bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 284: Length Of Stay In Index Hospitalization Of Decompensated Heart Failure With Preserved Ejection Fraction As A Factor For 30-day Readmission And 1-year Mortality
Authors: Saith Sunil , Khorolsky Ciril , Trikha Anuragh , Chkhikvadze Tamta , Ha Jung-eun , Jangda Umair , Chuquin Jose D
Published: May 2020

Introduction:
Heart Failure is one of the leading causes of readmission in the United States. Heart Failure with preserved Ejection Fraction (HFpEF) accounts for a growing proportion of heart failure hospitalizations and accounts for approximately half of hospitalizations today. Unlike Heart Failure with reduced Ejection Fraction (HFrEF), there are no consensus-driven guidelines for the management of HFpEF.

Methods:
We collected demographic data, co-morbidities, laboratory and echocardiographic data on patients hospitalized with HFpEF throughout our health care system between August 2016 to August 2017. We assessed length of stay (LOS), whether the patient was re-admitted for any cause within 30 days and whether the patient died within 1 year of index hospitalization. We performed a Wilcoxon rank-sum test comparing patients who were both readmitted within 30 days for any reason and died within 1 year, against patients who were readmitted but were verified alive at one-year follow-up.

Results:
There were 366 patients hospitalized for HFpEF during the study period. Overall 30-day readmission rate was 24.3%, with a one-year mortality of 19.9%. One-year outcomes was verifiable for 359 patients. There were 27 patients who were readmitted within 30 days and died within one year of follow-up. Median LOS was significantly greater in patients during index hospitalization who died within 1 year of follow-up (Median LOS: 8 days, IQR 5-10 days), compared to patients who were readmitted within 30 days, but were alive at 1-year follow-up (Median LOS: 5 days, IQR: 3-8 days; p-value = 0.001).

Conclusions:
Among patients who were re-hospitalized within 30 days of an index hospitalization for HFpEF, LOS was significantly greater than patients who died within one year, compared to patients who remained alive at one-year follow-up. This may help identify a high-risk subset on index hospitalization and assist care transition teams and primary care physicians at follow-up in regarding discussions on goals of care and life sustaining treatments.
Abstract 286: Clinic Time Required To Manage Cardiac Implantable Electronic Device Patients: A Time And Motion Workflow Evaluation
Authors: Biundo Eliana , Burke Alan , Rosemas Sarah C , Lanctin David , Nicolle Emmanuelle
Published: May 2020

Background:
The number of patients with cardiac implantable electronic devices (CIEDs) is growing, creating workload for device clinics to manage this population. Remote monitoring of CIED patients is a guidelines-recommended method for optimizing treatment in CIED patients in combination with in-person follow-up. However, the specific steps involved in CIED management, as well as the HCP time required for these activities, are not well understood. The aim of this study was to quantify the clinic staff time requirements associated with the remote and in-person management of CIED patients.

Methods:
A time and motion workflow evaluation was performed in 6 U.S. CIED clinics. Participating clinics manage an average of 4,217 (range: 870-10,336) CIED patients. The duration of each task involved in CIED management was repeatedly timed, for all device models/manufacturers, during one business week (5 days) of observation at each clinic. Mean time for review of a remote transmission and for an in-person clinic visit were calculated, including all clinical and administrative (e.g., scheduling, documentation) activities related to the encounter. Annual staff time (inclusive of all clinical and administrative staff) for follow-up of 1 CIED patient was modeled using device transmission data for the 6 clinics, clinical guidelines for CIED follow-up, and published literature (Table 1).

Results:
During 6 total weeks of data collection, 124 in-person clinic visits and 1,374 remote transmission review activities were observed and measured. On average, the total staff time required per remote transmission ranged from 11.9-13.5 minutes (depending on the CIED type), and time per in-person visit ranged from 43.4-51.0 minutes. Including all remote and in-person follow-ups, the estimated total staff time per year to manage one Pacemaker, ICD, CRT, and ICM patient was 2.3, 2.4, 2.4, and 9.3 hours, respectively.

Conclusion:
CIED patient management workflow is complex and requires significant staff time in cardiac device clinics. Remote monitoring is an efficient complement for in-office visits, allowing for continuous follow-up of patients with reduced staff time required per device check. Future research should examine heterogeneity in patient management processes to identify the most efficient workflow.
Abstract 305: Characteristics of Heart Failure Patients Referred to the Bridge Transitional Care Clinic By Time to Readmission
Authors: Cholack George , Garfein Joshua , Krallman Rachel H , Feldeisen Delaney , Eagle Kim , Rubenfire Melvyn , Kline-Rogers Eva M , Bumpus Sherry
Published: May 2020

Background:
Readmission reduction initiatives emphasize prompt follow-up post-discharge. Identifying factors that influence early readmission may inform discharge planning. We compared characteristics of heart failure (HF) patients (pts) based on time to readmission to determine which pt characteristics were associated with early readmission.

