bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 266: Incidence, Predictors and Outcomes of Permanent Pacemaker Implantation Among Patients With Bradyarrhythmias Following Cardiac Surgery: Insights From the National Inpatient Sample Database
Authors: Quelal Karol , Olagoke Olakanmi , Baez Jose
Published: May 2020

Introduction:
Significant atrioventricular blocks and bradyarrhythmias are known complications of open-heart surgery. These are frequently transient, however, some patients go on to need a permanent pacemaker (PP). We sought to describe the incidence, predictors, and outcomes of PP implantation among patients admitted for cardiac surgery who develop bradyarrhythmias.

Methods:
We queried the National Inpatient Sample (NIS) database from 2010 to 2014 for adults admitted for surgical valve replacement, valvuloplasty or coronary artery bypass grafting (CABG) who had bradyarrhythmias during the admission using the appropriate ICD codes. We identified patients who had permanent pacemaker implantation documented during the admission. Categorical and continuous variables were compared using the chi-square and student's t-test. Predictors of PP implantation and in-hospital mortality were evaluated by logistic regression.

Results:
Of the 1402930 patients who underwent cardiac surgery, 94748 patients had bradyarrhythmias defined as sinoatrial node dysfunction (SND) and/or atrioventricular block (AVB) during hospitalization. The primary procedure was identified as valve replacement in 50.3% (47615 of 94748), CABG in 29.9% (27622 of 94748) and valvuloplasty in 8.7% (8248 of 94748). SND was found in 29.9% (28372 of 94748) and AVB in 76% (72017 of 94748). Permanent pacemaker implantation was done in 39.3% (37246 of 94748). Valve replacement was the most common surgery associated with PP implantation [58% (21682 of 37246) compared to 21.5% in CABG (8007 of 37246) and 7.7% in valvuloplasty (2882 of 37246), p < 0.001). Female sex aOR 1.36 (95% CI 1.31 - 1.40), young age 18 - 44 years aOR 1.36 (95% CI 1.24 - 1.49), Asiatic and Hispanic origin aOR 1.36 (95% CI 1.23 - 1.51), aOR 1.25 (95% CI 1.17 - 1.34) respectively, diabetes mellitus with chronic complications aOR 1.16 (95% CI 1.09 - 1.24), drug abuse aOR 1.38 (95% CI 1.21 - 1.55) were associated with higher odds of pacemaker implantation. African American origin aOR 0.79 (95CI 0.74 - 0.85), AIDS aOR 0.33 (95% CI 0.17 - 0.67), south hospital region aOR 0.89 (95% CI 0.85 - 0.93), no-charge admissions aOR 0.66 (95% CI 0.49 - 0.89) were associated with a lower odds of PPM implantation. Death during hospitalization was found in 3% of the patients. After multivariable regression, PP implantation was associated with a lower likelihood of in-hospital death aOR 0.45 (95% CI 0.41 - 0.50).

Conclusion:
Approximately one-third of the patients hospitalized for cardiac surgery related to AVB and/or SND were implanted a permanent pacemaker. Factors like age, sex, race and comorbidities determine the likelihood of this procedure that has a significant impact on mortality. Having a better insight into these predictors would allow a better triage of patients who would benefit from its implantation.
Abstract 272: Sensitivity of Conventional Monitoring Strategies to Diagnose Patients With Pause Arrhythmias Relative to Insertable Cardiac Monitors
Authors: Rogers John D , Higuera Lucas , Rosemas Sarah C , Cheng Ya-Jian , Ziegler Paul D
Published: May 2020

Background:
Diagnosing cardiac pauses that could produce syncopal episodes is clinically important to guide appropriate therapy. However, the infrequent nature of these episodes can make their detection a challenge with conventional monitoring (CM) strategies with short-term ECG monitors. We simulated several CM strategies and analyzed the sensitivity to diagnose patients with pause arrhythmias compared to continuous monitoring with an insertable cardiac monitor (ICM).

Methods:
CM was simulated from syncope patients’ ICM data by assuming the 1st detected true pause episode (≥5s) was symptomatic and prompted further evaluation. Based on published literature, 32% of patients were assumed to be admitted for 3 days of inpatient monitoring followed by CM of varying durations (24 or 48 hrs, and 14, 30 or 60 days) beginning at random within the next week; the other 68% were assumed to be discharged home, with CM of varying durations beginning at random within the next week. Subsequent true pause episodes in patients remaining undiagnosed with CM triggered additional rounds of CM, with simulations repeated 1,000 times. Longer pause definitions of ≥6-8s were also evaluated. ECG diagnosis was considered successful if a pause episode occurred simultaneous to CM.

Results:
A total of 105 true pause episodes from 44 patients (mean±SD age 66±17, 48% male) were detected by ICM, during 505±333 days of continuous follow-up. Patients experienced an average of 2.4±2.7 pause episodes ≥5s during follow-up. Relative to ICM-diagnosed patients, the mean sensitivity of CM to capture an ECG diagnosis for these pause episodes during follow-up ranged from 13.8% (on average, 6.1 of 44 patients) with 24-hr holter to 30.2% with two 30-day monitors (13.3 of 44 patients) (Figure). Sensitivity further decreased for pause durations of ≥6-8s, due to the less frequent occurrence of these episodes and consequently lower likelihood of capture with CM. Average days of follow-up without a diagnosis was 109 days with ICM versus a range of 384-452 days with CM modalities.

