary syndromes is well established, but more controversial in stable ischemic heart disease (SIHD). We investigated the outcomes of Myocardial Infarction (MI) / death and all-cause mortality among published trials that compared PCI with optimal medical therapy (OMT).

Methods:
We retrieved all published papers that compared PCI with OMT in patients with SIHD or post-MI. Three clinician-researchers independently reviewed and abstracted a total of 110 articles meeting our inclusion criteria. 17 randomized controlled trials (RCT) published between 2000 and 2012 were analyzed by Bayesian random effects meta-analysis.

Results:
21,256 patients were analyzed: 11,502 had PCI and 9,754 OMT. There was no difference between PCI and OMT for the combined outcome of MI/death across all trials (RR = 0.99, 95% CI = 0.72-1.33, p = 0.98), although there was a trend for benefit with PCI all-cause mortality (RR = 0.81, 95% CI = 0.64-1.05, p = 0.48). When trials were analyzed by patient population, SIHD or post-MI, the trend for mortality benefit was noted only for the post-MI patients (Table 1).

Conclusion:
PCI did not yield any additional benefit above OMT for the end points of MI/Death or all-cause mortality in SIHD. However, there was a trend for reduced mortality with PCI in post-MI patients.
Abstract 43: Adherence to a Lifestyle Intervention Program Not Improved by Visual Knowledge of Carotid Intima Atherosclerosis
Authors: Walizer Elaine , Vernalis Marina , Modlin Randolph
Published: July 2021

Background:
The use of carotid intima media thickness (CIMT) ultrasound to identify subclinical atherosclerosis is widespread, but few studies examine its influence on patient behavior. This randomized, double-blinded clinical trial examined, in participants with ≥ 2 cardiovascular disease (CVD) risk factors and subclinical atherosclerosis, the use of CIMT ultrasound images to motivate adherence to a lifestyle change program.

Methods:
Participants were randomized into either the intervention group [receive CIMT results weekly (R-CIMT)] or control group [CIMT results withheld (W-CIMT)]. All participants received the 12-week lifestyle program (Mediterranean diet, aerobic exercise, group support). We determined the overall change in program adherence from baseline to week 12 using an ANCOVA model with CIMT group and gender as factors and age as the covariate. Percent adherence was calculated as a composite measure of diet and exercise adherence at baseline and 12 weeks: [Diet adherence = (Mediterranean Diet Score/14) X 100% + Exercise adherence = (weekly exercise time/180) X 100%]/2 where exercise adherence was capped at 100%. The R-CIMT group received a CIMT tutorial explaining results and associated increased CVD risk. Comprehension was assessed by a knowledge test at week 12 in the R-CIMT group only. Baseline motivation was assessed to determine its predictive ability of adherence when added to group assignment in a standard regression model.

Results:
142 participants (R-CIMT n=69; W-CIMT n=73) completed the study; mean age = 55 ± 10 yrs; 64% women (n=91); 45% black (n=64). Several demographic differences were seen between groups: R-CIMT group was older (57 vs. 53; p=0.02) and had a higher % female [73 (51 or 79) vs. 55 (40 of 73); p=0.02]. When comparing R-CIMT vs. W-CIMT group assignment, no difference was detected in overall % change in adherence respectively (19.6 ± 24.3 vs. 22.6 ± 24.2; p=0.52). Baseline motivation was similar in both groups and not predictive of change in adherence when added to group assignment (p=0.68). Median knowledge test score = 90% (80,100) in responding completers (80%; 55 of 69).

Conclusions:
Although the presence of subclinical atherosclerosis increased participant knowledge of their increased CVD risk, it did not act as a motivator in these participants to improve lifestyle change adherence more than those in the control group.
Abstract 86: Rates and Association of Risk Factors with Device Infection in Veterans Undergoing Cardioverter-Defibrillator Implantation Enrolled in the OVID Registry
Authors: Schneider Preston M , Katz David F , Pelligrini Cara N , Heidenreich Paul A , Aleong Ryan G , Keung Edmund C , Massie Barry M , Varosy Paul D
Published: July 2021

Introduction:
Implanted cardiac device infections are a source of significant morbidity, mortality, and cost. The rates and predictors of device infection among patients undergoing implantable cardioverter defibrillator (ICD) implantation in the VA population have not been previously described.

