bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 14567: Lipid Variability as a Risk Factor of Major Adverse Cardiovascular Outcomes. Meta-Analysis of Observational Studies
Authors: Rueda-Ochoa Oscar L , Vega Zambrano Laura Valentina V , Gomez Osma Juan Camilo R
Published: December 2023

Introduction:
Serum lipids variability has been described as a risk factor for cardiovascular disease. However, there is no published systematic review in the literature at the moment. The purpose is to evaluate the association between lipid variability and outcomes related to cardiovascular disease.

Methods:
We made a systematic search in Pubmed, Science Direct, Clinical Key, CINAHL, Lilacs, and Google Scholar using: lipids, variability, death, stroke, myocardial infarction, and cholesterol variability as keywords. Two independent researchers selected and made an extraction of the data. Non-agreement was solved by a third researcher. Non-language limitations were made. Exposure factors were coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM) from LDL, HDL, Non-HDL, Total Cholesterol, and Triglycerides. MACE was the outcome of interest. We made a forest plot and heterogeneity analysis using I2. All analyses were made using STATA v. 14.2

Results:
Eight papers from the initial 9785 met the inclusion criteria. All papers were cohort studies and a high heterogeneity was identified in the majority of them. The main heterogeneity causes were the difference in the number of participants in the studies, the years following, and the age of the participants included in the studies. In relation to the studies of low heterogeneity (<40%), we found that the high variability of HDL analyzed with CV increases the risk of myocardial infarction (RR=1.39 [95% CI 1.35-1.42, I2 0%]). On the other hand, there were found significative relations between the variability of HDL analyzed with VIM to cardiovascular disease (RR=1.26 [95% CI 1.20-1.33], however, it had a high heterogeneity (I2 68.4%).

Conclusions:
The comparisons of the studies that analyze lipid variability have a high heterogeneity due to population differences. A relationship was found in the variability of HDL and myocardial infarction.
Abstract 14575: Pupillary Reflex as an Independent Marker of Mortality in Decompensated Heart Failure. A Longitudinal and Prospective Study
Authors: Zamorano Margarita , Monteagudo Juan Manuel , Gonzalez Eduardo , Fernandez Santos Sara , Castillo Miguel , Rayo Isabel , de la Villa Pedro , Zamorano Jose
Published: December 2023

Introduction:
In heart failure (HF) compensatory mechanisms are triggered to maintain adequate cardiac output. Among them, hyperactivation of sympathetic nervous system (SNS) is one of the main ones and carries a worse prognosis. The pupillary reflex depends on the SNS.

Aims:
The aim of the study is to analyze whether changes in the pupillary reflex in HF are useful in the prognostic stratification of these patients.

Hypothesis:
Pupillary reflex may be a prognostic marker in patients with decompensated HF.

Methods:
We prospectively and consecutively included 107 patients admitted with decompensated HF. Quantitative pupillometry was performed with the NeuroOptics pupillometry during the first 24 hours after admission and prior to discharge. The basal maximum pupillary diameter (BMPD) before contraction, was measured.

Results:
Of the 107 patients, 51% were women and 49% men, mean age was 79 +/- 10 years, 77% had hypertension, and 34% Diabetes.6 patients died during admission, 11 died in the first month after discharge and 4 patients were readmitted in the first month.Of the patients who died, all had on admission BMPD > 3.8 mm. No patient with a BMPD < 3.7 mm died. The area under curve ROC for predicting the combined endpoint of 1- month mortality and admissions for HF using BMPD was 0.823.

The BMPD presented a weak correlation with heart rate and ejection fraction. It did not correlate with age, gender, BNP, mean E/e, left atrial volume indexed, creatinine, hematocrit, sodium.

Conclusions:
Patients with decompensated HF presented at admission a higher BMPD. This supports the hypothesis that decompensated HF present a hyperactivation of the SNS that promotes mydriasis. BMPD is provides a good independent predictor marker of in-hospital and 1-month mortality in patients admitted with HF. Pupillometry may be a new, non-invasive and simple tool that helps in the prognostic stratification of acute HF patients.
Abstract 14605: Association of SGLT-2 Inhibition With Size of Myocardial Infarction in Patients With Type 2 Diabetes Mellitus
Authors: Bojti Istvan , Bojti Felicitas , Hartikainen Tau , Breitbart Philipp , Valina Christian , Löffelhardt Nikolaus , Kaier Klaus , Wolf Dennis , Westermann Dirk , Olivier Christoph B
Published: December 2023

Introduction:
Preclinical data suggest that sodium-glucose-cotransporter-2 inhibitors (SGLT-2i) reduce the size of myocardial infarction (MI). This study aimed to assess the association of SGLT-2i use with the size of MI and clinical outcome.

Methods:
In a retrospective single center cohort study, patients with diagnosed diabetes mellitus type 2 who were admitted for MI and treated with PCI between November 2015 and November 2022 were analyzed and grouped according to SGLT-2i use. Following PCI, serial high sensitivity troponin T (cTn, Roche) measurements were performed according to in-house protocol. The primary outcome was the size of MI determined by the peak cTn normalized on the endangered myocardial area (EMA) calculated according to culprit lesion localization and coronary arterial dominance. Secondary outcomes were in-hospital adverse events (i.e. in-hospital death or stroke) and length of intensive care unit (ICU) treatment. The propensity score method was used to assess the association with outcomes.