Conclusion:
Of syncope patients diagnosed with pause arrhythmias via ICM, the vast majority would go undiagnosed via CM strategies and therefore may not be optimally managed for syncope prevention. The cost-effectiveness of these strategies requires further study.
Abstract 273: Exploring the Role of the Emergency Medical System in Promoting Bystander Cardiopulmonary Resuscitation During Out-of-hospital Cardiac Arrests
Authors: Fouche Sydney , Abir Mahshid , Lehrich Jessica , Hammond Stuart , Nham Wilson , Forman Jane , Nelson Christopher , Mendel Peter , Nallamothu Brahmajee K
Published: May 2020

Introduction:
Early bystander initiated cardiopulmonary resuscitation (BCPR) is a key link in the cardiac arrest chain of survival. Prior work indicates that BCPR has a greater impact on survival outcomes when arrests are witnessed, and bystanders are actively prepared. This study explores the role of the emergency medical system—including dispatch, police, fire, and emergency medical services (EMS), in promoting timely bystander response during an out-of-hospital cardiac arrest (OHCA) event.

Methods:
This sequential mixed-methods study used 2014-2017 data from the Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) to analyze the effect of BCPR on OHCA survival outcomes. Logistic regression models were used to analyze the effect of BCPR on sustained ROSC with pulse upon emergency department (ED) arrival and secondary outcomes. These data were supplemented with semi-structured key informant interviews and multidisciplinary focus groups conducted during site visits to 9 emergency medical systems across Michigan including dispatch, police, fire, EMS, and ED.

Results:
A total of 21,044 OHCA incidents met inclusion criteria. OHCA patients who received BCPR had 1.32 times higher odds of achieving ROSC with pulse upon ED arrival than those that did not after multivariable adjustment (Table 1). Qualitative data from interviews suggest that emergency medical systems can play a critical role in promoting BCPR. Several salient themes emerged across stakeholders including: 1) Preparing the community for proactive bystander response through educational campaigns; 2) Facilitating BCPR during an event through dispatch-assisted CPR and on-scene responders providing positive reinforcement to bystanders; and 3) Reinforcing the importance of performing bystander CPR to the involved community after post arrest care.

Conclusion:
We found that BCPR was associated with statistically significant improvements in survival outcomes compared to those that did not receive BCPR. These findings emphasize the importance of training bystanders to initiate and perform CPR, and points to engaging the emergency medical system as a leader for this initiative to improve OHCA survival across US communities.
Abstract 275: Cost of Hospitalization for Heart Failure in the United States: A Systematic Literature Review
Authors: Osenenko Katherine M , Kuti Effie , Pimple Pratik , Deighton Alison , Szabo Shelagh M
Published: May 2020

Objectives:
An estimated 6.5 million individuals were living with heart failure (HF) in the United States (US) between 2011 and 2014, with prevalence projected to increase 46% and direct medical costs to reach $53 billion by 2030. Hospitalizations are the largest component of direct medical costs for HF; however, recent publications synthesizing costs are lacking. The objective of this review was to synthesize contemporary estimates of cost per HF hospitalization (HFH) in the US.

Methods:
A systematic literature review was conducted using MEDLINE and EMBASE to identify articles reporting estimates of cost or charge per HFH in the US, published in English between 01/2014 and 5/2019. Double abstract and full-text review, and data extraction, were performed according to PRISMA guidelines. Subgroups of interest were those with both HF and renal disease or diabetes, as well as HF with reduced or preserved ejection fraction (HFrEF or HFpEF). All costs were converted to 2019 US dollars.

Results:
Of 2168 records identified, 207 full-text articles were screened, and 23 studies reporting cost (n=17 studies) or charge (n=4) per HFH were included; two studies reported both. Sample sizes ranged from 989 to approximately 11 million (weighted) HF patients. Mean age ranged from 65.0 to 83.3 years and percentage of males ranged from 38.7% to 74.0%. Median cost per HFH ranged from $7,094 to $9,769; mean cost ranged from $10,737 to $17,830 (see Figure). Charge per HFH ranged from $22,162 to $40,121 (median), and $50,569 to $50,952 (mean). Among patients with HF and chronic kidney disease, HFH mean cost ranged from $9,922 to $41,538. For those with HFrEF, mean cost ranged from $11,600 to $17,779 and $7,860 to $10,551 among those with HFpEF. No studies reported cost or charge per HFH for patients with both HF and diabetes. Cost and charge per HFH increased with length of stay (LOS), which ranged from 3.0 to 5.0 days (median) and 4.3 to 7.1 days (mean).

Conclusions:
This synthesis demonstrates the substantial economic burden of HFH, as well as variability in estimates of this burden. Factors contributing to variability in estimates include LOS, age and sex of the sample, HF severity, and percentage of patient with comorbidities. Further research into cost drivers of HF hospitalizations is warranted to understand potential ways to reduce associated costs.
Abstract 277: Fuster-BEWAT Score versus American Heart Association’s Life’s Simple 7 to Predict Subclinical Target Organ Damage: Findings From a Large-scale Asian Population
Authors: Wang Haoyu , He Jiang , Zhang Zugui , Dou Kefei , Sun Yingxian
Published: May 2020

Background:
The AHA’s Life’s Simple 7 score is recommended for use in primordial prevention. Simpler tools not requiring laboratory tests, such as the Fuster-BEWAT score (FBS) (blood pressure [B], exercise [E], weight [W], alimentation [A], and tobacco [T]), are also available. We aimed to investigate the relationships of FBS and Life’s Simple 7 with several subclinical markers of target organ damage (TOD) representing myocardial structure and function, carotid structure, and vascular function in the framework of general Chinese population.