Methods:
Among veterans enrolled in the Outcomes among Veterans with Implantable Defibrillators (OVID) registry between 2003 and 2009, 3,918 were identified as within 3 months of initial ICD implantation. Baseline clinical characteristics and clinical outcomes were abstracted from the electronic medical record and social security death index. The rates of device infection were calculated per 100 person years and a priori specified predictors of device infection were examined for association with device infection using Cox proportional hazards regression.

Results:
Over 11,290 person years of follow up, only 76 device infections were identified for a rate of 0.67 per 100 person years (95% CI 0.54 to 0.84). Among these, 21 (27.6%) occurred within 30 days of implantation, 19 (25.0%) occurred 30 to 90 days after implantation, 8 (10.5%) occurred 90 days to 1 year after implantation, and 28 occurred greater than 1 year after implantation. The most common type of infection was a pocket infection and it was most likely to occur within 30 days of implantation. Of the examined a priori specified predictors (age, generator change, diabetes mellitus, warfarin use, chronic kidney disease and congestive heart failure), only generator change was statistically significantly associated with device infection when adjusted for comorbidities (adjusted HR 2.95; 95% CI 1.42 - 6.12). The rate of device infection among those with a generator change was 1.26 per 100 person years compared to 0.60 per 100 person years for those without a generator change.

Conclusions:
The overall rate of device infection in this population is lower than previously published rates and only generator change was associated with an increased risk of device infection.
Abstract 92: Approaches to Decision Support and Preparation for Destination Therapy Left Ventricular Assist Device: A Nationwide Sample of Mechanical Circulatory Support Coordinators
Authors: McIlvennan Colleen K , Narayan Madhav , Cannon Anne , Bradley William J , Nowels Carolyn , Brieke Andreas , Cleveland Joseph C , Matlock Daniel D , Allen Larry A
Published: July 2021

Background:
Patients offered left ventricular assist device as destination therapy (DT LVAD) are typically faced with the decision to undergo major surgery and live their remaining life dependent on mechanical circulatory support (MCS) or transition to end-of-life care. MCS coordinators are often the first point of contact and provide education and support to patients making this difficult decision.

Methods:
We conducted semi-structured, in-depth interviews with MCS coordinators in order to characterize the range of decision support and preparation offered to patients considering DT LVAD and to solicit input on how to optimize that process. Interviews took place from August 2012 to January 2013. All interviews were digitally recorded and data were analyzed using a directed content analysis approach.

Results:
Our sample included 20 MCS coordinators from different programs around the United States. The following primary themes emerged: 1) cardiothoracic surgeons or heart failure cardiologists were primarily responsible for presenting risks and benefits of DT LVAD whereas coordinators provided the majority of patient education regarding practical concerns and patient/caregiver responsibilities; 2) existing consents and industry material are too complicated or overly optimistic; 3) tension exists between creating accurate expectations of DT LVADs and providing clinical reassurance - “I don’t want to scare them away from a life-saving therapy either, so I try to paint a realistic picture but not so realistic that it scares them;” and 4) when asked to theoretically consider if they were offered DT LVAD, the majority of coordinators stated that it would be a difficult decision influenced by their own age, co-morbidities, and family dynamics - “I think it would really depend on where I was in my life at that point in time.”

Conclusions:
MCS coordinators are in a unique position to assist in decision making and preparation for patients eligible for DT LVADs. In order to improve this process, a multidisciplinary and iterative approach appears helpful in conveying the risks and benefits of DT LVAD. Consents and educational materials must be simplified, patient-centered, and free of bias. Patient needs and values should be defined up front to help tailor the process. The uncertainty of many MCS coordinators, who arguably best understand the totality of therapy, to theoretically pursue DT LVAD themselves highlights the difficult trade-offs and personalized nature of this decision.
Abstract 154: Prevalence of Heart Team Decision-Making at Hospitals in Michigan
Authors: Bruckel Jeffrey , Gurm Hitinder S , Seth Milan , Prager Richard L , Jensen Andrea , Nallamothu Brahmajee
Published: July 2021

BACKGROUND:
Heart Team decision-making for patients with complex coronary disease is a new concept in patient management, increasingly supported by guidelines. Although the Heart Team concept is supported by theory, there are little real-world data on implementation and prevalence. We sought to assess the prevalence of Heart Teams, and their impact on collaborative practice.