Results:
631 patients were identified: 85 with ongoing SGLT-2i therapy and 537 with other antidiabetic medication. Patients using SGLT-2i were younger (median age [years]: 67 [interquartile range, IQR 59-73] vs. 73 [64-79], p<0.01) and had a higher eGFR at admission (75 [57-91] vs. 68 [49-88] ml/min/1.73m
2
, p=0.03). The median cTn samples per patient was 6 (5-8). There was no significant difference in the peak cTn levels between the two groups (SGLT-2i use vs. no SGLT-2i use: 53 (12-173) vs. 65 (20-174) х the upper limit of normal [ULN], p=0.26). After augmented inverse-probability weighted propensity score matching, ongoing SGLT-2i therapy was significantly associated with a reduced MI size (difference between means: -2.19 [95% confidence interval, -4.07 to -0.31] x ULN/EMA (1/%), p=0.02). SGLT-2i use was associated with less in-hospital adverse events (-4.69 [-8.70 to -0.69] %, p=0.02) and with less days on ICU (-0.27 [-0.53 to -0.01] days, p=0.045).

Conclusion:
In this retrospective cohort study of patients with DM presenting with MI, prior prescription of SGLT-2i was associated with reduced MI size and fewer adverse events during hospitalization. This might indicate that SGLT2i reduces the size of MI.
Abstract 14623: SGLT2 Inhibitors versus Sulfonylureas as Add-On Therapy to Metformin in Type 2 Diabetes: A Systematic Review and Meta-Analysis
Authors: Umer Muhammed , Salman Ali , Nadeem Shahrukh , Iqbal Abiha , Tashrifwala Fatema , Paryani Neha Saleem , Ali Eman , Kumar Jai , Maniya Muhammad Talha , Asad Dayab , Ansari Saad A , Siddiqi Tariq J , Usman Muhammad Shariq
Published: December 2023

Background:
Traditionally, in patients with type 2 diabetes mellitus (T2DM) poorly controlled on metformin sulfonylureas were used as add-on therapy. Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as novel antidiabetic agents that have also shown improvement in cardiovascular outcomes.
Aim:
To conduct a meta-analysis comparing SGLT2i with sulfonylureas as add-on therapy to metformin in patients with poorly controlled type 2 diabetes mellitus (T2DM).

Methods:
We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library up till March 2023, to identify studies comparing SGLT2i versus sulfonylureas as add-on therapy to metformin in patients with poorly controlled T2DM (regardless of the presence of comorbid cardiovascular disease). Effect estimates were pooled using a random-effects model, and reported as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) for continuous outcomes, along with 95% confidence intervals (CIs) for each.

Results:
Eleven studies met the inclusion criteria, all reporting mortality outcomes. Metformin-SGLT2i significantly reduced all-cause mortality (RR=0.76 [0.60, 0.95]; p=0.02;
Figure
) and myocardial infarction (RR: 0.65 [0.47, 0.89]; p=0.008), in comparison to metformin-sulfonylureas. Metformin-SGLT2i was also associated with a significantly greater reduction in HbA1c (MD: -0.10% [-0.17 - -0.03]; p=0.004), fasting plasma glucose (MD: -0.55 [-0.69 - -0.41]; p<0.001), systolic blood pressure (MD: -4.77 mmHg [-5.39, -4.16]; p<0.001), and weight (MD: -4.57 kg [-4.74, -4.39]; p<0.00), compared with metformin-sulfonylurea. Moreover, metformin-SGLT2i was associated with a significantly lower risk of hypoglycemic events (RR=0.13 [0.10-0.17]; p<0.001).

Conclusion:
In patients with poorly controlled T2DM on metformin, addition of SGLT2i may yield superior outcomes compared with sulfonylureas.
Abstract 14636: Social Determinants of Health and Clinical Outcomes in a Diverse Hypertrophic Cardiomyopathy Cohort
Authors: Ganti Rohan , Paul Ludwine , kpodonu jacques , Lakdawala Neal K , Ahluwalia Monica
Published: December 2023

Introduction:
Contemporary studies are needed to evaluate impact of social determinants of health (SDH) and clinical outcomes in diverse hypertrophic cardiomyopathy (HCM) populations.

Hypothesis:
Among predominant Black/Hispanic minority population, HCM-related death is higher than reported literature and may be related to SDH.

Methods:
Data from HCM patients were obtained in a large academic safety-net hospital from 2017 to 2022. Outcomes including heart failure (HF), atrial fibrillation, stroke, ventricular arrhythmias, septal reduction therapy (SRT) and death were obtained by chart review. Zip codes were extracted using the SDH database from the Neighborhood Atlas from University of Wisconsin to determine area deprivation index (ADI 1-10, higher ADI signifies greater neighborhood disadvantage). Chi-square and binary logistic regression analyses were conducted to assess association between ADI and outcomes, adjusting for demographic data.

Results:
At baseline, 118 HCM patients, were 52 ± 15 years old, 44% female, 54% Black, 20% Hispanic, 10% White, BMI 31± 6 kg/m2, and ESC score 2.4 ± 1.9. Seventy-eight (82%) patients had nonobstructive HCM (22 % apical variant) with maximal wall thickness of 19 ± 6 mm; 14% had late gadolinium enhancement (LGE)
>
15%. Among 50% patients with genetic testing, 31% had a pathogenic/likely pathogenic sarcomere variant and 44% had variants of unknown significance. Over 6.3 years follow up (IQR 6.6), 20% patients developed incident HF, 19% AF, 8% SRT, and 6 (5%) patients suffered HCM-related death. Among the 23% of patients who had an ICD placed, 15% had appropriate ICD shock over 7 ± 7 years. Among the 105 patients with available zip codes, 44% patients had ADI
>
6. There was no association between ADI and global outcome (OR [95% CI] = 1.32 [0.6-2.9], p = 0.49) or HCM-related death (OR [95% CI] = 0.46 [0.7-2.9], p = 0.41).

