bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 232: Comparison of Different Management Strategies for Acute Myocardial Infarction: A Multivariable Network Meta-analysis
Authors: Fazel Reza , Nallamothu Brahmajee K
Published: July 2021

Introduction:
Many contemporary trials have compared different management strategies, involving combinations of reperfusion therapies and early invasive approaches, for treatment of ST-elevation myocardial infarction (STEMI). We used multivariable network meta
-
analysis to compare these approaches.

Methods:
We identified 29 trials in which patients with STEMI were randomized to at least two of the following strategies: thrombolytic therapy (n=4255), primary PCI (n=5850), or routine PCI after administration of thrombolytic therapy (n=4738). We categorized the latter approach as facilitated PCI (FPCI) when the median time interval between thrombolytic therapy and PCI was less than 2 hours and as a pharmacoinvasive approach when this interval was 2 hours or more. We excluded trials that did not routinely use stents during PCI. We identified short-term outcomes (up to 42 days) of death, nonfatal reinfarction, stroke, and major bleeding. We performed multivariable random-effects meta-analysis to compare these strategies. In addition, we estimated the probability that each strategy was associated with maximum risk for each outcome under a Bayesian model with flat priors.

Results:
Among the strategies evaluated, primary PCI was associated with the lowest mortality and nonfatal reinfarction rates, as well as the lowest risk of stroke (
Table- top panel
). Of the remaining strategies, the pharmacoinvasive approach was associated with the lowest risks of mortality, reinfarction, and stroke. The Bayesian model indicated that the probabilities of death, nonfatal reinfarction, stroke, and major bleeding were lowest for primary PCI and highest for thrombolytic therapy (
Table- bottom panel
). Furthermore, the probability of these outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI.

Conclusions:
Primary PCI is the preferred approach for treatment of STEMI. Our analysis suggests that a pharmacoinvasive approach may be more effective and safer as compared to facilitated PCI and thrombolytic therapy.
Abstract 236: Obstructive Sleep Apnea in Hypertrophic Cardiomyopathy: Comparing Exercise Tolerance, Cardiac Remodeling, Clinical and Genetic Data
Authors: Kumar Suwen , Ebner Benjamin , Bragg-Gresham Jeniffer , Farrehi Peter , Day Sharlene
Published: July 2021

Background:
Prevalence of obstructive sleep apnea (OSA) in hypertrophic cardiomyopathy (HCM) is estimated between 32% and 71%. Individuals with HCM and OSA have increased blood pressure, BMI, , ascending aorta size, left atrial size, left ventricular end diastolic diameter, E/e’ ratio, atrial fibrillation rates and NYHA functional class. It has been suggested that treatment of OSA can decrease the need for septal reduction. However, studies have found no effect of OSA on septal thickness or outflow gradient. It is not known how OSA affects exercise performance or cardiac remodeling assessed by MR. Genetic propensity toward OSA in HCM has not been reported. We propose that OSA predicts decrease exercise tolerance and that cardiac remodeling could be identified using MR. We sought to report on HCM genotype in OSA as well as compare our clinical and echo data with other investigators.

Methods:
Subjects were identified through our institution’s HCM database. They were surveyed using the STOP-BANG (SB) questionnaire, a validated questionnaire to identify individuals at high risk for OSA. We stratified patients into high risk (HR) and low risk (LR) groups, based on a cut point of greater than or equal to 3 on SB. Demographics and clinical characteristics were extracted from our database. Prevalence and means were compared between the two groups, using Chi-square and t-tests. Differences between the groups were adjusted for age, sex, and BMI using linear mixed models for continuous measures and logistic regression for dichotomous measures.

Results:
There were 206 respondents, of those 160 (78%) scored high risk for OSA, 60 of which had a history of polysomnogram (PSG) confirming OSA. Having a HR vs. LR SB was associated with a significantly greater likelihood of stroke, CHF hospitalization, NYHA functional class >2, reduced peak VO2, reduced anaerobic threshold and increased LA diameter. Adjusted comparisons for age, gender, and BMI showed that had significantly higher PAWP and LV mass index. Of those with a prior diagnosis of OSA we compared therapy compliant and non-compliant individuals and found they differed on LV mass index (HR=98.7 g/m2 vs. LR=62.0 g/m2, p=0.01).