METHODS:
The Blue Cross Blue Shield of Michigan Cardiovascular Consortium and Michigan Society of Thoracic and Cardiovascular Surgeons performed a survey of 31 hospitals in Michigan where percutaneous coronary intervention (PCI) is performed. This survey was performed in 5/2011, before Heart Teams were recommended in National Guidelines. Physicians from each hospital were asked about the presence of a Heart Team or Case Conference, the frequency of collaboration, and the subjective level of collaboration (using a five-point Likert-type scale). We assessed the level of agreement between respondents from the same hospital about whether a Heart Team was active at their hospital. Due to disagreement at several hospitals, we classified them into Definite, Possible, or No Heart Team groups.

RESULTS:
Fifty-three physicians responded, representing 27/31 (87.1%) of hospitals surveyed. Seven hospitals out of 27 (25.9%) reported either a Heart Team or combined Case Conference, while 11/27 hospitals (40.7%) reported no Heart Team or Case Conference. There was disagreement about the presence of a Heart Team at 7/27 (25.9%) of hospitals and about Case Conferences at 9/27 (33.3%) of hospitals. There were few significant differences in the size or characteristics of hospitals between Heart Team groups. All Heart Team hospitals were teaching hospitals, compared with 73% (8/11) of non-Heart Team hospitals (p=0.056). The reported level of collaboration was significantly higher at Heart Team hospitals; this was reported as very good or best possible (4 or 5 out of 5) by 83.8% (31/37) of possible or definite Heart Team hospital respondents, compared with 50% (8/16) of respondents from hospitals without Heart Teams (p=0.017). Communication about patients undergoing multivessel PCI was higher at Heart Team hospitals (p=0.005).

Discussion:
This is the first report on the prevalence of Heart Teams in real-world practice, prior to the release of guidelines supporting their implementation. The most important findings of this study are the low initial prevalence of Heart Teams, and the level of disagreement between survey respondents about whether their hospital has a Heart Team or Case Conference. The survey shows higher levels of collaboration at hospitals with Heart Teams or Case Conferences. As Heart Teams become more widespread, more formal definition of the implementation and activities of a Heart Team will be crucial. Further study is needed to clarify the institutional characteristics that lead to a successful Heart Team.
Abstract 159: Evaluation of Downstream Utilization Following Stress-only versus Rest-Stress Myocardial Perfusion Imaging
Authors: Gahlot Vikram , Pappas Orestis , Rehder John , Poornima Indu
Published: July 2021

Background:
Current evidence and guidelines in nuclear cardiology support the use of stress-only myocardial perfusion imaging (SO-MPI), without rest imaging, to decrease radiation dose to the patient. We sought to determine the downstream utilization of cardiac procedures in patients undergoing SO-MPI in comparison to those undergoing rest-stress myocardial perfusion imaging (RS-MPI). Demonstration of the decreased need for cardiac procedures following SO-MPI would increase the confidence of interpreting nuclear cardiologists and referring physicians.

Methods:
We retrospectively analyzed the nuclear cardiology database at Allegheny General Hospital for patients undergoing stress testing with MPI from Jan 2010 to June 2011. Selection criteria for SO-MPI in our laboratory, includes no prior history of revascularization and low pre-test probability of coronary artery disease (CAD) based on symptoms and risk factors. We analyzed the rate of follow-up cardiac catherizations and repeat stress testing upto12 months after the index stress MPI. We compared the rate of procedure utilization following SO-MPI and RS-MPI.

Results:
A total of 5269 stress tests were performed during the enrollment period, of which 829 (16%) underwent SO-MPI, and the remainder (n=4440, 84%) had RS-MPI. Abnormal MPI was more likely in patients undergoing RS-MPI vs SO-MPI (525 vs 5; p<0.05). Patients undergoing RS-MPI were more likely to have a follow-up procedure compared to those undergoing SO-MPI (odds ratio 2.5; p<0.0001). Specifically the rate of cardiac catherization (565/4440; 13% in RS-MPI vs 27/829; 3%in SO-MPI p<0.05) and the rate of repeat stress testing (177/4440; 4% in RS-MPI vs 15/829; 1.8% in SO-MPI, p<0.05) were significantly higher in the RS-MPI group. Among patients undergoing SO-MPI, rate of cardiac catherization was significantly higher in patients having follow-up rest images compared to those that did not (odds ratio: 12.5, p<0.001). There were 6 revascularizations in the SO-MPI group in the follow-up period of which 5 occurred in those with abnormal MPI and 1 occurred in a patient with normal SO-MPI but in the setting of an acute infarct.