Methods:
Pts referred to the BRIDGE clinic following index admission for HF from 2008-2017 were eligible. Demographics and inpatient clinical characteristics were compared between 1) pts who were and were not readmitted within 30 days post-index discharge, and 2) pts who were readmitted early (0-7 days post-discharge) versus late (8-30 days post-discharge).

Results:
Of 978 HF pts, 226 (23.1%) were readmitted within 30 days. Compared to those not readmitted, 30-day readmits were more likely to be male, white, and have higher NYHA class, longer index stay, ICU admission during index admission, and lower Hgb, higher Cr, and higher BUN during index admission. Among those with a 30 day readmit, 56 (24.8%) were readmitted within 7 days of discharge. Early readmits were more often female (p=0.07) and had index stays in the ICU (p=0.07).

Conclusion:
Pts readmitted within 30 days had more complicated hospital courses than those not readmitted, and those readmitted early had higher incidences of females and index stays in the ICU. Efforts to define a high risk subset of HF pts likely to be readmitted early and targeting them for enhanced discharge planning is warranted.
Abstract 308: Effect of Watchman Implantation in Atrial Fibrillation Patients on Healthcare Utilization: Insights From National Readmission Database 2016-2017
Authors: Mohammed Moghniuddin , Ranka Sagar , Reddy Madhu
Published: May 2020

Background:
Prior studies have shown that WATCHMAN device can be an alternative for anticoagulation in atrial fibrillation (AF) patients for stroke reduction. Its impact on healthcare utilization in AF population remains unknown.

Methods:
We queried the 2016-2017 National Readmission Database for all adult AF patients undergoing WATCHMAN procedure using ICD10 codes. All patients discharged alive from February to November were included (N = 13192), and their bleeding/thrombosis related admissions pre- and post-index procedure were recorded. Hierarchical longitudinal negative binomial regression was done to calculate incidence rate ratios (IRR) of admissions pre- and post-procedure with patient and hospital as level 2 and 3 variables, respectively. Person-time was included as an offset variable to account for variation in pre and post-procedure time contribution by each patient. A second model was created that included a blanking period of 2 months post-procedure to account for continued anticoagulation after the procedure. For this analysis, patients who received the procedure in October and November (N = 3265) and also patients who died within 2 months of the procedure (N = 49) were excluded.

Results:
For 13192 patients, the mean age was 77 years and 39% were female. Overall, we found a decrease of ~23% in all-cause readmissions after the procedure (IRR = 0.77; 95% CI = 0.74-0.81; p<0.001). A much greater decrease in thrombosis related admissions of ~69% (IRR = 0.31, p<0.001) and bleeding related admissions of 46% (IRR=0.54, p<0.001) were noted. When applying the 2-month blanking period after the index procedure, we observed an even greater decrease in all-cause readmissions of ~37% post-procedurally. Similarly, there was a decrease of ~75% and ~74% in thrombosis- and bleeding-related admissions respectively (Figure 1).

Conclusions:
AF patients undergoing WATCHMAN procedure have a significantly lower readmission rate, especially for thromboembolic/bleeding related readmissions. Thus, there is a trend towards decrease in healthcare utilization post-procedurally. Further studies are needed to confirm and evaluate the reasons for these findings.
Abstract 309: Outcomes of Depressed Patients With and Without Antidepressant Prescription
Authors: Francis Ashley , Krallman Rachel H , Feldeisen Delaney , Montgomery Daniel G , Kline-Rogers Eva M , Eagle Kim , Bumpus Sherry
Published: May 2020

Background:
Many studies have shown a relationship between depression and an increased risk of rehospitalization, suggesting assessment and management, potentially including antidepressants, should remain an important part of inpatient treatment. However, studies analyzing the outcomes associated with antidepressant use among cardiac patients have shown mixed results. This study aims to describe the long-term outcomes (ED visits, readmissions, and death) of a cohort of cardiac patients with concomitant depression treated with antidepressants.

Methods:
A total of 151 patients with a medical history of depression were randomly selected between 2008-2017 from a cardiac transitional care clinic registry. A retrospective chart review was conducted to determine the frequency of antidepressant prescription at discharge following a cardiac hospital admission. Demographics and outcomes were compared between those prescribed and those not prescribed antidepressants at discharge.

Results:
Of 4,298 patients, 1,067 (24.8%) had a diagnosis of depression recorded in their medical record. Of the 151 randomly selected depression patients, 106 (70.2%) were on at least one antidepressant at discharge. Significantly more females were prescribed antidepressants at discharge than males (78.0% v. 58.3%, p=0.010). No significant differences were seen in race, socioeconomic status, or outcomes at 30, 60, 90, or 180 days post-discharge between those prescribed and those not prescribed antidepressants at discharge. However, when compared to patients without depression (n=3,231), those on at least one antidepressant had significantly more 30-day ED visits (25.5% vs 17%, p=0.026), 180-day ED visits (52.9% vs 38.1%, p=0.002), and 180-day readmissions (55.8% vs 40.1%, p=0.001).