Conclusions:
OSA occurs frequently in HCM and is associated with decreased exercise tolerance, worse hemodynamics, poor outcome as well as increased LV mass, which may be attenuated by therapy. OSA is an important and modifiable risk factor in HCM. Prospective evaluation utilizing PSG based diagnosis and positive pressure therapy is warranted.
Abstract 238: Causes Of Readmission In Congestive Heart Failure Patients: Analysis Of 2,536,439 discharges
Authors: Aggarwal Sourabh , Gupta Vishal
Published: July 2021

Introduction:
Congestive heart failure (CHF), a major cause of morbidity, is associated with a high 30-day re-admission rate and economic burden on health care. However, detailed description of the causes and preventability of readmissions after CHF are lacking. Determination of the causes of 30-day re-admissions can help hospitals to formulate strategies to reduce readmission and improve quality of life. This study was done to determine causes of re-admission within 30-days after index visit from CHF.

Methods:
We used Agency of Healthcare Research and Quality sponsored Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) data to extract data. NIS represents 20% of all hospital data in US. Patients discharged with CHF during years 2009-2011 were identified using ICD 9 codes of 398.91, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43 and 428.9. Patients readmitted within 30 days were identified and categorized based on admitting diagnosis.

Results:
We identified a total of 2,536,439 admissions for CHF nationwide during the study period with 630,998 patients readmitted within 30 days (re-admission rate of 24.88%). Out of these, CHF was responsible as a primary diagnosis for 236,572 readmissions (37.49%) and secondary diagnosis for 319,178 readmissions (50.58%). Renal failure was primary diagnosis in 25,652 readmissions (4.07%), arrhythmia in 23,580 readmissions (3.74%), septicemia in 21,891 readmissions (3.47%) and pneumonia in 20,875 readmissions (3.31%).

Conclusions:
Strategies to reduce 30-day readmissions secondary to CHF should be focused on control of risk factors for congestive heart failure, renal failure, arrhythmia, septicemia and pneumonia.
Abstract 24: Non-Obstructive Coronary Artery Disease Is Not Benign: Insights from the VA CART Program on the Association between Non-Obstructive Disease and Cardiac Events
Authors: Maddox Thomas M , Stanislawski Maggie , Grunwald Gary , Bradley Steven , Ho P. Michael , Tsai Thomas , Patel Manesh , Sandhu Amneet , Valle Javier , Magid David , Leon Benjamin , Bhatt Deepak L , Fihn Stephen , Rumsfeld John
Published: July 2021

Introduction:
The traditional focus of cardiac care on obstructive (>70% stenosis) CAD potentially distracts from the risks inherent in non-obstructive CAD. However, surprisingly little is known about non-obstructive CAD outcomes. Therefore, we determined the association between non-obstructive CAD and cardiovascular outcomes.

Methods:
Using the national VA CART program, we studied all veterans undergoing elective coronary angiography for angina between October 2007 and September 2012. Patients were categorized by CAD extent (none (no stenosis >20%), non-obstructive (no stenosis >=70%), obstructive (any stenosis >=70%)) and distribution (1, 2, or 3 vessel), and assessed for major adverse cardiac events (MACE), defined as all-cause mortality and MI. We adjusted for demographic, clinical, and treatment factors using Cox proportional hazards modeling. Secondary analyses sub-divided non-obstructive CAD into mild (20-49% stenosis) and moderate (50-69% stenosis) disease.

Results:
During the study period, 40,872 veterans underwent catheterization. Of these, 8411 (20.6%) had no CAD, 5219 (17.7%) had 1V non-obstructive CAD, 3034 (10.3%) had 2V non-obstructive CAD, 1388 (4.7%) had 3V non-obstructive CAD, 8588 (29.1%) had 1V obstructive, 5227 (17.7%) had 2V obstructive, and 6017 (20.4%) had 3V/LM obstructive CAD. MACE rates progressively increased with increasing CAD severity (Figure). This association persisted after risk adjustment (HR 1.28 (1.08, 1.51) for 1V non-obstructive, 1.29 (1.08, 1.52) 2V non-obstructive, 1.44 (1.12, 1.86) 3V non-obstructive, 1.93 (1.64, 2.28) 1V obstructive, 2.73 (2.28, 3.27) 2V obstructive, and 2.98 (2.52, 3.53) 3V/LM obstructive CAD)). A trend toward higher MACE in moderate 3V non-obstructive compared to 1V obstructive CAD (HR 1.34 (0.71, 2.52)) was noted.