Methods:
The study population consisted of 11,163 community-based adults (mean age 53.9 years; 54% female) who were recruited in the NCRCH (Northeast China Rural Cardiovascular Health) study between January 2013 and August 2013.

Results:
With poor Life’s Simple 7 and FBS as references, subjects with ideal Life’s Simple 7 and FBS presented substantially lower adjusted odds of having ECG-LVH (OR, 0.57; 95% CI, 0.49-0.66 vs. OR, 0.54; 95% CI, 0.46-0.64), LV diastolic dysfunction (OR, 0.34 [0.26-0.45] vs. OR, 0.43 [0.33-0.57]), carotid wall thickness (OR, 0.66 [0.51-0.87] vs. OR, 0.68 [0.50-0.93]), and arterial stiffness (OR, 0.22 [0.19-0.26] vs. OR, 0.21 [0.18-0.25]). In a similar model, per each additional metric at recommended optimal level of Life’s Simple 7 (0-7) and FBS (0-5) was predictive to a similar degree of reduced odds of all subclinical TOD. Similar levels of significantly discriminating accuracy were found for Life’s Simple 7 and FBS with respect to ECG-LVH (Life’s Simple 7: C-statistic of 0.623; FBS: C-statistic of 0.625), LV diastolic dysfunction (FBS C-statistic of 0.729; CVHS C-statistic of 0.721), carotid wall thickness (FBS: C-statistic of 0.720; Life’s Simple 7: C-statistic of 0.721) and arterial stiffness (FBS: C-statistic of 0.701; Life’s Simple 7: C-statistic of 0.704).

Conclusions:
Both scores exhibited comparable discriminatory values for detection of subclinical TOD in a large sample of middle-aged adults, highlighting the potential usefulness and clinical relevance of FBS as an easy, practical, and affordable option for elucidating the impact of CV risk behaviors and factors on subclinical CVD in settings where limited access to laboratory analysis and resource-constrained health-care areas hinder the possibility of estimating CV risk.
Abstract 282: Long Term Exercise And Women With Heart Disease
Authors: Behnke Lyn M , Pattison Kelley
Published: May 2020

A sedentary lifestyle has long been recognized as a risk factor for heart disease. Although little data exists on the relationship of exercise based on gender in the risk factor analysis, most guidelines support the importance of exercise in the prevention and treatment of heart disease. Bach (2020) published the American Heart Association scientific statement of long-term exercise and cardiovascular events that provides guidance for clinicians recommending exercise.

A recent survey of 395 women living with varying types of heart disease revealed that although many had been referred to cardiac rehabilitation, many did not exercise on a routine basis.

Interestingly, the barriers to attending cardiac rehab were relatively sparse. Eleven (3%) women who met criteria identified that their insurance wouldn’t cover cardiac rehab. Travel was a barrier for nine(3 %) patients, 21 (6%) patients identified distance as a barrier and eight(2%) couldn’t get off work to attend.

The worrisome component is that now, only 27.86% of the participants exercise on a routine basis. This has implications for morbidity in the future as Mediano, Leifer, Cooper, et al (2018) identify in the evaluation of baseline physical activity and outcomes in heart failure.

In this population, living in both suburban and rural areas are not conducive to exercise. Although the number of urban participants who exercise is higher than the other geographic areas, the percentage is still unsatisfactory.

The next steps for clinicians: •Develop a realistic evidence-based exercise prescription
OR
•Develop an interdisciplinary team of exercise physiologists, nurses, respiratory therapists and physical therapists who can identify specific exercise plans that meet the needs and resources of the female patient with heart disease. •Participate with communities to develop a mindset for exercise. •Participate in developing infrastructure for exercise facilities, trails, and other resources needing development, especially in rural areas.
Abstract 283: Variation In Ticagrelor Utilization And Outcomes In Patients With Acute Coronary Syndrome
Authors: Ozaki Aya , JACKEVICIUS Cynthia , Chong Alice , Koh Maria , Sud Maneesh , Fang Jiming , Ko Dennis T
Published: May 2020

Background:
Ticagrelor is a P2Y12 inhibitor with better cardiovascular outcomes than clopidogrel in clinical trials for acute coronary syndromes. However, the adoption of ticagrelor into clinical practice has been understudied. Therefore, we evaluated: 1) temporal trends in ticagrelor use, 2) factors associated with its use, and 3) hospital variation in its adoption and clinical outcomes.

Methods:
We conducted a population-based cohort study using administrative claims data in Ontario, Canada between 4/2014 and 3/2018. We identified individuals >65 years of age who were admitted for myocardial infarction (MI) or unstable angina (UA) and filled a prescription for ticagrelor or clopidogrel at or within 7 days of discharge. We categorized hospitals into quartiles based on ticagrelor utilization rates. The primary composite outcome was 1-year death or hospitalization for MI/UA, and 1-year bleeding hospitalization was a secondary outcome. Outcomes were evaluated using a Cox proportional hazards model to compare high vs. low utilization groups. Further, we quantified the between-hospital variability of ticagrelor utilization using multi-level logistic regression analysis, expressed as median odds ratios (MOR).