Conclusions:
Patients with depression had worse outcomes than those without depression, despite the majority (70.2%) being treated with antidepressants. These results suggest efforts should be made post-discharge to closely monitor patients with depression, even if they are prescribed antidepressants, and additional treatment modalities should be researched.
Abstract 314: Institution-level Variability in 30-day Patient Outcomes After Transcatheter Mitral Valve Repair in The United States
Authors: Malik Ali O , Stebbins Amanda , Hejjaji Vittal , Jones Philip , Cohen David J , Arnold Suzanne V , Vemulapalli Sreekanth , Wegermann Zachary , Kosinski Andrzej S , Spertus John
Published: May 2020

Background:
Clinical trials have demonstrated that transcatheter mitral valve repair (TMVr) with MitraClip within carefully selected enrolling institutions improves the health status of patients with severe mitral regurgitation. The real-world institution-level variability in health status outcomes for this procedure remain unknown.

Methods:
Among patients who underwent TMVr at sites participating in the STS/ACC TVT registry from November 2013 to March 2019, health status was measured at baseline and 30 days with the Kansas City Cardiomyopathy Questionnaire-Overall Summary (KCCQ-OS) score. Institution-level variability in 30-day change in KCCQ-OS was examined by calculating the median odds ratio (MOR) from a hierarchical logistic regression model, with ≥20-point improvement as the dependent variable.

Results:
Our analytic cohort included 12,415 patients (mean age 79.0 ± 9.5 years, 46.1% women, 89.5% White) from 339 sites. Overall mean KCCQ-OS scores were 43.0 ± 24.4 at baseline and 67.0 ± 24.9 at 30 days. There was substantial variability in the percentage of patients at each site, achieving a ≥20-point improvement in KCCQ-OS and in median change in 30-day KCCQ-OS by site; median 22.9, Interquartile Range 36.2 (Figure). The MOR for a ≥20-point improvement in 30-day KCCQ-OS across sites was 1.58 (95% CI 1.46-1.68), which was not reduced after adjusting for baseline health status, comorbidities, procedural complications (residual mitral regurgitation, bleeding) and annual volume of cases per site (fully adjusted MOR 1.58, 95% CI 1.46-1.69).

Conclusions:
We identified substantial variations in the health status benefits of TMVr across institutions. However, we were unable to identify the causes of this variability, including patient selection (baseline KCCQ-OS and comorbidities), procedural complications, and site volume. Further work is needed to better define how to support more consistent benefits of this novel therapy across institutions.
Abstract 316: A Novel Risk Tool to Predict Chronic Stress in Patients With Cardiovascular Disease
Authors: Malik Ali O , Jones Philip , Hejjaji Vittal , Tran Andy T , Spertus John , Smolderen Kim G
Published: May 2020

Background:
Chronic stress in patients with cardiovascular disease (CVD) is independently associated with higher mortality, increased risk of cardiovascular events, and poorer health status. However, stress is a modifiable risk factor, and interventions to reduce chronic stress have previously shown to improve outcomes in patients with cardiovascular disease. A clinically practical tool to identify patients at risk of developing chronic stress is needed to appropriately select patients for interventions to reduce stress.

Methods:
In the prospective US multicenter myocardial infarction (MI) registry (TRIUMPH), we used hierarchical logistic regression on 27 patient demographic, socioeconomic and clinical factors, adjusting for site, to identify predictors of chronic stress over 1 year. Stress at baseline and at 1-, 6- and 12-month follow-up was measured using the 4-point Perceived Stress Scale (PSS-4) [range 0-16, scores ≥ 6 depicting high stress]. Chronic stress was defined as at least 2 follow-up PSS-4 scores ≥ 6. We use multiple imputation to account for patients with missing assessments. We identified a simplified model using backward selection on the

R
2

of the full-model predictions and validated this final model (recalibrating the intercept) in another prospective US multicenter registry of patients with symptomatic peripheral arterial disease (PAD), the PORTRAIT study.

Results:
Our derivation cohort consisted of 3,470 MI patients (mean age 59±12, 33% females, 27% non-white), of whom 30% had chronic stress at follow-up. Of the 27 factors examined, higher baseline PSS-4 score, patient financial distress, lower ENRICHD Social Support Instrument (ESSI) score, younger age and smoking status were associated with higher likelihood of chronic stress (Figure A). The bootstrap-validated c-index was 0.81. In the validation cohort of 696 PAD patients (mean age 69±9, 41% females, 28% non-white, 18% chronic stress) the c-statistic for the model was 0.78 and calibration was excellent (Figure B).

Conclusions:
We describe and externally validated a novel risk prediction tool to predict chronic stress in patients presenting with worsening CVD. Our tool is practical and can be used in clinical practice to select patients for interventions to mitigate the adverse cardiovascular effects of chronic stress.
Abstract 317: Implications of the Ischemia Trial Results on Appropriateness of Percutaneous Coronary Intervention for Stable Coronary Artery Disease: Insights From the Ncdr Cathpci Registry
Authors: Malik Ali O , Spertus John , kennedy kevin , Chan Paul S
Published: May 2020

Background:
The recent ISCHEMIA trial found that percutaneous coronary intervention (PCI) did not reduce rates of cardiovascular events (death, myocardial infarction) in patients with stable ischemic heart disease (SIHD), regardless of ischemic burden, but improved patients’ health status, if they had angina. These findings have significant implications for appropriate use criteria (AUC) for PCI and suggest that PCI in asymptomatic patients may be classified as rarely appropriate given the lack of cardiovascular event or health status benefit.