Conclusions:
Non-obstructive CAD, relative to no CAD, is associated with 28-44% higher odds of MACE. MACE risk progressively increases by CAD extent, rather than abruptly increasing between non-obstructive and obstructive CAD. The risks of adverse events were similar for 3V non-obstructive CAD and 1V obstructive CAD, highlighting the limitations of a dichotomous characterization of angiographic CAD and a need to recognize the risks inherent in non-obstructive CAD.
Abstract 240: Cardiovascular-related Healthcare Resource Utilization and Costs among Patients with Hypertension Switching From Metoprolol to Nebivolol
Authors: Chen Stephanie , Fu An-Chen , Jain Rahul , Tan Hiangkiat
Published: July 2021

Background:
Metoprolol is a commonly prescribed β-blocker for hypertension in the US. Evidence suggests that the vasodilating β1-blocker, nebivolol, is superior to non-vasodilating beta-blockers, such as metoprolol, in lowering central blood pressure, an effect which is thought to be highly correlated to future cardiovascular (CV) risk. The aim of this study was to evaluate CV-related healthcare resource utilization (HCRU) and costs before and after patients switched from metoprolol to nebivolol for hypertension treatment.

Methods:
This retrospective study utilized medical and pharmacy claims from HealthCore-Integrated-Research-Database with 14 US commercial health plans representing over 33 million lives. The study cohort included only patients who were initially taking metoprolol for at least 6 months (pre-period) and then switched to nebivolol and remained on it for at least 6 months (post-period). The date of switching to nebivolol between 1/1/ 2008 and 12/31/2012 was defined as the index date. Patients were excluded if they had angina, myocardial infarction and congestive heart failure (compelling indications for metoprolol but not for nebivolol); unstable regimen of background antihypertensive medication at the drug class level; or did not have continuous health plan enrollment during these two periods. CV-related HCRU (per-100 patient-per-month) and costs (per-patient-per-month (PPPM)) were calculated for pre- and post- periods respectively by type of service - hospitalizations (INP), emergency room (ER) visits, and outpatient (OP) visits. Bootstrapping t-test was used to compare the differences of HCRU and costs between these two periods.

Results:
There were 765 patients included in the study with mean age 55(±11)years, 59% males and mean Deyo-Charlson Comorbidity Index (DCI) score of 0.5(±0.9). Relative to pre-period, the number of CV-related ER visits and CV-related OP visits per-100 patient-per-month were significantly lower in the post-period (ER: 0.17±1.88 vs.0.04±0.84, p=0.012; OP: 9.2±19.9 vs. 6.7±17.5, p<0.001). No differences were observed in number of CV-related INP visits. Additionally, relative to the pre-period, the ER cost and the total CV-related medical were significantly lower in the post-period (ER: $6 ±$78 vs. $1±$27 PPPM, p=0.028; total CV-related medical costs: $94±$526 vs. $54±$266 PPPM, p=0.020). There were no differences found in INP or OP costs.

Conclusions:
This study suggests that hypertensive patients switching from metoprolol to nebivolol have lower CV-related ER and OP visits as well as lower total CV-related medical costs, despite higher pharmacy costs after switching from a generic to a branded drug. Further studies are needed to identify these key drivers.
Abstract 241: Utility and Appropriateness of Echocardiography - Insights from Nonagenarians
Authors: Delmas Thomas , Anderson Allan , Barnett Brian
Published: July 2021

Background:
More than 20 million echocardiograms are performed every year in the United States at an average cost of approximately five hundred dollars per study. Despite this large expense, these studies can provide significant information that influences patient care. In the fast growing segment of nonagenarians, we sought to determine if echocardiograms have been appropriately obtained according to current Appropriate Use Criteria (AUC).

Methods:
Over a one-year period at Baylor Scott and White Memorial Hospital, the following characteristics of echocardiography cases performed for elderly patients (90 years and older) were summarized according to Appropriate Use Criteria class: age, gender, patient origin (inpatient/outpatient), type of study (TTE/TEE), and clinical service. Each characteristic was compared among 3 AUC classes (appropriate, inappropriate, and undetermined). ANOVA or Kruskal-Wallis test was used for continuous variable comparisons and Chi-square test or Fisher’s exact test was used for categorical variable comparisons. Proportion (95% confidence interval (CI)) of cases that received echocardiography due to appropriate reasons was estimated for entire group. A p-value of less than 0.05 indicated a statistical significance.