Results:
Among 23 962 patients in our cohort, 42.5% were prescribed ticagrelor ≤7 days post-hospital discharge. Ticagrelor utilization increased from 32.6% in 2014 to 51.8% in 2017. Hospitals at the lowest quartile of ticagrelor utilization (<8.8%) had a higher hazard of the primary outcome (adjusted hazard ratio: 1.27 95%CI: 1.11-1.46, p<0.001) compared with high ticagrelor utilization hospitals (>40%). No significant difference in bleeding hospitalization across hospital quartiles was observed. Some factors associated with higher ticagrelor use were cardiologist as most responsible physician during index hospitalization and urban hospital. After adjusting for patient-, prescriber- and hospital-level characteristics, substantial variation remained between hospitals in the likelihood of patients receiving ticagrelor at discharge (MOR: 2.54).

Conclusion:
Increasing trends of ticagrelor utilization were observed. Ticagrelor utilization rates varied across hospitals, and hospitals with higher ticagrelor adoption were associated with better clinical outcomes.
Abstract 302: Factors Influencing Heart Failure Readmissions at the Jesse Brown Veterans Administration Hospital
Authors: Lee Lauren Y , Twing Aamir , Wachsberg Kelley , Kansal Mayank M
Published: May 2020

Background:
Heart failure (HF) hospitalizations and readmissions are a major financial burden on patients, caregivers, and the healthcare system. The Jesse Brown Veterans Administration Medical Center (JBVAMC; Chicago, Illinois) has recently been scoring in the 90
th
percentile in its HF risk-standardized readmission rate (RSRR) compared to other VA medical centers. Here, we present the factors influencing HF readmission at the JBVAMC.

Methods:
Veterans discharged from JBVAMC between 7/1/18 and 6/30/19 with a primary diagnosis of HF were identified per ICD-10 codes (I11.0, I13.X, and I50.X). For primary HF discharges between 7/1/18 and 12/31/18, retrospective chart review was performed to assess patient and hospitalization characteristics. Charts were excluded from review if the same veteran’s chart was reviewed for another admission within the preceding 30 days, or if a veteran was discharged against medical advice or to a skilled nursing facility. Continuous variables were analyzed using Student’s t-test and categorical variables with Pearson Chi-Square.

Results:
Between 7/1/18 and 6/30/19, there were 485 HF discharges resulting in 96 30-day readmissions. Of them, 51 (53%) were due to recurrent HF exacerbation, and 8 (8%) were due to hypotension, dehydration, or acute kidney injury. Only 32% of readmissions (8/25) during the first 7 days after discharge were due to recurrent HF, compared to 70% (19/27) during day 8-14 and 57% (13/23) during day 15-21. In characterizing the index hospitalizations between 7/1/18 and 12/31/18 (N=188), there were 42 (22%) admissions that resulted in readmissions (Table 1). Veterans in this cohort were 72 years old on average, 98% male, and 77% African-American. HF with reduced ejection fraction (HFrEF; EF≤40%) comprised 53% of non-readmitted and 57% of readmitted cohort. Readmitted patients had a higher prevalence of smoking (33% vs 16%, p=0.012) and less likely to have outpatient follow-up within 14 days of discharge (52% vs 29%, p=0.007). There was a low rate of sacubitril/valsartan utilization (N=6) and dietitian consultation (N=7).

Conclusion:
Over half of our HF readmissions are due to recurrent HF. An emphasis on timely outpatient follow-up after discharge, consideration for sacubitril/valsartan initiation, and dietary education may help reduce our HF readmissions.
Abstract 303: Inpatient Sleep Interruptions Among Patients With Congestive Heart Failure
Authors: Claggett Evan , Krallman Rachel H , Feldeisen Delaney , Montgomery Daniel G , Eagle Kim , Kline-Rogers Eva M , Bumpus Sherry
Published: May 2020

Background:
The effects of sleep deprivation are vast, ranging from increased stress responses, to lowered immunity and delayed wound healing. However, sleep disruptions are common in the inpatient setting. This study sought to quantify the number and frequency of inpatient sleep disturbances and analyze post-discharge outcomes (emergency department visit, readmission, death) among congestive heart failure (CHF) patients.

Methods:
Data were collected retrospectively from 30 randomly selected patients admitted for CHF and referred to a cardiac transitional care clinic from 2014 to 2017. Each night over the course of the hospitalization was broken into 12 one-hour intervals (1900-0659 hours), and the electronic health record was examined for 20 variables indicative of sleep disruption (e.g. vitals taken, medications dispensed, wound care) (Figure 1). Demographics and outcomes were compared between high (above median) and low (below median) groups for average number of nightly interval interruptions and average longest uninterrupted sleep interval (LUSI).

Results:
On average, patients had a length of admission of 5.4 nights, a LUSI of 2.9 hours (range: 1-4), and 6.3 disruptions between 1900-0659 hours (range: 3-8). The readmission rates for the total population were 23% at 30 days and 63% at 180 days. No significant differences were seen in demographics or outcomes up to 180 days post-discharge when comparing high and low patient groups in either average nightly interval interruptions or average LUSI.