Methods:
Patients with SIHD, who were enrolled in the NCDR Cath-PCI registry v5, from April 1
st
, 2018 to June 30
th
, 2019 were included in this study. To examine the potential implication of the ISCHEMIA trial on AUC, we modified the AUC definition to reclassify PCIs in asymptomatic patients with SIHD (without left main coronary artery involvement) as rarely appropriate. We then compared the current and modified AUCs.

Results:
Our final analytical cohort included 324,715 patients (mean age 67.9 years, 11.3% non-Caucasian, 30.4% females). At baseline, comorbidities were common with 42.9% having diabetes, 56.8% being current or recent smokers and 16.0% having chronic lung disease. Based on the current AUC definition, 113,110 (34.8%) PCIs were classified as appropriate, 79,859 (24.6%) as maybe appropriate, 6,660(2.1%) as rarely appropriate, and 125,086 (38.5%) could not be classified. Recategorizing the AUCs based on ISCHEMIA, 51,502 (15.9%) PCIs were classified as rarely appropriate; with 22,753 being reclassified from maybe appropriate and 22,089 asymptomatic patients being reclassified from unclassifiable to rarely appropriate (Figure).

Conclusion:
One in five patients with SIHD who undergo PCI are asymptomatic and might not be considered rarely appropriate under current AUC. The ISCHEMIA trial may have large implications on the number and proportion of patients with SIHD considered to receive little to no benefit from elective PCI.
Abstract 319: Development of a Knowledge Measure to Evaluate a Decision Aid for Patients Choosing Between Home and Hospital Based Cardiac Rehabilitation
Authors: Kirkpatrick Scott , Durfee Josh , Ponomaryova Anastasiya , Heyn Hilde , Matlock Daniel , Knoepke Christopher , Peterson Pamela
Published: May 2020

Background:
Home-based cardiac rehabilitation (CR) has similar efficacy as center-based CR, but the choice of which meets the needs of individual patients is preference-sensitive. Our objective was to develop a knowledge measure to be used to evaluate a shared decision-making tool for patients choosing between home and center-based CR.

Methods:
We generated 11 true/false questions about home and hospital-based CR. The statements were reviewed for accuracy by 8 exercise physiologists. Cognitive testing was performed with 10 patients using the “think-aloud” method to understand their interpretation of what each item was asking. The statements were then revised to improve acceptability and clarity. We tested the knowledge statements in a sample of 124 participates from the lay public recruited via mTurk. Psychometric properties of item difficulty, item uncertainty, and index of discrimination were evaluated. Differences between groups based on education level, age, sex, and race/ethnicity were also evaluated.

Results:
Of 124 respondents 66% were female, 69% were white, 69% were between 18-44 years of age, and 89% had at least some college education. On average respondents answered 70% of questions correctly. Item difficulty ranged from 51% to 98% correct. Item uncertainty ranged from 9% to 36%. Index of discrimination was highest for questions 2 (75%), 7 (74%) and 9 (68%). (see Table) Within each subgroup, the following groups had the highest average score: African Americans, (77%), females (74%), advanced degree (80%) and ages 55-64 (78%).

Conclusion:
The knowledge measure developed in this study can be used to assesses knowledge about key concepts central to making an informed decision about home vs. hospital-based CR. This knowledge measure will be further validated and used to evaluate a decision aid for patients in our safety net hospital system choosing between home and hospital-based CR.
Abstract 322: The Mayo Cardiac Intensive Care Unit Admission Risk Score Predicts Resource Utilization During Hospitalization
Authors: Breen Thomas J , Bennett Courtney E , Anavekar Nandan S , Murphy Joseph G , Bell Malcolm R , Barsness Gregory W , Jentzer Jacob C
Published: May 2020

Background:
With the rising cost of critical care and limited availability of critical care resources, improvements are need in the current cardiac intensive care unit (CICU) triage process. We sought to determine whether the Mayo Clinic Intensive Care Unit Admission Risk Score (M-CARS) could be used to predict which CICU patients will require critical care resources.

Methods:
Adult patients admitted to our CICU from 2007 to 2018 were retrospectively reviewed. The M-CARS was calculated using data from the time of admission. Groups were compared using Wilcoxon test for continuous variables and chi-squared test for categorical variables.