Results:
Four hundred eighty cases that met inclusion criteria were included in the analysis. Among 480 cases, 91% (435 cases, 95% CI (88-93%)) were conducted due to appropriate reasons. Four percent (21 cases, 95% CI (3-7%)) were performed due to inappropriate reasons and 5% (24 cases, 95% CI (3-7%)) were done due to undetermined reasons. There were no significant differences among the three AUC classes by age, gender, or type of study. However, there are significant differences (P<0.05) among the three AUC classes in regards to clinical service requesting the study and site of origin of the patient.

Conclusions:
9% of echocardiograms performed in this demographic, including 26% of outpatient studies, were not appropriate according to current AUC. There was significant variance between referring service and by site of origin. Investigation in larger groups of patients may provide enhanced awareness of and improved adherence to AUC.
Abstract 258: Adherence To The AHA / ACCF / SCAI / ASE /ASNC - 2012 Appropriate Use Criteria For Diagnostic Cardiac Catheterization In An Academic Medical Center.
Authors: UTHAMALINGAM SHANMUGAM , Gadiraju Taraka V , Frederici Jennifer , Maqsood Khawar , Gupta Ankur , Hiser William , Gokaraju Santhi , Islam Ashequl
Published: July 2021

Objective:
To examine the adherence to the published appropriate use criteria (AUC) for diagnostic cardiac catheterization (DCC) in an academic medical center.

Background:
In May 2012, the American Heart Association and other subspecialty societies have developed AUC for DCC to address the growing rational use of cardiac catheterization in delivering high quality health care. The application of all the subsets of AUC indications to examine the adherence of cardiologists in academic center has not been well studied.

Methods:
We retrospectively examined a random sample of 499 patients who underwent DCC in our institution between January 1, 2013 to June 30, 2013, seven months after the publication of AUC for DCC; and classified as appropriate, uncertain and inappropriate categories according to the AUC. Indications not addressed in the AUC were considered unclassified.

Results:
The mean age of the study population was 65 (± 13) years with 67% males. Distribution of DCC according to AUC is shown in Table-1. Most DCC were appropriate (93%; n= 462), 6% (n=31) were uncertain and none were inappropriate. Approximately 1% (n=6) DCC were unclassifiable and all had known obstructive coronary artery disease (CAD) with worsening or limiting symptoms without non invasive stress testing and did not meet criteria for unstable angina. About one quarter (22%; n= 21/86) of DCC performed for patients in the suspected CAD with or without prior non invasive stress testing group were uncertain, 78% (n= 65/86) were appropriate and none were inappropriate. Most DCC (92%) were performed by interventional cardiologists (Figure 1).

Conclusions:
Most DCCs performed at this academic hospital are adherent with AUC criteria, however variability exists by indication and provider type. Unclassified patients as mentioned above who got referred for DCC by treating cardiologists led to a significant change in their management plan, thereby suggesting these group of patients which currently do not fit to any subset AUC criteria need consideration for further subset AUC categorization. About 22% of the DCC performed in the suspected CAD group were uncertain, none were inappropriate which make our results prominently discordant to recent findings observed among DCC procedures performed for suspected CAD in New York State.
Abstract 259: Identifying Predictors of Cumulative Health Care Costs in Incident Atrial Fibrillation: a Population-Based Study
Authors: Wijeysundera Harindra C , Qiu Feng , Micieli Andrew , Bennell Maria C , Atzema Clare , Ko Dennis T , Dorian Paul , Singh Sheldon M
Published: July 2021

Background:
The dramatic increase in the incidence of atrial fibrillation (AF) has substantial impacts on health care resource utilization. Our objective was to understand the pattern and predictors of cumulative health care costs in patients with incident AF.

Methods:
All patients discharged after a first presentation of AF to the emergency department (ED) in Ontario, Canada were identified from April 1st, 2005 to March 31st, 2010. Per patient cumulative health care costs were determined until death or March 31st 2012. The cost sectors included were acute and chronic hospitalizations, same-day surgeries, emergency room visits, physician fee-for-service billings, home care, long term care and drug costs for patients over the age of 65 years. All costs were adjusted to 2013 Canadian dollars. Join-point analyses identified clinically relevant phases of health care costs. Hierarchical generalized linear models with a logarithmic link and gamma distribution determined predictors of cost per phase.