Conclusions:
Downstream procedure utilization following a SO-MPI strategy is low. This complements the low mortality rate noted in this population by prior studies. It further confirms that the current selection criteria for SO-MPI is appropriate as most patients require only one image and do not need additional testing. In patients with low-intermediate pretest probability for CAD that are referred for MPI, SO-MPI with limited use of rest imaging can facilitate throughput, reduce patient radiation dose and is associated with appropriately low downstream utilization.
Abstract 200: Outcomes of the American Heart Association’s Check. Change. Control Program: A Multi-Community Hypertension Intervention
Authors: Anderson Monique L , O'Brien Emily , Allen Lapointe Nancy M , Urrutia Peragallo Rachel , Alexander Angel M , Christian Alexander J , McCoy Lisa , Crawford Juliana , Webb Laura M , Chaudhuri Paramita S , Wayte Patrick , Peterson Eric D
Published: July 2021

Objectives:
Previous trials have demonstrated that individual, multi-faceted and intensive community-based BP intervention programs can improve BP control. It is unknown whether such programs can be effective using a more simplified format and generalized to multiple community settings.

Methods:
The AHA Check.Change.Control. program was implemented over a 7-month period in 18 US cities with high minority populations and burden of cardiovascular disease. AHA staff partnered with local community organizations/businesses and trained volunteer health mentors (VHM) to develop and implement a program centered on the use of Heart360™ health information technology, health education and events, and support to participants to monitor and reduce BP. We evaluated programs based upon their performance on three outcomes of interest: participant enrollment, participant engagement (8 BPs uploaded over 4 months), and blood pressure (BP) change. BP change was defined continuously comparing first and last recorded BP. We then examined program factors associated with program success.

Results:
From 1/1/2013 to 7/31/2013, n=4069 participants were enrolled in the program across 18 geographically-distinct communities. Most programs were implemented in churches, work-site wellness programs, and healthcare institutions. The mean number of patients enrolled by each site was 226 (SD=106) over 3 months. Programs with the highest enrollment were more likely to recruit from senior residential institutions and service organizations, hold hypertension management classes, hold more frequent kick-off events, and utilize a combination of established and new community partners. Participant engagement ranged from 0% to 52.8%. Programs with the highest engagement were more likely to hold hypertension education classes and follow-up with participants via call or face-to-face contact. Among all participants, systolic BP decreased by a mean of -7.5 mmHg (SD 20.1 mmHg, p<0.0001) and diastolic BP by -3.3 mmHg (SD 11.2 mmHg, p<0.0001). There was significant program level variation in systolic (+7.2 to -29.3 mmHg) and diastolic (+1.84 to -9.89 mmHg) BP change. Top programs for BP change were more likely to distribute blood pressure cuffs as incentives, check BPs at engagement activities, and use volunteer leads to oversee program activities. Increasing number of BP uploads was associated with larger declines in systolic (r=-0.27, p<0.0001) and diastolic (r=-0.17, p<0.0001) BP.

Conclusions:
Check.Change.Control. is a novel community-based initiative that demonstrated significant reduction in BP among 18 communities. We have identified several programmatic factors associated with improved program implementation and success that may guide future implementation in other communities.
Abstract 209: The Safety of Emergent Bedside Gastrointestinal Endoscopy in Patients with Moderate and Severe Aortic Stenosis in the Cardiac Intensive Care Unit
Authors: Faza Nadeen N , Hanouneh Ibrahim , Krishnaswamy Amar , Menon Venugopal
Published: July 2021

Purpose:
Recent advances in the management of aortic stenosis (AS) including the availability of percutaneous valve therapies have resulted in the evaluation of patients with increased co-morbidities. AS is associated with an increased risk of Gastrointestinal (GI) bleeding which is further increased by antithrombotic and antiplatelet treatment that often accompany hospitalization. The aim of our study was to determine the safety of emergent bedside endoscopies in patients with moderate to severe AS in the Cardiac Intensive Care Unit (CICU) setting presenting with acute GI bleeding.