Results:
We included 12,428 patients with a mean age of 67 ± 15 years (37% females). The mean M-CARS was 2.1 ± 2.1, including 5,890 (47.4%) patients with M-CARS <2 and 644 (5.2%) patients with M-CARS >6. Critical care therapies were frequently used, including mechanical ventilation in 28.0%, vasoactive medications in 25.5%, dialysis in 4.8% and invasive lines in 44.3%. The low-risk cohort with M-CARS <2 was less likely to require invasive or noninvasive mechanical ventilation (8.0% vs. 46.1%), vasoactive medications (10.1% vs. 38.8%), dialysis (1.0% vs. 8.2%) or invasive lines (34.6% vs. 53.0%), as compared to patients with M-CARS ≥2 (all p<0.001). A higher M-CARS was associated with greater use of critical care therapies and longer CICU and hospital length of stay.

Conclusions:
In addition to predicting hospital mortality, the M-CARS predicts resource utilization during CICU admission and could be used in the triage of critically ill cardiac patients. Patients with M-CARS <2 infrequently require critical care resources and have extremely low mortality, yet account for nearly half of all CICU admissions, suggesting a potential to avoid CICU admission in many patients.
Abstract 341: Population-level Insights Into 30-day Mortality in Medicare Beneficiaries After Inpatient and Outpatient Catheter Ablation for Atrial Fibrillation
Authors: Andukuri Venkata , Xu Liou , Puckrein Gary A , Walters Ryan W , Kim Michael H
Published: May 2020

Background:
Recent inpatient data abstracted from the National Inpatient Sample and/or National Readmissions Database have shown higher than expected (0.46%) 30-day mortality rates of AF ablation prior to 2016. AF ablation has been increasingly coded as an outpatient procedure and primarily as of late 2015. Prior studies did not include some of these outpatient ablation cases. As such, more complete data on mortality and health-disparity outcomes for combined inpatient and outpatient-coded AF ablation is lacking. The purpose of our study was to assess updated 30-day mortality rates following inpatient or outpatient AF ablation following coding changes with ICD-10. Patients were also stratified by demographics and geographic region.

Method:
Data were abstracted from the 2017 inpatient and outpatient Medicare institutional claims files. AF was identified based on primary or secondary ICD-10 diagnosis codes. Inpatient procedures were identified by matching a CPT code for AF ablation that occurred on the same day as a primary or secondary ICD-10-PCS code for AF ablation. Outpatient AF ablation was identified using the CPT code. AV nodal ablation or a pacemaker procedure on the same day as AF ablation were excluded. AF ablation had to occur within the first 11 months of the calendar year to allow 30-day mortality data for all patients. We used the Medicare Master Beneficiary Summary File to further stratify beneficiaries by sex, race, and ethnicity, and geographic region. Mortality rates are shown as frequency and percent, compared using the chi-square test.

Results:
In 2017, a total of 40,373 AF ablations (58% men) were identified, of which 30,539 (75.6%) were coded as outpatient. The mean age in years was 71.5 (SD = 7.1), and median age was 71 (21 to 100). In total, 294 patients died within 30 days of procedure (0.73%, 95% CI: 0.65% to 0.82%). The 30-day mortality rate was higher following inpatient coded procedures compared to outpatient coded procedures (2.34% vs. 0.21%,
p
< .001). Further, higher 30-day mortality rates were observed for male patients compared to female patients (0.83% vs. 0.59%,
p
= .006) as well as in non-white patients compared to white patients (1.32% vs. 0.69%,
p
< .001). Finally, 30-day mortality rates differed by region (South: 0.85%, Midwest: 0.81%, Northeast: 0.56%, and West: 0.51%;
p
= .007).

Conclusion:
Overall 30-day mortality post-AF ablation appears high, particularly following inpatient coded AF ablation. Most notably, it is significantly higher than the recent estimate of 0.46% mortality risk following AF ablation from primarily inpatient data. The findings of higher mortality in males, in the non-white population, and in certain regions of the US are notable. Further studies are needed to understand the factors impacting mortality.
Abstract 344: Low Density Lipoprotein Cholesterol and Major Adverse Cardiovascular Events After Percutaneous Coronary Intervention
Authors: Sud Maneesh , Han Lu , Koh Maria , Abdel-Qadir Husam , Austin Peter , Farkouh Michael E , Lawler Patrick R , Udell Jacob A , Wijeysundera Harindra C , Ko Dennis T
Published: May 2020

Introduction:
Lowering low-density lipoprotein cholesterol (LDL-C) reduces the risk of major adverse cardiovascular events (MACE). Few studies have examined LDL-C control and outcomes exclusively after percutaneous coronary intervention (PCI). Furthermore, guidelines provide no formal recommendation on when to check LDL-C after PCI. It is therefore conceivable that LDL-C is not routinely measured after PCI, many patients may have elevated LDL-C levels (≥ 70mg/dL), and that elevated LDL-C levels after PCI are associated with adverse long-term outcomes.

Objective:
To evaluate LDL-C levels after PCI procedures, and to assess the association between LDL-C and cardiovascular events in a population-based cohort.

Methods:
All patients who received their first PCI between Oct 2011 and Sep 2014 in Ontario, Canada, and had a cholesterol measurement within 6 months after PCI were included. Multivariable Fine and Gray sub-distribution hazards models were used to assess the association between LDL-C measured after PCI and the incidence of MACE (myocardial infarction, coronary revascularization, stroke and cardiovascular death) through December 31, 2016.