Conclusions:
Compared to published literature, our cohort was mainly Black/Hispanic with high degree of apical remodeling and low frequency of obstruction, highlighting need for focused efforts to improve HCM diagnosis in this population. Further, global outcome and HCM-related death were not related to zip-code level SDH. Larger diverse cohorts are needed to include individual level SDH in relation to outcomes.
Abstract 14665: Cybrid Analysis Delineates Nuclear and Mitochondrial Contributions to Oxidative Stress in Pulmonary Arterial Hypertension
Authors: Balachandar Srimmitha , OConnell Thomas M , Aldred Micheala A
Published: December 2023

Rationale
: Heritable pulmonary arterial hypertension (HPAH) is a serious vasculopathy caused by remodeling of pulmonary arterioles. It is inherited in an autosomal dominant pattern with reduced penetrance, suggesting additional triggers are needed for disease development. Past study shows increased DNA damage and total reactive oxygen species (ROS) in lymphoblastoid cells (LCL) from PAH patients and unaffected relatives, indicating a potential genetic component.

Hypothesis:
Increased oxidative stress is an independent genetically-determined modifier of PAH susceptibility.

Methods:
LCL from patients, relatives and unrelated controls were analyzed for total and mitochondrial (mt) ROS and mt function (Seahorse). Untargeted metabolomics were performed by Metabolon. Nuclear vs mt gene contribution was studied using cybrids created by transferring the mitochondria from high (HC) and low ROS LCL (LC) to mt negative 143B Rho0 cells.

Results:
Metabolomics revealed significant differences between PAH and control LCL in the TCA cycle and glutathione metabolism relating to oxidative stress. HPAH LCL showed significant upregulation of both ROS species compared to controls. LCL from relatives clustered into two groups, one with increased mtROS, the other comparable to controls
.
Like PAH lung vascular cells, LCL with increased mtROS had reduced spare respiratory capacity (SRC) suggesting dysfunctional mitochondria, but no glycolytic switch. Cybrid analysis revealed that HCs had significantly higher basal respiration (p=0.02), with SRC trending higher compared to LCs, indicating a functional electron transport chain. These cells also had elevated mtROS (p=0.04), suggesting reduced antioxidants.

Conclusions:
HPAH is a complex disease, and mutation status alone doesn’t determine its susceptibility. Patient LCL recapitulate some of the metabolomic pathways dysregulated in lung vascular cells. Oxidative stress in LCL extends to some unaffected relatives, suggesting this is an independent genetic trait that modifies PAH risk. Our cybrid analysis, novel in PAH highlights the importance of nuclear-mt crosstalk. WGS is underway to identify nuclear variants that could affect the mt, and act as potential modifiers and second hits in PAH pathogenesis.
Abstract 14671: Investigating Health Disparities in Arrival From Last Known Well Times in Queens, NY
Authors: Pierre Stanley , Huang Anna , Wilson Shaun-marie , Jules Vanessa , Holson Holson , Chuang Denise , Sengupta Debashree , Punsalan Jason , Mohan Suja , Thomas Susan , Merisier Gilbert
Published: December 2023

Background:
Stroke is a leading cause of death in the US and the third leading cause of disability worldwide, so timely access to care must be considered as it is a salient predictor of prognosis and outcomes.
1,2
Specifically, because the recommended treatment window for IV tPA (alteplase) is within 4.5hr of last known well (LKW), it is imperative for patients to present to the facility within 3.5hr from symptom onset to receive treatment.
3
There are known health disparities in stroke treatment/outcomes
4
, and this study seeks to explore the population of patients that disproportionately have unknown or LKW >4.5hr to arrival, and the impacts of such.

Methods:
Stroke patients entered into the Get With The Guidelines™-Stroke excluding patients whose symptoms began after hospital arrival and were discharged from October 2021 to December 2022 from NYC Health + Hospitals/Queens were included. Arrival from LKW time was categorized into ≤0-4.5hr and >4.5hr. Covariates collected and included are age, Hispanic ethnicity, sex, race, final clinical diagnosis of stroke, and history of previous stroke. Logistic regression models were used to analyze data and results are presented as adjusted odds ratios at 0.05 significance.

Results:
A total of 342 patients were included in this study with 211 patients arriving after 4.5hr. The median time to arrival from LKW was 829min. Notably, patients identifying as Asian were more likely to arrive within 4.5hr of LKW (3.21 adjusted OR, 95% CI 1.30-7.91, p = 0.01) compared to their Black counterparts. White patients were also more likely to arrive within the 4.5hr treatment window compared to Black patients (11.69 adjusted OR, 95% CI 3.39-40.36, p = 0.0001). Increase in age was associated with decrease in timely arrival from LKW (0.98 adjusted OR, 95% CI 0.96-0.99, p = 0.04). Clinically, those that were diagnosed with ischemic stroke were more likely to arrive within 4.5hr of LKW (2.55 adjusted OR, 95% CI 1.37-4.77, p = 0.003) as well as those with a history of previous stroke (2.74 adjusted OR, 95% CI 1.39-5.40, p = 0.004).

Conclusion:
There are health disparities in stroke treatment because of prolonged patient arrival from or unknown LKW, and these findings will help inform further practices in community education and outreach.
Abstract 14678: Racial/Ethnic Disparities in Low-Density Lipoprotein Cholesterol Testing Following Myocardial Infarction Hospitalization Among Medicare Beneficiaries in the United States, by State
Authors: Jones Jenna , Colantonio Lisandro D , Wang Zhixin , Bittner Vera A , Rosenson Robert S , Kalich Bethany , Dhalwani Nafeesa
Published: December 2023

Introduction:
Low-density lipoprotein cholesterol (LDL-C) is used to guide lipid-lowering treatment following hospitalization for myocardial infarction (MI). Recent analyses illustrate a lack of short-term LDL-C testing across the United States, but it is unclear whether race/ethnicity differences exist in all states. Lack of LDL-C testing following an MI may represent a missed opportunity to identify groups of patients with low response to lipid-lowering therapy.