Objective and Methods:
We identified all patients with moderate to severe AS who were admitted to the CICU at the Cleveland Clinic and experienced GI bleeding requiring emergent bedside endoscopies between Jan 2011 and Jan 2013. Data collection included demographics, indication for admission to the CICU, indication for bedside endoscopy, etiologies of GI bleeding, and intra procedural as well as post procedural hemodynamic instability and respiratory distress. AS was defined as moderate for aortic valve area (AVA) in the range 1.5-1.00 cm square and severe for AVA < 1.00 cm square.

Result:
17 patients (10 males) with a mean age 78.4 ± 10.6 years were identified. Overall 4 patients had moderate AS while 13 had severe AS. The peak gradient across the aortic valve was 53.8 ± 24.8 with a mean AVA 0.74 ± 0.25 cm square. Indication for urgent bedside endoscopies included episodes of acute melena, hematemesis, acute anemia of an undetermined etiology, in addition to evaluation of acute anemia in the perioperative period. 88% of patients were on either antiplatelet or anticoagulation or both. The patients underwent a total of 20 bedside endoscopies: 16 upper endoscopies and 4 colonoscopies. IV fentanyl and midazolam were used for sedation in patients not previously intubated. The etiologies of GI bleeding were peptic ulcer disease (n=5), hemorrhagic gastritis (n=5), esophagitis with esophageal ulcer (n=3), GI angiodysplasias (n=3), and diverticulitis (n=1). None of the patients developed acute hemodynamic instability or acute respiratory distress during or after the endoscopy.

Conclusion:
The etiologies of acute bleeding in patients with AS are diverse. Emergent bedside GI endoscopies done in the CICU for the diagnosis and management of acute GI bleeding is a safe procedure in patients with moderate to severe AS.
Abstract 226: Integration of Traditional and Alternate Chronic Care Models within a Primary Care Setting for Diabetes Management and Cardiovascular Disease Prevention
Authors: Thanikachalam Mohan , Shanmugasundar G , Ravikiran Muthuswamy , Harivanzan Vijaykumar , Ravi Sripriya
Published: July 2021

Background:
Several chronic care models (CCMs) for diabetes management and cardiovascular disease prevention have been implemented, but outcomes have been marginal. Traditionally, CCMs have been offered within the trusted primary care practice environment, but self-management support is episodic, cost ineffective and difficult to scale. Alternate CCMs that offer self-management support mostly through telephone coaching or virtual (web/mobile platforms) interventions, enable easy access, scalability and cost effectiveness, yet are impaired by the limits of isolated self-management support when provided outside the context of the trusted, therapeutic relationship of a primary care practice. We hypothesize that an integrated model taking advantage of positive aspects of traditional and alternate CCMs will lead to positive behavioral change (empowerment), sustained patient participation and better outcomes.

Methods:
To test this hypothesis, we implemented the Empowerment and Participatory Care Model (EPCM) in a study center in Chennai, India by integrating face-to-face support with customized telephone, Internet and mobile phone enabled interventions within a primary care setting. Patients who participated in the traditional CCM formed the control group.

Results:
In the participents in traditional CCM (n=422), there was an average reduction of 0.57% in HbA1c, 16 mg/dl in fasting blood sugar, 30 mg/dl in post prandial blood sugar and 16 mg/dl of LDL at the end of year-one. In comparison, among the patients (66% men; mean age 52 yrs) who participated in the EPCM and had completed one-year in the program (n=112) there was average reduction of 1.6% in HbA1c, 57 mg/dl in fasting blood sugar, 80 mg/dl in post prandial blood sugar and 18 mg/dl of LDL (p<0.01). Figure 1 shows the difference in percent reduction of the various biochemical parameters between the EPCM and the control group. The total cost of care (other than medication) per patient per year in the EPCM, after taking into consideration purchasing power parity between USA and India, was 900 USD.

Conclusion:
The persons with diabetes who participated in the EPCM had better quality of metabolic control, but long-term follow up is required to assess overall reduction in the risk of cardiovascular complications and cost effectiveness.
Abstract 248: National Trends in Utilization and Economic Outcomes of Catheter Ablation for Atrial Fibrillation in the United States 2003-2008
Authors: Mandawat Anant , Mandawat Aditya , Mandawat Rama , Mandawat Mahendra
Published: July 2021

Introduction:
Data on the utilization and economic outcomes of catheter ablation in atrial fibrillation (AF) is scarce, limiting the ability to make informed policy decisions.