Results:
There were 47,884 patients who had their first PCI during the study period, and 52% had an LDL-C measurement within 6 months post-procedure (median age 63 years, 27% female). Among them, 57% had LDL-C < 70mg/dL, 28% had LDL-C 70 to < 100mg/dL, and 15% had LDL-C ≥ 100mg/dL. After a median of 3.2 years of follow-up, 19% of patients had a qualifying MACE. After adjustment, the incidence of MACE was significantly higher in patients with higher LDL-C levels (Figure).

Conclusions:
Only one in two patients had LDL-C measured within 6 months after undergoing PCI and only about half had LDL-C < 70mg/dL. Higher levels of LDL-C after PCI were associated with a significantly higher incidence of MACE. Recommendations for routine LDL-C assessment and optimization may improve patient outcomes after PCI procedures.
Abstract 346: A Trial of Pre-discharge Point of Care Ultrasound for Acute Decompensated Heart Failure
Authors: Olarte Neal , Jacobs Mark , Vincent Louis , Salter Jonathan , Andreu Aileen , Labrada Mabel , Madeira Charles
Published: May 2020

Background:
Acute decompensated heart failure (ADHF) is a primary reason for hospital admission and readmission in the elderly. Prior studies have demonstrated that sonographic pulmonary B-lines and large inferior vena cava (IVC) diameter with reduced collapsibility may accurately predict ADHF readmission. Ultrasound is a readily available bedside tool that can be used to assess a patient’s volume status, which can be difficult to assess under certain clinical conditions. The purpose of this project is to determine if a pre-discharge focused lung and IVC ultrasound exam can be used to predict readmission in a veteran patient population.

Methods:
This is a single-center study conducted at the Miami Veterans Affair Medical Center (VAMC). Only patients with a primary diagnosis of ADHF admitted to a hospitalist team through the emergency room will be considered. Exclusion criteria include: pre-existing structural lung disease; primary right-sided heart failure; severe tricuspid regurgitation; or hospice status. A single operator will evaluate all included patients for B-lines and IVC dimension within 24 hours of admission and discharge. Ultrasound results, without management recommendations, will be given to hospitalists to use at their discretion to support clinical decision-making. Patients will be categorized based on positive or negative ultrasound findings. The primary outcome of interest is 30-day readmission rate. Secondary outcomes include 90-day readmission, all-cause mortality, length of stay, and changes in weight or renal function. Chi-square and Mann-Whitney testing will be used to analyze categorical and continuous variables, respectively. Kaplan-Meier survival curves will be generated for both patient cohorts.

Results/Anticipated Results:
Through quarter 3 of fiscal year 2019, the Miami VAMC had 215 unique admissions for ADHF. The average 30-day readmission rate per quarter was 18.44% (total 40 of 215). Study enrollment is ongoing. We anticipate that many patients may demonstrate discrepancy of volume status between their clinical and ultrasound exams, and that patients found to have B-lines and/or large IVCs with poor collapsibility will have worse outcomes.

Conclusion:
Decreasing readmissions for acute decompensated heart failure is a priority for both patients and physicians. Persistent volume overload has been associated with increased risk for readmission. Ultrasound may be a useful augmentation to the physical exam to determine a patient’s volume status to further guide inpatient treatment, predict prognosis, and determine readiness for discharge.
Abstract 347: Can Radiation Exposure in the Catheterization Lab be Controlled With an Increasing Frequency of Complex and High Risk Procedures?
Authors: Lawson William E , Gulino Kathie , Wilbert Lisa , Afshar Arash , Bonvento Michael J , Parikh Puja B , Chen On , Pyo Robert
Published: May 2020

Background:
Radiation [stochastic and deterministic] exposes patients and providers that must be balanced against the benefits achieved. Data derived from high exposure events has resulted in a goal of ALARA [as low as reasonably achievable] with concerns at 50 mSv [single event], 100 mSV [proximate exposures], 400 mSv [lifetime exposure]. Cath lab patients may receive high radiation as a consequence of high risk/ complex procedures, obesity, prior PCI/CABG and lesion complexity [ESRD, calcified, CTO], structural disease, supported interventions. Initiatives to reduce radiation exposure include: procedure staging, collimation, mapping, decrease fluoro frame rates and cine run number/length.

Procedure:
Radiation of patients with invasive procedures in 2018 and 2019 with high exposure stochastic risk [Dose Area Product ≥20,000 μGy* m
2
( 200 Gy*cm
2
) or Skin Dose deterministic risk > 5 Gray were analyzed for associations and compared. Effective dose [0.23 mSy/Gy*m
2
] provides a lifetime risk of fatal cancer related to radiation.