Research Question:
Does use of LDL-C testing at 90 days post-MI differ by race in each state and across states?

Methods:
We conducted a retrospective cohort study of Medicare beneficiaries with fee-for-service coverage, pharmacy benefits, and ≥66 years of age with an MI hospitalization between 2016 and 2020 and estimated the cumulative incidence of LDL-C testing at 90 days post-MI overall, by state, and by race.

Results:
Of the 532,767 MI hospitalizations, 84.4% and 8.4% were among non-Hispanic White and non-Hispanic Black beneficiaries, respectively, with Asian and Hispanic beneficiaries each representing 2.0% of the hospitalizations. The cumulative incidence of LDL-C testing in the US was 29.9%. Hawaii had the highest overall cumulative incidence of LDL-C testing (43%) while Arkansas had the lowest (17%). Cumulative incidence of LDL-C testing was lowest among non-Hispanic Blacks (26.0%) compared to all other racial groups with testing rates between 30-33%. In most states, cumulative incidence of LDL-C testing among Non-Hispanic Blacks was lower than the state average, whereas among Whites it was higher than the state average (see Table 1).

Conclusions:
LDL-C testing was low in the 90 days after hospital discharge for MI among Medicare beneficiaries, with substantial geographic and race disparities. In many states, our data suggests testing for Black Americans was lower than the state average.

Funding: Amgen Inc.
Abstract 14684: Ambulatory Electrocardiogram for Mortality Risk Stratification in Arrhythmic Mitral Valve Prolapse
Authors: Cesmat Andrew , Chaudry Abdul , Gupta Suhani , Weickert Thelsa , Simpson Ross J , Syed Faisal
Published: December 2023

Introduction:
Mitral valve prolapse (MVP) has been associated with sudden death. There is little data on whether ambulatory ECG monitoring can be used to better define risk.

Hypothesis:
Severity of ventricular arrhythmia (VA) on ambulatory ECG is associated with mortality in MVP patients.

Methods:
We studied patients aged 18 - 90 years with MVP on echocardiography between 2016-19 at our institution who underwent ambulatory ECG monitoring. Ambulatory ECGs were reviewed for PVC burden and rate of non-sustained ventricular tachycardia (NSVT). VA severity was classified as none (PVC<1% and no NSVT), mild (PVC>1% or NSVT<120 beats per minute [bpm]), moderate (NSVT 120-179 bpm) and severe (NSVT≥180 bpm). Kaplan-Meier survival analysis was used to assess whether VA severity is associated with mortality.

Results:
Holter monitoring was performed in 188 (29.5%) of 637 MVP patients. None, mild, moderate and severe VA was present in 91 (48.4%), 27 (14.4%), 56 (29.8%) and 14 (7.5%), respectively. On multivariate analysis of clinical and echocardiographic features, only bileaflet prolapse was associated with moderate to severe VA (odds ratio [95% CI], 2.10 [1.05-4.16, p=0.03). After a median (IQR) follow-up of 33 (19-46) months, 8 (4.2%) died. VA severity was positively associated with mortality (p=0.0189).

Conclusions:
Ventricular arrhythmia is frequently present in MVP. Increased severity of ventricular arrhythmia on ambulatory monitoring portends a worse prognosis in MVP patients. Ambulatory ECG monitoring should be considered for risk stratification in MVP patients.
Abstract 14691: Safety and Efficacy of Catheter Ablation for Atrial Fibrillation in Patients With a History of Cancer: A Systematic Review and Meta-Analysis
Authors: Costa Thomaz A , Felix Nicole , Clemente Mariana R , Teixeira Larissa , Antonio Pinheiro Braga Marcelo , Silva Livia , Florido Roberta
Published: December 2023

Background:
Patients with an active or past medical history of cancer have an increased risk of atrial fibrillation (AF) and drug-refractory AF. However, evidence for the safety and efficacy of catheter ablation in this population remains limited.

Hypothesis:
Catheter ablation is a safe and effective strategy for rhythm control in cancer survivors with AF.

Aims:
To perform a systematic analysis of published studies comparing the safety and efficacy of AF catheter ablation in persons with and without prior or active cancer.

Methods:
We systematically searched PubMed, Cochrane Library, and Embase from inception to April 2023 for studies comparing the safety and efficacy of AF catheter ablation in persons with and without cancer. Outcomes of interest were bleeding events, recurrence of AF after 12 months, and the need for repeat ablation. Statistical analyses were performed using Review Manager 5.4.1.

Results:
We included five retrospective cohort studies comprising 998 patients, of whom 413 (41.4%) had a history of cancer diagnosis, including 58 (14%) with active cancer at the time of catheter ablation. Patients with a diagnosis of cancer had at significantly higher risk of clinically relevant bleeding (OR 2.07; 95% CI 1.03-4.15; p=0.04; Figure 1A) compared to those without cancer. Recurrence of AF after 12 months (OR 1.26; 95% CI 0.81-1.96; p=0.31; Figure 1B) and the need for repeat ablation did not differ significantly between groups (OR 0.71; 95% CI 0.37-1.37; p=0.31), respectively.