Hypothesis:
We hypothesized that the number of catheter ablations for AF increased while length of stay and charges decreased.

Methods:
Patients > 18 years undergoing catheter ablation for AF were selected in the 2003-2008 HCUP-Nationwide Inpatient Sample, the largest all-payor inpatient database in the US. Patient demographic and clinical variables, including a Charlson comorbidity index, as well as hospital characteristics were analyzed. We calculated trends in rates of utilization, economic (mean LOS and total inflation-adjusted charges) and clinical (in-hospital mortality and in-hospital complications, defined using ICD-9 codes) outcomes using χ
2
, Mantel-Haenszel tests, and analysis of variance (ANOVA).

Results:
There were 40,145 admissions for catheter ablation for AF (mean age 60.01 years (SD 11.74; Range 18-98). The number of ablations increased by nearly 300% between 2003 and 2008 (Table). A comparison of use rates between 2003-2005 (early) vs 2006-2008 (late) showed a higher utilization among patients aged 65-79 (27.3% vs 34.0%), those with moderate comorbidities (30.3% vs 46.3%), and medium-sized hospitals (9.8% vs 19.7%), all p<0.001. During the study period, the mean LOS decreased by 30% while inflation-adjusted charges increased by 25% (Table). There was no significant change in clinical outcomes (Table).

Conclusions:
The number of catheter ablations for AF has increased rapidly. Although the procedure is being applied to a broader patient population and being performed in smaller-sized hospitals, LOS has decreased and clinical outcomes are stable. Factors contributing to and strategies to limit rising charges for this expanding procedure are important areas of future research.
Abstract 25: Early Coronary Angiography and Survival After Out-Of-Hospital Cardiac Arrest
Authors: Vyas Ankur , Chan Paul , McNally Bryan , Girotra Saket
Published: July 2021

Background:
Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are common rhythms seen in out-of-hospital cardiac arrest (OHCA). Although acute myocardial infarction is a frequent cause of VF and pulseless VT, it is unknown whether a strategy of early coronary angiography is associated with improved survival in patients with OHCA.

Methods:
Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 1810 adult patients who had an OHCA due to VF, pulseless VT, or an unknown but shockable rhythm and were successfully resuscitated and admitted to a hospital. Using a matched propensity score analysis, we examined the association between a strategy of early coronary angiography within the first day of cardiac arrest and survival to discharge.

Results:
Early coronary angiography was performed in 874 (48.3%) patients, of whom 523 (59.8%) received coronary stents. Compared to those without early angiography, patients undergoing early coronary angiography were younger (59.9 vs. 62.5 years); more likely to be men (77.9% vs. 64.5%), have a witnessed arrest (86.3% vs. 76.7%), have a diagnosis of ST-elevation myocardial infarction (STEMI) (68.5% vs. 20.3%); and less likely to have known cardiovascular disease (37.3% vs. 54.3%), diabetes (15.4% vs. 26.6%), and renal disease (3.7% vs. 8.3%) (P <0.01 for all comparisons). A total of 565 patients without early angiography were successfully matched to 565 patients with early coronary angiography (c-statistic of 0.77). A strategy of early coronary angiography was associated with higher rates of in-hospital survival (adjusted OR: 1.22, [1.02- 1.45], P=0.025). There were no differences in favorable neurological outcome between the two groups (adjusted OR: 1.10, [0.98-1.23], P=0.12).

Conclusion:
Among patients with an OHCA due to VF or pulseless VT who were successfully resuscitated and admitted to a hospital, a strategy of early coronary angiography was associated with better survival, which was not compromised by worse neurological outcomes. Given that many patients with an OHCA due to VF or pulseless VT do not currently undergo early coronary angiography, randomized trials are needed to confirm whether a strategy of early coronary angiography can improve outcomes in patients with OHCA.
Abstract 261: Applying Clinical Trial Data to Real-World: Apixaban, Dabigatran, and Rivaroxaban
Authors: Amin Alpesh , Stokes Michael , Wu Ning , Gatt Elyse , Makenbaeva Dinara , Wiederkehr Daniel , Lawrence John H
Published: July 2021

BACKGROUND:
Data from randomized controlled trials and a real-world sample of non-valvular atrial fibrillation patients were combined to estimate the absolute effect of each new oral anticoagulant (NOAC, apixaban, dabigatran, and rivaroxaban) versus warfarin on stroke and major bleeding rates in real-world clinical practice.