Results:
Interventional volume increased from 1431 to 1547 PCI. The number and frequency of high DAP exposures decreased [237 to 161] and for 10 of 11 high volume operators; there was no decrease in high Skin Dose cases [83 versus 119]. Associations with high DAP rates: Surgical turndowns [14/161; 9%], high risk/complex procedures (e.g. rotablator [42/161; 26.1%], CTOs [27/161; 16.8%]), Obesity [100/161; 62%; Morbid Obesity 31/161; 19%]. Single vessel PCI patients comprised 41/161; 25.5% of high exposures with 10/41 [24% having a prior CABG]. Single event Dose Area Products were as high as 167,235 μGy* m
2
[effective dose 368 mSv; lifetime risk of fatal cancer 0.92%]; repeat procedures [up to 5 returns/ year with cumulative doses 10/161 in the 100-200 mSv range [1:200 -1:400 lifetime fatal cancer risk]. 36 of the 161 patients were ≤ 60 years old. Despite Skin Doses as high as 14 Gray no skin sequelae occurred. Operators varied in the frequency of high radiation procedures [highest volume 56/268; 21%; all others 105/1547; 8%], influenced by patient selection and procedure, but also by technical variables [e.g. fluoro verus cine, frame rate, collimation].

Conclusions:
Despite efforts, radiation exposure remains a concern, aggravated by the need for increasingly high risk, structural heart, and supported interventional procedures. Opportunities for improvement include: lab upgrade to improve imaging in progress, increase staging [CABG , multivessel PCI patients], limit runs/ frame rates, increase mapping, optimize collimation. Lifetime fatal cancer risk is higher in younger than older patients with similar exposures due to both the latency period for cancer development and the likelihood of repeat radiation exposure. Efforts are underway to limit and track the cumulative radiation exposure of patients.
Abstract 350: Assessment of Clinicians’ Attitudes and Knowledge About Cardiac Troponin Testing
Authors: Jain Sandeep , Hammes Andrew , Rudofker Eric , Ream Karen , Levy Andrew E
Published: May 2020

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4
th
Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted.

Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below.

The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4
th
Universal Definition of Myocardial Infarction.

These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.
Abstract 352: Early Data From an Implementation Science Study Suggests the Need for Identification and Adoption of Best Practices to Improve the Timeliness of Stroke Treatment
Authors: Monk Lisa M
Published: May 2020

There is a disconnect from discovery of best treatment options and application into clinical practice in a timely manner. The I
M
plementation of best
Pr
actices f
O
r acute stroke care-de
v
eloping and optimizing regional systems of
Stroke Care
(IMPROVE Stroke Care) goal is to develop a regional integrated stroke system that identifies, classifies, and treats patients with acute ischemic stroke more rapidly and effectively with reperfusion therapy. These improvements in acute stroke care delivery are expected to result in lower mortality, fewer recurrent strokes, and improved long term functional outcomes. Recent discoveries in stroke care and advancement in technology extends the window for both TPA administration and mechanical thombectomy. The challenge of implementing these latest advances are difficult considering the ability of hospitals to implement the original American Heart Association (AHA) Systems of Stroke Care recommendations. Early data from this project shows that the challenges continue to exist in recommendations that have been in place as early as 2005. EMS is not utilizing pre-hospital stroke screening tools, only 5% of the time, stroke severity tools, only 7% of the time, lytic checklists, 0% of the time, destination decision changed due to severity score, 0% of the time, and pre-notifying emergency rooms, only 63% of the time. Emergency departments door to CT <45 minutes, only 55% of the time, Lytic given in CT scanner, only 35% of the time, Door to lytic therapy< 45 minutes, 77% of the time, Door to Groin puncture, 81% of the time, and Door to TICI Flow 2c/3 flow <90 minutes, 39% of the time. The Systems of Stroke Care have recommendations that will improve time to treatment and outcomes for patients. This project is working to provide tools, guidance, data, and feedback to improve application of these recommendations and identify best practices and solutions to barriers.
Abstract 356: Hospital Safety Net Status and Clinical Outcomes After Trans-catheter Aortic Valve Replacement
Authors: Sheikh Muhammad A , Deo Salil V , Riaz Haris , Khan Shahzeb , Raza Sajjad , Altarabsheh Salah E. , Wilson Brigid , Deo Vaishali S , Elgudin Yakov , Cmolik Brian L , Markowitz Alan H , Pelletier Marc
Published: May 2020

Introduction:
Safety-net hospitals (SNH) treat a large population of un-insured and low income patients; several prior studies report worse outcome at these centers. Trans-catheter valve replacement (TAVR) is emerging as first-line therapy for aortic stenosis irrespective of surgical risk scores. However, results of TAVR performed at these centers is limited.

Objective:
To determine whether post-procedural outcomes of TAVR are comparable at safety-net (SNH) and non-safety net hospitals (non-SNH).

Methods:
We conducted a retrospective, cohort study with propensity-matched analysis. Complex survey data from the Agency for Healthcare Quality and Research containing weighted sample of all hospital admissions nationwide was utilized for this study. Adults undergoing TAVR at US hospitals participating in the National In-patient sample (NIS) database from January 2014 - December 2015 were included. A 1:1 propensity-matched cohort of patients operated at safety-net hospitals (SNH) and non-SNH institutions was analyzed. Propensity-matching was performed on the basis of sixteen demographic and clinical confounding co-variates. Main outcome studied was all-cause post-procedural mortality. Secondary outcomes compared were stroke, acute kidney injury and length of post-operative stay.