Conclusions:
The findings from our meta-analysis suggest that patients with a history of cancer have an increased risk of bleeding after AF catheter ablation compared to patients without cancer, with no significant differences in the efficacy of the catheter ablation between patients with or without cancer.
Abstract 147: Is Effect Size of Targeted Temperature Management Different for Pediatric Post-Cardiac Arrest Syndrome According to the Severity?
Authors: Namba Takeshi , Ohshimo Shinichiro , Nishikimi Mitsuaki , Miyoshi Hiromi , Masuka Yuki , Shime Nobuaki
Published: December 2023

Introduction:
The beneficial effect of target temperature management (TTM) for pediatric post-cardiac arrest syndrome (PCAS) patients is controversial, and there are few studies on the differential effects of TTM according to the risk classification.

Objective:
The aim of this study was to evaluate the differential effects of TTM for pediatric PCAS patients according to a risk classification tool we previously developed, rCAST.

Methods:
We used data from the Japanese nationwide out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine. We classified eligible pediatric PCAS patients (aged ≤18 years) who achieved return of spontaneous circulation (ROSC) according to the quintile of score points on the rCAST. The effect of TTM for their neurological outcome was evaluated for each severity group. And then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by the propensity score analysis with several adjustment factors. Good neurological outcome was defined as a Cerebral Performance Categories score or Pediatric Cerebral Performance Categories score ≤2 at 30 days.

Results:
Among 1,526 OHCA pediatric patients in the registry, data of 307 PCAS patients who achieved ROSC were analyzed. The proportion of patients with a good neurological outcome was higher among those who underwent TTM compared to those who did not in the first to forth quintile (TTM vs non-TTM; 81% [21/26] vs 58% [21/36] [p=0.10] in the first, 11% [2/19] vs 7% [2/31] [p=0.63] in the second, 12% [2/17] vs 0% [0/55] [p=0.053] in the third, and 11% [1/9] vs 0% [0/21] [p=0.30] in the fourth). In the group of the fifth quantile (rCAST ≥ 18.5), no patients showed good neurological outcome regardless of TTM (0% [0/20] vs 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with their good neurological outcome in the patients classified into the first to fourth quantile group (Odds ratio; 1.21 [1.04-1.40], p = 0.014).

Conclusions:
TTM was significantly associated with a good neurological outcome in the pediatric PCAS patients with rCAST ≤ 18.0. All patients with rCAST ≥ 18.5 showed poor neurological outcomes even if they underwent TTM.
Abstract 14700: Associations of Left Ventricular Structure With Cumulative Systolic Blood Pressure Load: A Report From Women’s Ischemia Syndrome Evaluation - Coronary Vascular Dysfunction Study
Authors: Ranasinghe Sachini , Cui Yujie , Obrutu Okezi , Nelson Michael D , Bairey Merz C Noel , Wei Janet
Published: December 2023

Background:
Recent studies have identified cumulative systolic blood pressure load to be associated with increased risk of adverse cardiovascular disease (CVD) outcomes. Similarly, associations between left ventricular (LV) structure and CVD events have long been recognized.

Purpose:
The purpose of this study was to assess the association between cumulative systolic blood pressure (CuSBP) load and LV structure in women with suspected ischemia with no obstructive coronary arteries (INOCA).

Methods:
Women enrolled in the Women’s Ischemia Syndrome Evaluation - Coronary Vascular Dysfunction (WISE-CVD) study (NCT00832702) underwent cardiac magnetic resonance imaging (CMRI) for LV structure and those (n= 225) who had at least 2 blood pressure (BP) measures recorded at a single site before their baseline CMRI were included in this analysis. Cumulative systolic BP (CuSBP) was defined as systolic BP (SBP) ≥ 130 divided by all SBP readings and each mean value multiplied by the years. LV remodeling index was defined as the ratio between LV mass and LV end diastolic volume (LVEDV).

Results:
The mean age was 55±10 years, body mass index (BMI) 26.3 ± 5.5 kg/m
2
, 36% had a history of hypertension, number of BP medications was mean 2.7 ± 1.6 [median 2 (range 0, 8)], and SBP and DBP were 126 ± 15 and 66 ± 10 mmHg respectively. Age, BMI and history of hypertension were significantly associated with higher CuSBP load. In univariate analyses, LV end diastolic volume and LV end systolic volume decreased, and LV remodeling index increased across CuSBP quartiles while LV mass index did not significantly differ among the quartiles
(Figure 1)
. In multivariable regression analysis, the association between CuSBP and LV mass index and LV remodeling index remained significant.

Conclusions:
Among women with suspected INOCA, higher CuSBP load was associated with greater LV mass index and concentric LV remodeling independent of age. Changes in LV volumes may represent age-related changes in LV structure.
Abstract 14707: Telehealth Usage for Outpatient Cardiology Evaluations During the COVID-19 Pandemic
Authors: Solomon Matthew D , Somers Madeline , Huang Jie , Millman Andrea , Leong Thomas K , Garcia Elisha , Low Deborah , Njuguna Veronica W , mcnulty edward , Roblin Douglas , Go Alan S , Reed Mary
Published: December 2023

Introduction:
The use of telehealth for cardiac services rapidly expanded during the pandemic, but little is known about the factors driving use of telehealth versus traditional in-person outpatient evaluation.

Research Question:
What factors are associated with telehealth use for patients with symptoms of cardiovascular disease referred for outpatient cardiology evaluation during the COVID-19 pandemic?

Methods:
In a large, integrated healthcare system caring for >4.5M patients, we identified those aged >18 years without prior cardiology diagnoses or visits who were evaluated for symptoms of incident heart failure, coronary disease, or arrhythmias before (Jan 2018-Dec 2019) and during the pandemic (June 2020-May 2022) periods. We categorized patients based on initial cardiology visit type: telehealth (video or telephone) or in-person. We compared unadjusted demographic, socioeconomic (SES), and clinical characteristics between visit types, and examined multivariable associations using Cox regression.