METHODS:
Non-valvular atrial fibrillation patients were selected from Medco healthplans during 2007-2010. Reference rates for stroke and major bleeding excluding intracranial hemorrhage (to avoid double counting) were calculated for real-world Medco patients during warfarin use. Real-world event rates for NOACs were estimated by multiplying the corresponding relative risk from the randomized clinical trials by each reference rate. Absolute risk reductions and numbers needed to treat (NNT) or numbers needed to harm (NNH) for each NOAC vs. warfarin were then estimated. Reduction in net clinical outcome was calculated by summing the absolute risk reductions for stroke and major bleeding excluding intracranial hemorrhage for each NOAC versus warfarin.

RESULTS:
Each NOAC resulted in a reduction in stroke events compared with warfarin in the real-world (TABLE). Apixaban was the only NOAC to reduce the rate of major bleeding excluding intracranial hemorrhage compared with warfarin. The NNT to avoid one net clinical outcome (stroke plus major bleeding excluding intracranial hemorrhage) per year was 32 and 84 for apixaban and dabigatran, respectively. Rivaroxaban resulted in an increase in net clinical outcome (NNH=166).

CONCLUSIONS:
If relative risk reductions from randomized clinical trials persist in the real-world, apixaban would result in the greatest clinical benefit versus warfarin of all NOACs in terms of stroke and major bleeding excluding intracranial hemorrhage events avoided.
Abstract 276: Asymmetric Dimethylarginine Is A Potential Risk Factor For Transient Ischemic Attack
Authors: Zhang Yuanjin , Laskowitz Daniel , Fan Dongsheng
Published: July 2021

Objective:
Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase which has been shown to be involved in the pathogens of atherosclerosis. Vascular endothelial growth factor (VEGF) is apleiotropic growth factor involved in neurovascular remodeling in the cerebral ischemia disease. ADMA has been validated to be a risk marker of stroke and transient ischemic attack (TIA). VEGF has been demonstrated associated with risk of stroke. This pilot study aimed to verify the correlation between serum ADMA, VEGF levels and ABCD2 score which has been validated to predict short term risk of stroke following transient ischemic attack (TIA).

Methods:
TIA was defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction even the focal transient neurologic symptoms last less than one hour. We enrolled 40 TIAs and 40 healthy controls in Peking University Third Hospital Neurology wards and clinics since May to July 2013. The TIA diagnosis and ABCD2 score evaluation is conducted by the same neurology physician. The mean age of TIAs and controls was 61.9±12.9yrs and 63.4±10.9yrs respectively (P=0.544). Blood samples were drawn within 24 hours after the TIA diagnosis clarified. ADMA and VEGF levels were measured by ELISA.

Result:
The ADMA levels in TIAs and control group are 0.52±0.06mmol/L and 0.23±0.04mmol/L (t=24.14, P<0.01). The VEGF levels in TIAs and control group are 272.01±26.36mmol/L and 148.87±21.05mmol/L (t=24.65, P<0.01). In the non-stroke history TIAs (23 cases) sub-group the spearman correlation coefficient between ADMA and ABCD2 score is 0.6(P=0.002).

Conclusion:
ADMA and VEGF are absolutely increased in TIAs. There is no correlation between ADMA, VEGF, age, sex, blood pressure, glucose and ABCD2 in this small sample size population. But ADMA is probably associated with risk of TIA with no-stroke history. Thus, these findings reveal a possibly new challenging potential of the ADMA and VEGF role in the pathogenesis of TIA.
Abstract 302: Echocardiographic Parameters in Perioperative Atrial Fibrillation in Cardiac and Non-Cardiac Surgery Patients
Authors: Arora Jaspreet , Nair Arjun , Cagino Leigh , Du Le , Torosoff Mikhail
Published: July 2021

Background:
We hypothesized that patients with new onset atrial fibrillation (AFib) following cardiac or non-cardiac surgery have similar echocardiographic features, regardless of the type of surgery.