Conclusion:
Although no differences were seen between groups, the majority of patients had poor outcomes (23% were readmitted at 30 days; 63% at 180 days) as well as poor sleep during their admission. The lack of sleep across the entire patient population may be contributing to the poor outcomes observed. Many of the variables reviewed (e.g. vitals taken, medications dispensed, etc.) had potentially elective timing, which suggests actionable changes to the inpatient process may be possible to improve sleep quantity and quality. This was an exploratory pilot study to determine the ability to use electronic health record data for this purpose. As such, the sample size was too small to detect differences. A larger sample size is needed to better understand the extent to which sleep disruptions impact patient outcomes.
Abstract 307: Real-world Clinical Characteristics and Recurrence Burden of Patients Diagnosed With Recurrent Pericarditis in The United States
Authors: Lin David , Majeski Christine , DerSarkissian Maral , Magestro Matt , Cavanaugh Cristi , Laliberté François , Lejeune Dominique , Mahendran Malena , Duh Mei Sheng
Published: May 2020

Introduction:
Real-world data describing acute pericarditis (AP) etiology in the US are limited. Data on the characteristics of recurrent pericarditis (RP) patients (pts) are also sparse. To fill this gap, our study assesses longitudinal data from a nationwide privately-insured population.

Methods:
OptumHealth Reporting and Insights employer claims data (1/2007-3/2017) were used. AP pts were identified and categorized as idiopathic or non-idiopathic etiology based on presence or absence of attributable conditions. Among idiopathic AP pts, a subgroup of RP pts was identified. Recurrence was defined as ≥2 AP events separated by >4 weeks. First recurrence date marked the index date. Pts aged ≥18 years with ≥12 months of continuous enrollment pre-index (baseline) were included.

Results:
Of 17,168 AP pts, 4,175 (24.3%) had non-idiopathic and 12,993 (75.7%) had idiopathic etiology (Table 1). Application of inclusion criteria left 8,822 idiopathic AP pts, of whom 1,604 (18.2%) had ≥1 recurrence during a mean observation period of 29 months. On average, idiopathic RP pts were aged 50.7 years, 51.6% female, and 42.3% had baseline history of hypertension, 23.8% of coronary artery disease, 11.7% of hypercholesterolemia, and 7.3% of myocardial infarction. Mean (±SD) time from initial AP diagnosis to first recurrence was 8.7 (±12.1) months and mean (±SD) number of recurrences was 1.7 (±1.3) per pt. In idiopathic RP pts with ≥4 years of follow-up after the initial AP diagnosis (N=512), 35.9% had ≥2, 18.2% had ≥3, and 9.8% had ≥4 recurrences within 4 years.

Conclusions:
The etiologic distribution and proportion of pts with RP are consistent with previous reports. About 36% of RP pts experience ≥2 recurrences after AP diagnosis over 4 years. RP represents a significant clinical burden for affected pts.
Abstract 313: Investigation of Substance Use in the Bridge Population
Authors: Abbasi Rossteen , Krallman Rachel H , Feldeisen Delaney , Montgomery Daniel G , Kline-Rogers Eva M , Eagle Kim , Bumpus Sherry
Published: May 2020

Background:
Alcohol and drug dependence has been linked to increased readmissions and ED visits in some populations. This study investigated the impact of different substance use (SU) on outcomes (ED visit, readmission, death) among hospitalized cardiac patients (pts).

Methods:
Data on all pts referred to the BRIDGE cardiac transitional care clinic from 2008-2017 were collected. Chart review was conducted on a random selection of pts with a history of SU (n=152) to determine the type of substance used: alcohol, tobacco, illicit substances (i.e. cocaine, narcotics, marijuana) (study conducted prior to Michigan’s legalization of marijuana), or multiple substances. Demographics and outcomes at 30 and 180 days were compared between SU groups.

Results:
Of 3536 pts, 305 (8.6%) had a history of SU. Compared to those without SU, SU pts were younger (57.3±13.2 v 66.7±14.5 years, p<0.001), male (72.8% v 62.1%, p<0.001), single (62.5% v 38.0%, p<0.001), non-white (21.9% v 15.6%, p=0.005), less likely to attend their BRIDGE appointment (35.7% v 28.3%, p=0.012), had lower Charlson comorbidity scores (CCS) (3.7 v 4.9, p<0.001), and were more likely to visit the ED within 180 days of discharge (44.4% v 38.1%, p=0.033). Of 152 randomly selected SU pts, 57 (37.5%) used alcohol, 20 (13.2%) tobacco, 28 (18.4%) illicit, and 47 (30.9%) multiple substances. Illicit substance users were more likely to be from low SES communities. Despite older age and higher CCS than the other SU groups, alcohol users had fewer 180 day ED visits (p=0.007) and 180 day readmissions (p=0.024) than illicit substance users, as well as fewer 180 day readmissions (p=0.044) than multiple substance users.

Conclusion:
Compared to the national average (US Department of Health and Human Services), pts referred to BRIDGE appear more likely to have a history of SU (6.4% v 8.6%). Despite being younger and having lower comorbid burden, SU pts in this population had worse outcomes, as seen in prior studies. Additionally, they were less likely to attend a transitional care appointment, putting them at greater risk. Alcohol users, while older and sicker, had the best outcomes among SU pts; illicit substance users had the worst. Further research to identify the causes of these ED visits and readmissions, as well as targeted strategies to improve outcomes in this population are warranted.
Abstract 315: The Prevalence of Cardiovascular Health Expenditure Disparities in Aging US Adults
Authors: Nnacheta Lorraine C , Terrillion Albert J
Published: May 2020

Introduction:
Cardiovascular disease is a leading cause of mortality among adults in the United States. Chronic diseases, and resultant higher medical expenditures for treatment and prescription medications, have increased steadily alongside cardiovascular disease diagnoses in recent years.