Results:
Only 146 (2.2%) of 6376 pre-pandemic patients versus 4074 (69%; 1213 telephone, 2861 video) of 5898 pandemic patients had an initial cardiology telehealth visit. In the pandemic period, compared to those with in-person visits, patients with video visits were more likely to be younger (58 vs 64 yrs; p<0.01), female (49% vs 45%; p<0.01), and to be linked to a facility with parking fees (11% vs 7%; p<0.01). Telephone visits had the highest proportion of patients with low SES, low internet usage, and a higher comorbidity burden. In adjusted models, these relationships were generally upheld (
Figure
), and the later year of the pandemic (2022) were strongly associated with increased in-person visits.

Conclusions:
Many patient and system level factors were associated with telehealth use during the COVID-19 pandemic. Future studies should examine the relationship between clinical outcomes and visit type, as telehealth has become part of routine care.
Abstract 14711: Prediction of Persistent High-Need High-Cost Cardiology Patients With and Without Renal Failure
Authors: de Ruijter Ursula W , Kaplan Z.L.R. R , Cornel Jan H , Lingsma Hester F , Bax Willem A
Published: December 2023

Introduction:
Heart failure (HF) and coronary artery disease (CAD) are increasingly complex disease entities, in particular in older patients with multiple long-term conditions. High-Need High-Cost (HNHC) patients are at risk of receiving inefficient care that does not contribute to better outcomes. Prediction models may help to identify patients at risk of becoming HNHC with potential benefit for care coordination interventions.
Aim:
To predict persistent HNHC status at outpatient presentation for cardiovascular populations with HF, CAD, with and without renal failure (HF&RF; CAD&RF).

Methods:
We performed a retrospective cohort study in the claims database of a large healthcare insurer in the Netherlands. We included patients with consecutive data between 2015 - 2019, at their first outpatient appointment in 2016. Potential predictors were based on the previously published Persistent High Utilizer (PHU) model and collected in the year prior to presentation. HF, CAD and RF were defined by Diagnosis Treatment Combination insurance codes. The outcome of interest was PHU status, defined as belonging to the top 10% of total annualized healthcare expenditures for three consecutive years. To account for inflation, all costs were scaled towards 2015. Predictor effects were quantified through logistic multivariable regression analysis as odds ratios. Models were validated internally by bootstrapping procedure. Model performance was assessed as discrimination, quantified by the C-statistic.

Results:
219.567 patients were included, of whom 2.0% (
n
=4286) became PHU. The most important predictors were chronic kidney disease diagnosis (OR 3.1 95%CI 2.4-4.1), gastroenterology involvement (OR 3.0 95%CI 2.7-3.3) and COPD diagnosis (OR 2.1 95%CI 1.8-2.5). Model performance in the overall population was good (C-statistic 0.77). Model performance varied in the more homogeneous populations with HF (
n
=2261;
n
=157 PHU), CAD (
n
=7221;
n
=292 PHU), HF&RF (
n
=163;
n
=40 PHU) and CAD&RF (
n
= 196;
n
=34 PHU) resulting in C-statistics of 0.74, 0.78, 0.60 and 0.67 respectively.

Conclusions:
Persistent HNHC status can be predicted in the outpatient setting for patients with HF and CAD. These models can be used to select cardiology patients for HNHC care coordination.
Abstract 14729: Association of Iliac Artery Non-Calcified Plaque Volume and Acute Limb Ischemia: Insights From the VOYAGER PAD Angiographic Core Lab
Authors: Bonaca Marc P , Capell Warren , Tong Cameron , Popoola Tolulope , Kinninger April , Manubolu Venkat Sanjay , Patel Manesh R , Hess Connie N , Nehler Mark R , Debus Sebastian , Anand Sonia S , Haskell Lloyd P , Muehlhofer Eva , Szarek Michael , Budoff Matthew J
Published: December 2023

Introduction/Background:
Acute limb ischemia (ALI) is a severe complication of peripheral artery disease. Lipid lowering and antithrombotic therapies reduce ALI but pathologic studies have described thrombus in distal arteries without plaque, suggesting that artery to artery embolism from proximal (aortic-iliac) athero-thrombosis may be a key driver.

Research Questions/Hypothesis:
We hypothesized that the burden and character of atherosclerosis in the iliac arteries of patients with PAD would be associated with long term risk of ALI.

Methods:
VOYAGER PAD enrolled 6,554 patients with PAD and collected 2,200 baseline angiograms in 1,664 patients including 400 CT angiograms enabling plaque characterization. A case-control of 9 who had ALI during follow up and 9 controls were matched on anatomic and patient characteristics, type of index revascularization and disease pattern. Images were read by a blinded, independent imaging core lab.

Results/Data:
Of the 9 ALI cases, 45% had iliac artery occlusion and 55% had distal artery occlusion. Plaque characteristics were different in cases relative to controls including significantly greater non-calcified plaque volume (OR 2.36, 95% CI 1.05 - 9.38, p=0.03) as well as similar trends for low attenuation plaque (OR 1.65, 95% CI 0.89 - 4.72, p=0.05), and plaque burden (OR 1.16, 95% CI 1.00 - 1.25, p=0.03, Figure). In patients who experienced ALI, there was a trend for greater non-calcified plaque in the limb that experienced the ALI relative to the contra-lateral limb (index 7.2 vs contra-lateral 5.4, p=0.08).