Methods:
Study cohort included 4562 consecutive patients without history of atrial fibrillation undergoing general, thoracic or cardiovascular surgeries at a single tertiary academic medical center. Retrospective chart and echocardiogram review was performed. Chi-square, logistic regression, and analysis of variance were performed. Long-term all cause mortality was determined through Social Security Death Index. The study was approved by the institutional IRB.

Results:
Post-operative AFib was noted in 24% (275/1141) after cardiac surgery, 1.2 % (10/804) after thoracic non-cardiac surgery, and 0.7% (18/2617) after general non-cardiac non-thoracic surgery (p<0.0001).

On available echocardiograms, 18% (48/264) had LV dilatation and 38% (98/261) had moderate or severe LV dysfunction. The left atrium was dilated in 53% (139/260). Moderate or severe tricuspid regurgitation was noted in 11% (15/128), mitral regurgitation in 28% (45/16), mitral stenosis in 13% (11/82), aortic insufficiency in 27% (37/135), and aortic stenosis in 63% (19/135).

When adjusted for the presence of coronary artery disease, valvular disease, age, and gender, only aortic valve stenosis remained an important independent predictor of post-operative atrial fibrillation in non-cardiac surgery patients, HR=13.9 (95%CI 1.5-132.3, p<0.022).

Conclusion:
Despite significantly increased prevalence of new onset AFib after cardiac surgery, pre-existing cardiovascular conditions, specifically aortic valve stenosis, confer an increased risk of post-operative atrial fibrillation rather than the procedure itself. Improved resource utilization can be expected if post-operative ECG monitoring is limited to the high risk patients, identifiable during peri-operative screening. Prospective studies of this important subject are needed.
Abstract 312: Anatomic Runoff Score Predicts Cardiovascular Outcomes in Patients with Lower Extremity Peripheral Artery Disease
Authors: Jones William S , Patel Manesh R , Tsai Thomas T , Go Alan S , Gupta Rajan , Hedayati Nasim , Ho P M , Jazaeri Omid , Rogers R K , Shetterly Susan M , Wagner Nicole M , Magid David J
Published: July 2021

Background:
Although the presence, extent, and severity of obstruction in patients with lower extremity peripheral artery disease (LE-PAD) affect their clinical care, it is not known if these factors are associated with future cardiovascular endpoints. We empirically created an anatomic runoff score (ARS) that was based on the severity of stenosis of each lower extremity segment, and determined its association with clinical outcomes.

Methods:
We evaluated 908 patients with LE-PAD and bilateral angiography undergoing endovascular or surgical revascularization in a community based clinical study from 2005-2011. Clinical outcomes of interest were 1) all-cause death, 2) myocardial infarction (MI), 3) stroke, and 4) composite of all-cause death, MI, and stroke. Cox proportional hazards models were created and hazard ratios estimated for a standard deviation increment for continuous variables.

Results:
A total of 260 patients reached the composite endpoint (45 MI, 63 stroke, 152 death) during the study period. ARS ranged from 0-15 [Mean 4.7 (SD 2.5), Figure]. Patients who experienced the composite endpoint were more likely to be older, have more co-morbid conditions, were more likely to have undergone revascularization for CLI, and had a higher ARS (indicating more extensive PAD). The most significant predictors of the composite endpoint (death/MI/stroke) were age (delta=10 years; HR 1.40, CI 1.25-1.55, p<0.0001), diabetes mellitus (HR 1.51, CI 1.16-1.98, p=0.0026), ARS (delta=2 points; HR 1.15, CI 1.03-1.26, p=0.0187), and indication for procedure (CLI vs. claudication; HR 1.68, CI 1.28-2.21, p=0.0002). The use of the ARS to predict the composite outcome was comparable for patients with CLI and patients with claudication (in patients with CLI, ARS HR=1.15; in patients with Claudication, ARS HR=1.21; interaction p value=0.70).

Conclusions:
After adjustment for clinical factors, the LE-PAD anatomic runoff score, age and indication for procedure were the most significant predictors of future cardiovascular morbidity and mortality in a broadly-representative patient population undergoing revascularization for symptomatic PAD. The use of a clinically useful anatomic scoring system, if validated, may assist clinicians in risk-stratifying patients during the course of clinical decision-making.