Objective:
To investigate the increased prevalence of cardiovascular disease diagnoses and possible association with increased medical expenditures in adults 65 or older. The increase in expenditures will be compared to medical costs for adults 64 and younger, based on type of health service utilized.

Design, Setting, and Participants:
A quantitative, deductive, retrospective cross-sectional study was conducted from January 2011 to December 2015. Data from the household component (medical conditions, socioeconomic and demographic characteristics, healthcare expenditures, and use of medical services) and the medical conditions component were obtained from the Medical Expenditure Panel Survey database and information was extracted for adults ≥ 18 years between 2011 and 2015. Analyses were conducted using binary logistic regression.

Results/Findings:
Older adults ≥ 65 years with cardiovascular disease incurred higher costs for outpatient (odds ratio 1.235; 95% CI, 1.227, 1.243), inpatient (odds ratio 2.142; 95% CI, 2.124, 2.161), and emergency room expenditures (odds ratio 1.063; 95% CI, 1.047, 1.079) when compared to adults aged 64 and younger.

Conclusion and Relevance:
Assessing the influences of cost disparities on chronic diseases can help address variations in health care expenditures, and can initiate tailored educational modules and evidence-based practice guidelines that can help older adults. While this study may inform and improve stakeholder collaboration between various components of the United States health care system, it also expresses a greater need for chronic disease prevention education, health care quality improvement and improved patient understanding for a rapidly aging adult population, especially among those with cardiovascular disease experiencing increased medical expenditures.
Abstract 324: Use of Troponin Testing After Non-cardiac Surgery in Ontario
Authors: Azizi Paymon M , Koh Maria , Austin Peter , Han Lu , Jerath Angela , Wijeysundera Duminda N , Wijeysundera Harindra C , Ko Dennis T
Published: May 2020

Background:
Myocardial infarction after non-cardiac surgery is common and associated with worse patient outcomes. In 2017, the Canadian Cardiovascular Society (CCS) published guidelines endorsing postoperative cardiac troponin surveillance in higher-risk patients having non-cardiac surgery. The objective of this study was to evaluate the proportion of non-cardiac surgery patients recommended for post-operative troponin testing and use of troponin testing in accordance with this guideline.

Methods:
We conducted a retrospective observational study of patients aged 40-105 years having moderate to high risk non-cardiac surgery in Ontario, Canada from January 1, 2010 to December 31, 2017. Classes of surgeries included orthopedics, gynecology, general, urology, vascular, and thoracic. Recommendations for troponin testing was determined by CCS criteria. Troponin testing within 2 days of the surgery was ascertained using the Ontario Laboratory Information System.

Results:
There were 268,269 patients in the cohort recommended for troponin testing during the study period. Mean age was 66.7 ± 11.9 years, 58.2% were female, and 12.3% underwent urgent surgery. According to CCS guidelines, 72.4% of elective surgery patients and 81.2% of urgent surgery patients would be recommended for post-operative troponin screening. The observed testing rate was 10.5% for elective patients and 26.4% for urgent surgery patients. Observed rates of testing for CCS recommended patients varied significantly by surgery: 5.5% for hysterectomies to 64.0% for open abdominal aortic aneurism repair (see Figure).

Conclusions:
Based on the current CCS guidelines, the majority of patients undergoing moderate to high-risk surgery should receive troponin testing. However, testing rates in Ontario were substantially lower with significant variations based on the type of surgery. The implication for routine troponin testing recommendation is substantial given the low utilization of troponin testing.
Abstract 327: Electronic Health Record Integration of Predictive Analytics to Select High-risk Stable Patients With Non-st-segment Elevation Myocardial Infarction for Intensive Care Unit Admission
Authors: Kansal Aman D , Fanaroff Alexander , Green Cynthia , Patel Manesh R , Wang Tracy Y , Newby L Kristin K , Peterson Eric D , Sendak Mark , Balu Suresh
Published: May 2020

Background:
Nationwide, intensive care unit (ICU) utilization for initially stable patients with non-ST-segment elevation myocardial infarction (NSTEMI) is not associated with patient risk. Use of the ACTION ICU risk score, which predicts clinical deterioration requiring ICU care in initially stable NSTEMI patients, could guide admission of high-risk patients to the ICU and low-risk patients to a lower acuity unit.

Methods:
We created a modified best practice advisory (BPA) within the electronic health record (EHR) at a single institution. The BPA semi-automatically calculates the ACTION ICU score (5 elements automatically populate from the EHR and 4 are entered manually) and recommends a location for admission based on a 10% risk threshold for clinical deterioration over the course of admission. The BPA was triggered for all ED patients with serum 4
th
generation troponin T above the local upper limit of normal. Physicians could temporarily hide the BPA, permanently cancel it if they felt the patient’s presentation was not primarily due to NSTEMI, or generate the ACTION ICU score. We measured how ED physicians used the BPA, and clinical and utilization outcomes for patients admitted through the ED with a discharge diagnosis of NSTEMI in the 12 months before and after BPA roll-out.