Conclusions:
In a case-control series, total non-calcified plaque volume and overall plaque burden in the iliac arteries were associated with future ALI over 3 years. Based on the observations in this case-control, we are now analyzing plaque and outcomes in the full cohort. These data are hypothesis generating and suggest that plaque characteristics may be associated with ALI and may serve a surrogate marker of risk.
Abstract 14750: Performance of a Polygenic Risk Score for Coronary Artery Disease Across the Spectrum of ASCVD: An Analysis of 60k Patients From 6 TIMI Randomized Trials
Authors: Zimerman Andre , Kamanu Frederick , Melloni Giorgio , Roselli Carolina , Antman Elliott M , Bhatt Deepak , Bonaca Marc P , Cannon Christopher P , Giugliano Robert , O'Donoghue Michelle , Scirica Benjamin , Wiviott Stephen D , Braunwald Eugene , Ellinor Patrick T , Sabatine Marc S , Ruff Christian , Marston Nicholas A
Published: December 2023

Background:
Coronary artery disease (CAD) polygenic risk scores (PRS) may improve risk stratification, but whether performance differs by ASCVD status remains unclear.

Purpose:
To compare the predictive ability of a CAD PRS for coronary events in pts with ASCVD and prior event, ASCVD without event, and without overt ASCVD.

Methods:
We studied genotyped pts from 6 multinational TIMI RCTs. Using a 2.3 million SNP CAD PRS, we first assigned pts to low (Q1), intermediate (Q2-4), or high (Q5) genetic risk, after which pts were grouped by ASCVD status at baseline. The primary endpoint was any coronary event, a composite of death from coronary disease, myocardial infarction, or coronary revascularization. Cox proportional hazards models were used to estimate risk of events, adjusted for ancestry (principal components 1-5), age, sex, SBP, eGFR, diabetes, smoking, and trial.

Results:
We included 59,905 pts (mean age 66 yrs; 71% male; 79% with prior ASCVD; 49% with diabetes), of whom 10.6% had coronary events during follow-up. Compared with low genetic risk pts, event rates were greater in intermediate (HR 1.59 [95% CI 1.47-1.71]; p<0.001) and high (HR 2.08 [1.91-2.27]; p<0.001) genetic risk pts. There was a significant interaction between the CAD PRS and clinical ASCVD (P
interaction
<0.001), such that genetic risk discriminated relative risk of future coronary events more strongly in pts without overt ASCVD (
Fig 1A
). In this subgroup, high genetic risk pts had a nearly 5-fold higher hazard of events than low genetic risk pts (8.5% vs 1.6% at 3 yrs; HR 4.63 [3.46-6.21]; p<0.001). Pts without clinical ASCVD and high genetic risk had event rates comparable to pts with established ASCVD and low genetic risk (
Fig 1B
).

Conclusion:
The gradient of relative risk prediction of coronary events from a CAD PRS depends on the presence of known ASCVD and is strongest in patients without clinical disease. Genetic risk stratification may be more useful in pts without overt ASCVD to help focus preventive measures.
Abstract 14758: Using Interprofessional Continuing Education to Identify and Address Knowledge and Practice Gaps Regarding Lipoprotein(a) as a Cardiovascular Risk Factor
Authors: Robinson Katie , Frederick Jennifer , Esgro Robert A
Published: December 2023

Introduction:
High levels of Lp(a) are an independent and casual risk factor for ASCVD, though there is a lack of standardization of assays, guidelines, and targeted treatments.

Hypothesis/Goals:
To provide a dynamic, expert-led interprofessional continuing education (IPCE) activity for cardiologists, primary care (PC) clinicians, and pharmacists to educate on evolving standards in the assessment and management of Lp(a) as a CV risk factor.

Methods:
Vindico Medical Education provided a 2-day IPCE webinar on February 11 and 25, 2023. Baseline knowledge and behaviors, educational impact, and persisting perceived challenges were assessed via pre-, intra-, and post-test.

Results:
Complete datasets were available for 1,364 HCPs (13% cardiologists, 18% PC, 53% pharmacists, 16% other). Baseline knowledge was lowest in all cohorts regarding Lp(a) assessment vs management, and higher among cardiologists vs other professional cohorts. Low baseline knowledge translated to poor baseline competence on case-based questions, particularly regarding assessment and desirable Lp(a) levels. Additionally, only 42% of cardiologists were currently recommending Lp(a) screening for patients. Regarding management, while most were aware that PCSK9 inhibitors produced the greatest reduction in Lp(a) levels, knowledge scores regarding the use of lipid-apheresis and emerging pharmacotherapies was low (30% and 49%, respectively). Moreover, 64% on average were using statins to reduce Lp(a), despite proven benefit. Overall there was a 146% relative increase in knowledge, though the top requested topics for additional education were updates on how and in whom to offer Lp(a) screening and testing, communicating with the interprofessional care team and patient, and options for Lp(a) management, particularly as new options become available.

Conclusions:
Cardiology, pharmacy, and primary care clinicians who manage at elevated CV risk have inadequate knowledge regarding Lp(a) screening and management. While the IPCE provided addressed these knowledge and practice gaps, continued education is needed to facilitate practice change towards optimal patient care. As new options for screening and treatment become available, continued education is warranted.
Abstract 14766: Acute Impact of Transapical Ventricular Reshaping Device on Dilated Left Ventricle With Functional Mitral Regurgitation in Swine Model
Authors: Onohara Daisuke , King Chase , Tom Stephanie , Kikuchi Yuta , Lane Brooks A , Padala Muralidhar
Published: December 2023

Introduction:
Functional mitral regurgitation (FMR) after myocardial infarction (MI) exacerbates morbidity and mortality. Correcting FMR plays a critical role in mitigating or reversing ventricular remodeling in MI patients with FMR. However, the COAPT trial demonstrated that FMR correction yields favorable results in smaller left ventricles (LVs) but not in severely dilated LVs. In this study, we evaluated the efficacy of a transapical device in MI swine model with FMR, which can perform papillary muscle approximation (PMA) and simultaneous reduction of LV volume.