Results:
Between 2014 - 2015, 41410 patients (mean age 80 +/- 0.11 years, 46% female) underwent TAVR at 731 centers nationwide; 6996 (16.80 %) procedures were performed at safety net centers. SNH comprised 135/731 (18.4%) of all centers performing TAVR. SNH patients were more likely to be female (49 % vs 46 %, p <0.001); admitted emergently (31% vs 21%; p <0.001) and at the lowest quartile for household income (25% % vs 20 %; p <0.001). A large proportion of SNH patients were minorities (Blacks 5.9% vs 3.9%; Hispanic 7.2% vs 3.2%). Adjusted logistic regression was performed on 6995 propensity-matched patient pairs. Post-procedural mortality [OR 0.99 (0.98 - 1.007); p = 0.43], stroke [OR 1.009 (0.99-1.02); p = 0.08], and acute kidney injury [OR 0.99 (0.96 - 1.01); p = 0.5] were comparable in both cohorts. Overall length of stay was also similar (6.9 +/- 0.1 vs 7.1 +/- 0.2 days; p = 057).

Conclusion:
Post-procedural outcomes after TAVR at SNH are comparable to national outcomes. Our study provides preliminary evidence that wider adoption of TAVR may not adversely influence outcomes at SNH.
Abstract 357: Comparison of Comorbidities Between Patients Admitted With Index Myocardial Infarction and Recurrent Myocardial Infarction
Authors: Nair Raunak , Johnson Michael , Kravitz Kathleen A , Anabila Moses , Rajeswaran Jeevanantham , Blackstone Eugene H , Menon Venu , Lincoff A Michael M , Kapadia Samir R , Khot Umesh
Published: May 2020

Background:
Several comorbidities are known to increase the risk of coronary artery disease. However, the relationship between modifiable risk factors and recurrent Myocardial Infarction (MI) has not been clearly defined. The purpose of our study was to assess if there were certain comorbidities that increase the risk of recurrent myocardial infarction.

Methods:
We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of readmission with a recurrent MI within 90 days after index MI. All patients with index MI were screened for accompanying comorbidities and compared with patients with recurrent MI.

Results:
There were a total of 2051 readmissions (31%) within 90-days of index MI, of which 168 readmissions were for recurrent MI. Hypertension and Dyslipidemia appeared to be the most prominent modifiable risk factors in patients with index MI and recurrent MI (86%, 94% for HTN & 81%, 93% for DLP). All comorbidities were substantially more prevalent in patients with recurrent MI than in patients with index MI.

Conclusion:
Patients with recurrent MI have a higher risk factor burden than the general population with MI. This highlights the importance of risk factor management in patients with acute Myocardial infarction.
Abstract 358: Meta-analysis Comparing the Results of Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis in Patients With and Without Prior Chest Radiation Therapy
Authors: Zafar Meer R , Miller Timothy W , Alkhawlani Talal , Alkhafaji Nawfal , Shahbaz Amir , Mustafa Syed F
Published: May 2020

Objective:
Cancer survivors with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort for management. Here we present a meta-analysis and systematic review of the literature regarding the outcomes of transcatheter aortic valve replacement (TAVR) in patients with prior chest radiation therapy (XRT group) versus patients without prior chest radiation therapy (non-XRT group). Following a comprehensive database search filtering through 129 relevant studies 4 most robust studies were included for in-depth analysis.

Methods and Results:
Articles were screened from Scopus, PubMed, and Cochrane Library databases (updated through December 31, 2019). Rev Man 5.3 was used for data analysis. We included four observational studies (Dijos M et al: 2015, Bouleti C et al: 2016, Agrawal N et al: 2019, Gajanana D et al: 2019). The primary outcomes measured are 30-day mortality, cardiovascular mortality, major bleeding event, post-procedural pacemaker implantation, and strokes / transient ischemic attacks.The pooled random effect analysis demonstrated no statistically significant difference in two groups undergoing TAVR in 30-day mortality, cardiovascular mortality, post-procedure major bleed event, and permanent pacemaker implantation with an odds ratio of 1.44 [95% CI: 0.57, 3.67]; 1.42 [95% CI: 0.50, 4.04]; 1.29 [95% CI: 0.71, 2.34] and 1.31 [95% CI: 0.61, 2.81] respectively.Statistically significant higher risk of stoke/transient ischemic attacks in non-XRT group as compare to XRT group undergoing transcatheter aortic valve replacement with an odds ratio of 2.34 [95% CI: 1.18, 4.62].

Conclusion:
XRT group undergoing TAVR have few post-procedural complications, with rates similar to those of non-XRT group undergoing TAVR. Although, our study showed statistically significant higher risk of stroke/ transient ischemic attach in non-XRT group as compare to XRT group. Larger, multicenter studies are needed to assess long-term outcomes of TAVR patients with prior chest radiation.