Results:
Between August 14, 2017 and August 13, 2018, the BPA triggered 972 times. It was hidden until the patient left the ED 230 times (23.7%) and canceled 561 times (57.7%). Providers opted to calculate a risk score 181 times (18.6%), and a score was successfully calculated 146 times. Among 135 patients for whom the BPA triggered that had a final hospital diagnosis of NSTEMI, the BPA was inappropriately canceled in 62 (45.9%) and hidden in 16 (11.9%). Overall, there were 190 NSTEMI admissions through the ED in the year after BPA integration into the EHR and 253 in the year prior. In the year after BPA integration 32.6% of the NSTEMI patients were admitted directly to the ICU compared with 37.5% admitted to ICU prior to BPA (p=0.32). No change was found in the distribution of ACTION ICU scores of NSTEMI patients admitted to the ICU prior to vs after BPA integration, as well as no differences in ICU length of stay (p=0.96), hospital length of stay (p=0.27), the proportion of patients transferred from the ward to the ICU (p=0.78), or in-hospital mortality (p=0.18).

Conclusions:
Embedding the ACTION ICU risk score into the EHR did not affect clinical or utilization outcomes for patients presenting to the ED with NSTEMI, but was limited by inappropriate cancellation of the risk score calculator. Better EHR mapping to enable risk calculation without the need for user input may be needed for successful deployment of predictive analytics in this patient population.
Abstract 334: Impact of Sex, Gender and Healthcare System on the Quality of Care in Young Adults With Acute Myocardial Infarction
Authors: Raparelli Valeria , Pilote Louise , Behlouli Hassan , James Dziura D , Bueno Hector , D'Onofrio Gail , Krumholz Harlan M , Dreyer Rachel P
Published: May 2020

Background:
The quality of care among young adults with acute myocardial infarction (AMI) may be related to biological (sex) or psycho-socio-cultural (gender) determinants or healthcare system-level factors.

Objectives:
To examine whether sex, gender, and the type of healthcare system influence the quality of AMI care among young adults.

Methods:
A total of 4,564 AMI young adults (<55 years) (59% women, 47 years, 66% US) were analyzed from the VIRGO and GENESIS-PRAXY studies consisting of single-payer (Canada, Spain) versus multipayer (US) systems. For each patient treated in each system, we calculated a quality of care score (QCS) for pre-AMI (1-year pre-admission), in-hospital, and post-AMI (1-year post-discharge) phases of care (the number of quality indicators received divided by the total number [range=0-100%], with higher scores indicating better quality). The standard quality of care indicators were selected on the basis of being the standard of care to which young adults with AMI should have access to, based on European and North American Guidelines. Ordinal logistic or linear regression models and 2-way interactions between sex, gender and healthcare system were tested.

Results:
Women in the multipayer system had the highest risk factor burden. Across the phases of care for AMI, 20% of quality indicators were missed in both sexes. High stress, earner status, and social support were associated with a higher QCS in the pre-AMI phase, whereas only employment and earner status were associated with QCS in all other phases. In the pre-AMI phase, women had higher QCS than men, mainly in the single-payer system (adjusted-OR=1.85, 95%CI 1.46,2.35 vs. 1.07, 95%CI 0.84,1.36, P-interaction=0.002). Regardless of sex, only employment status had a greater effect in the multipayer system (adjusted-OR=0.59, 95%CI 0.44,0.78 vs 1.13, 95%CI 0.89,1.44, P-interaction<0.001). In the in-hospital phase, women had a lower QCS than men, especially in the multipayer system (adjusted-mean-difference: -2.48, 95%CI-3.87,-1.08). Employment was associated with a higher QCS (2.0, 95%CI 0.9-3.17, P interaction >0.05). Finally, in the post-AMI phase, men and women had a lower QCS, predominantly in the multipayer system. However, primary earners had higher QCS regardless of the healthcare system.

Conclusion:
Sex, gender, and the healthcare system affected the quality of care after AMI. Women had a poorer in-hospital than men and young adults had suboptimal post-discharge care. Being unemployed lowered the quality of care, more so in the multipayer healthcare system.
Abstract 335: Association of Amyloidosis With In-hospital & 30-day Outcomes Among Patients Hospitalized With Heart Failure
Authors: Patil Nikita , Arora Sameer , Strassle Paula D , Qamar Arman , Vaduganathan Muthiah , Fatima Amber , Mogili Kalyan , Garipalli Deepak , Grodin Justin L , Vavalle John P , Fonarow Gregg C , Bhatt Deepak L , Pandey Ambarish
Published: May 2020

Objectives:
Cardiac amyloidosis is an underdiagnosed cause of heart failure (HF). We investigated the prevalence and impact of amyloidosis in HF.

Methods:
All hospitalizations for primary diagnosis of HF between January 1, 2010, and August 31, 2015 were identified in the National Readmission Database (NRD). Of these, hospitalizations with amyloidosis were matched in a 3:1 fashion to hospitalizations without amyloidosis using the year of admission, discharge quarter, age, sex, and Charlson comorbidity index. Primary outcomes of interest were inpatient mortality and 30-day readmission. Multivariable logistic regression models were used to estimate the association of HF with amyloidosis with adverse clinical outcomes.

Results:
Overall, 2,846 (0.2%) hospitalizations had HF with amyloidosis. Hospitalizations for HF with amyloidosis had a higher prevalence of renal disease (56% vs. 45%), atrial fibrillation (48% vs 42%) and malignancy (20% vs 4%) as compared with HF without amyloidosis. In adjusted analyses, HF with amyloidosis had higher odds of in-hospital mortality (6% vs. 3%; OR 1.60, 95% CI 1.28, 2.00), 30-day readmission (OR 1.18, 95% CI 1.06, 1.32), and longer length of stay (CIE 1.73, 95% CI 1.44, 2.03). Among the HF with amyloidosis group, there were similar incidences of CV and non-CV-related readmissions (48% and 52%, respectively), but HF was the most common primary readmission diagnosis, constituting 35% of all readmissions. The incidence of inpatient mortality and 30-day readmission did not change significantly over time during the study period for either HF hospitalizations with or without amyloidosis.