Methods:
Yorkshire pig (n=15) were used in this study. MI was induced by percutaneous occlusion of the left circumflex artery, which caused LV dilatation and FMR by 3 months. The device was implanted through the LV apex to achieve PMA and LV reshaping until FMR was eliminated (Figure A). The immediate effects of the device implantation on the mitral valve and the LV were assessed using echocardiography and pressure-volume loops.

Results:
The device implantation decreased inter-papillary muscle distance from 24.5±3.8mm to 16.7±3.8mm (p<0.0001), and significantly reduced FMR. Coaptation length significantly increased from 3.4±0.7mm to 5.5±1.2mm (p<0.0001). End-diastolic volume decreased from 153±48ml to 117±33ml, a 23.5% reduction (p=0.0004). The end-systolic pressure-volume relationship and preload adjusted dP/dt max significantly increased after the device implant, indicating an improvement of LV contractility. There were no differences observed in Tau and end-diastolic pressure-volume relationship, depicting minimal acute impact on diastolic ventricular function after device implantation (Figure B and C).

Conclusions:
This transapical reshaping device effectively corrects FMR in very enlarged LVs, but also reduces systolic chamber wall stress by reducing the LV volume. An acute improvement in LV systolic function was observed, potentially indicating a therapeutic effect.
Abstract 14767: Obesity is Associated With Greater Intensity of Guideline Recommended Therapy in Patients With Heart Failure With Reduced Ejection Fraction in the CHAMP-HF Registry
Authors: Khan Mirza S , Fendler Timothy J , Butler Javed , Devore Adam D , Fonarow Gregg C , Spertus John A
Published: December 2023

Introduction:
Despite the importance of guideline-directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF), treatment disparities by sex, race and age have been described. We hypothesized obesity might also be associated with less aggressive GDMT, due to both the difficulty of assessing volume status in obese patients and the challenge of separating the symptoms of obesity from those of HFrEF. We recently developed an intuitive measure for quantifying GDMT, the Kansas City Medical Optimization (KCMO) score, which is the average of total daily to target dose percentages for eligible GDMT drug classes, reflecting the percent of optimal GDMT prescribed (range 0-100%).

Aim:
To examine the association between BMI and KCMO score, accounting for other factors influencing GDMT use.

Methods:
Using the CHAMP-HF registry, we applied the KCMO score as the dependent variable and BMI as the primary predictor in a hierarchical linear regression model with site-level random effects to account for clustering by site, and adjusting for age, sex, SBP, CKD, and KCCQ-12 scores. We also fit a separate model using WHO BMI classes in place of BMI. Non-linear associations were tested with restricted cubic splines.

Results:
Among 4,163 patients across 150 sites in the CHAMP-HF registry, we found a significant and positive association between BMI and KCMO score (β
BMI
= 0.40, SE = 0.06;
p
< 0.001). Compared to those with normal BMI, those with Class I-III obesity had higher KCMO scores by 3.95 ± 1.16, 6.11 ± 1.44, and 8.68 ± 1.53, respectively (
p
< 0.001 for each).

Conclusions:
Patients with HFrEF and higher BMIs received more intense GDMT. It remains to be seen whether this may contribute to the known “obesity paradox” in HFrEF, where higher BMI is associated with lower mortality. Further study is also needed to examine whether obese patients with HFrEF receive similar intensity and extent of treatment in regard to decongestive strategies.
Abstract 14774: Differences in the In-Patient Mortality in Marantic Endocarditis Per Etiology: Systematic Review of Case Reports
Authors: Alhuarrat Majd Al Deen , Garg Vibhor , Borkowski Pawel , Nazarenko Natalia , Alhuarrat Mohammad Rasoul , Abushairah Ayman , Al Zyoud Batool , Bitsis Exarchos-Marios , Barzallo Zeas Diego , Alemu Rebecca , Kharawala Amrin , Nagraj Sanjana , Abdou Claudine , Minuti Aurelia , Faillace Robert , Palaiodimos Leonidas
Published: December 2023

Introduction:
Non-bacterial thrombotic endocarditis (NBTE; also known as marantic endocarditis) is a unique entity characterized by sterile fibrin deposits on valves caused by hypercoagulability and endocardial injury. Literature is limited regarding the distinction between its causes based on in-hospital mortality.

Hypothesis:
Would a significant difference in in-patient mortality be present in NBTE admissions depending on etiology?

Methods:
A review of the literature using the PubMed, Embase, Cochrane, and Web of Science databases was conducted to obtain case reports and series reporting NBTE from inception to September 2022. Crude and univariate analyses were performed.

Results:
396 case reports and 20 case series were identified, of which 450 patients were extracted. Females represented 64% of our sample (median age: 46, interquartile range [IQR]: 32 - 60) while 36% were males (median age: 50, IQR: 36 - 64). Overall all-cause in-hospital mortality was 36%. NBTE was associated with cancer in 202 (47%), autoimmune disease in 191 (45%), and other causes in 34 (8%) cases. Older population and cancer etiology were associated with higher mortality (OR: 1.77, CI 95%: 1.19 - 2.62 & OR: 8.29, CI 95%: 4.97 - 13.83, respectively). A significant decrease in mortality is noted in the more recent years compared to the 20
th
century (OR: 0.10, 95% CI: 0.06 - 0.18).

Conclusions:
Although an improvement in all-cause in-hospital mortality for admission related to NBTE has been noticed in recent years, cancer as an etiology and old age are two risk factors associated with higher mortality.