Conclusion:
In decompensated HF, presence of amyloidosis was associated with higher risk of inpatient mortality and 30-day readmission.
Abstract 340: Evaluating the Use of Pharmacological Stress Agents During Single-photon Emission Computed Tomography Myocardial Perfusion Imaging Tests After Inadequate Exercise Stress Test
Authors: Yang Hongbo , Faust Elizabeth , Gao Emily , Sethi Sakshi , Kitt Therese M , Kristy Rita M , Spalding James R , Xu Yanqing
Published: May 2020

Objective:
To evaluate how pharmacological stress agents (PSAs) are used during single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) for patients (pts) with an inadequate exercise stress test (EST).

Methods:
This was a cross-sectional study. One-on-one telephone interviews with nuclear imaging center staff were used to develop an online survey, which was administered to evaluate patterns/processes around PSA use during SPECT-MPI in pts with inadequate EST. Eligible survey participants included nuclear technicians, nurses, physicians, and imaging center managers/directors with sufficient familiarity with SPECT-MPI/use of PSAs. Primary endpoint measures included gaining insights on how imaging centers convert to PSAs after inadequate EST and associated resource use.

Results:
Of 50 participating centers, 35 (70%) used only regadenoson (REG), 3 (6%) only adenosine (ADN), 3 (6%) REG and ADN, 7 (14%) REG and dipyridamole (DP), and 2 (4%) all 3 agents for converting pts after inadequate EST. Most centers (94%) used protocols to guide conversions. Post-test monitoring, including monitoring of pt performance and managing adverse reactions after completion of SPECT-MPI following PSA, was not conducted by 66%, 38%, and 56% of centers using REG, ADN, and DP, respectively. Same-day conversion occurred for 92%, 89%, and 98% of pts for REG, ADN, DP, respectively; the mean (standard deviation) number of pts converted in the past 30 days were 29.6 (44.1), 9.3 (9.9), and 1.9 (1.8), respectively. After an inadequate EST, average pt wait times to receiving REG, ADN, or DP were 4.9, 12.4 or 17.4 min, respectively; among centers using REG, 60% administered the PSA within a mean of 3 min, compared to 11% (1 center) using DP and no centers using ADN. Nearly 100%, 38%, and 11% of REG, ADN, and DP centers, respectively, reported that PSA administration was “not at all complex.” Of the centers using >1 PSA, 92% found REG to be the most preferred PSA (overall) among staff. Total staff time (aggregating time for multiple staff members who may have worked concurrently at each step) required from PSA transition to post-test monitoring was shortest for REG (
Table
).

Conclusions:
Imaging center staff prefer REG and its use is associated with operational efficiencies during SPECT-MPI after inadequate EST.
Abstract 345: Non-inferiority Trials With a Primary Surrogate Endpoint: An Increasing Phenotype in Cardiovascular Trials
Authors: Caraballo Cesar , Bikdeli Behnood , Welsh John , Ross Joseph S , Kaul Sanjay , Stone Gregg W , Krumholz Harlan M
Published: May 2020

Background:
Non-inferiority trials are increasing in cardiovascular medicine, with approval of many drugs and devices on the basis of such studies. Surrogate endpoints have been also increasingly used for efficient assessment of cardiovascular interventions, but there is uncertainty about their concordance with clinical outcomes. Non-inferiority designs using a primary surrogate endpoint in cardiovascular trials may pose particular challenges in clinical interpretation.

Methods:
We searched six high-impact journals (NEJM, JAMA, Lancet, JACC, Circulation, and EHJ) from 01/01/1990-12/31/2018 and identified non-inferiority cardiovascular trials that used a primary surrogate endpoint. We assessed the non-inferiority margin reported in the manuscript and other publicly available platforms (e.g. protocol, clinicaltrials.gov). We determined whether surrogate outcome non-inferiority trials were followed by clinical outcome trials.

Results:
We screened 15,553 publications and identified 247 cardiovascular trials that used a non-inferiority design. Of these, 37 had a primary surrogate endpoint (18 drug trials, 13 device trials, 6 others). All of these non-inferiority trials with surrogate outcomes were published after 2000, mostly in cardiology journals (13 in JACC, 9 in European Heart Journal, 8 in Circulation, 6 in Lancet, 1 in NEJM), and their publication rate increased over time (P<0.001 for linear trend). The median number of patients in the primary analysis was 263 (IQR: 191 - 460). The study protocol or a methods paper was publicly available for only 12 (32.4%) trials, of which the non-inferiority margin was not reported in 4. In 16 (43.2%) studies the manuscript did not acknowledge the limitations of using a surrogate endpoint, or the need for a definitive clinical outcome trial. Thirty-four trials (91.9%) concluded that the tested intervention met non-inferiority ocriteria. However, only 3 (9.1%) were followed by clinical outcomes trials the results of which did not always confirm non-inferiority (Figure).

Conclusion:
Non-inferiority trials with a primary surrogate endpoint are being increasingly performed. However, these trials pose particular challenges with design, reporting and interpretation, which are not systematically and consistently addressed or reported.