Results:
There were a total of 61,112 ED visits for AF over the period of interest. Our cohort consisted of 17,980 patients with new onset AF who were discharged from the ED. Mean age was 65.7 and 45.8% were female. Over the mean follow-up period of 3.9 years, 17.1% of patients died. Three distinct phases of cumulative cost were identified: 2 month phase post index ED visit; 12 month phase pre-death and a stable/chronic phase. The mean cost per patient in the 1st month post-index was $1,876 (95% CI 1,822-1,931), while the mean cost per patient in the month prior to death was $8,050 (95% CI 7,666-8,434), compared to $640 (95% CI 624-655) per month for the stable/chronic phase. The main component of costs in the post-index and stable/chronic phases were physician services (67% of all costs for 1-month post-index; 44% of all costs for stable/chronic phase). In contrast, acute-hospitalizations represented the largest component of costs in the pre-death phase at 72%. The CHA2DS2VASC clinical risk score was the strongest predictor of increasing costs, with a gradient of increasing per patient cost with increasing score (Rate ratio (RR) of 6.8 and 2.06 for score of 9 versus score of 0 in pre-death phase and post-index phase respectively)

Conclusion:
There are distinct phases of resource utilization after the diagnosis of AF, with highest costs in the pre-death phase. Cumulative costs are driven by patient co-morbidities, as captured by the CHA2DS2VASC risk score.
Abstract 262: Aspirin vs. Warfarin Therapy Outcomes for Non-Valvular Atrial Fibrillation Patients with Moderate Stroke Risk
Authors: An JaeJin , Jazdzewski Kristin P , Le Paul T , Rashid Nazia , Lang Daniel T , Niu Fang , Meissner Brian , Mendes Robert , Dills Diana , Bruno Amanda
Published: July 2021

Background:
The American College of Cardiology Foundation and American Heart Association guidelinerecommends aspirin 81-325 mg or warfarin use for Non-Valvular Atrial Fibrillation (NVAF) patients with one risk factor for stroke. This study evaluated outcomes associated with antithrombotic treatment among NVAF patients with CHADS
2
=1 in an integrated healthcare system.

Methods:
Patients age ≥18 years newly diagnosed with NVAF with a CHADS
2
score=1 at diagnosis were identified between 01/01/2006-12/31/2011 within Kaiser Permanente Southern California’s membership and followed until 12/31/2012. The rate of stroke or systemic embolism (SE) and major bleeding events per 100 person-years were evaluated for: 1) aspirin (ASA) only, 2) warfarin time in therapeutic range (TTR) ≥55%, 3) warfarin TTR <55%, and 4) no antithrombotic therapy. The 55% threshold was selected as the lower bound of reported means from previous studies.

Results:
Among 7,899patients with CHADS
2
=1, 336 stroke and 34 SE events were observed during the 22,542 person-years of follow-up. ASA only therapy was associated with 2.3 times higher risk of stroke/SE (Rate Ratio [RR] = 2.34 [95% CI: 1.61-3.39]) compared to warfarin TTR ≥55%. ASA only events were similar to warfarin TTR <55% but were 23% lower than no antithrombotic therapy. Major bleeding events were lower in ASA therapy compared to warfarin TTR ≥55% (RR = 1.50 [1.23-1.83]) or warfarin TTR <55% (RR= 4.09 [1.23-1.83]). The higher bleeding rates in no therapy compared to warfarin TTR ≥55% or ASA only needs to be further investigated.

Conclusion:
ASA therapy was associated with a higher rate of stroke/SE but with a lower rate of bleed compared to TTR ≥55% warfarin in NVAF patients with CHADS
2
=1. These results suggest that treatment decisions should be carefully made based on the risk and benefit assessment in patients whose CHADS
2
=1.
Abstract 264: Assessing Thromboembolic Risk In Patients Undergoing Direct Electrical Cardioversion Within 48 Hours After Onset Of Atrial Fibrillation
Authors: Garg Aatish , Khunger Monica , Seicean Sinziana , Chung Mina , Tchou Patrick
Published: July 2021

Background:
Direct Electrical Cardioversion (DCC) has been known to increase the risk of thromboembolism (TE) in patients with Atrial Fibrillation (AF). However, guidelines and current practices are unclear if this risk exists in patients undergoing DCC < 48 hours after AF onset. We aim to assess TE risk in these patients with and without the use of therapeutic anti-coagulation.

Methods:
All DCC done at Cleveland Clinic between 1996 to 2012, <48 hours after AF onset were selected from Electrophysiology database. They were divided into two groups on the basis of their anti-coagulation status. We did extensive chart review in these patients to look for outcomes of major TE complications within a month of DCC.

Results:
Among 567 DCC in 510 patients without therapeutic anti-coagulation, the mean (SD) CHA2DS2-VASc score was 2.34(1.66). At the time of DCC, 54% of these patients were on aspirin, while 12% were on warfarin with INR ≤1.5. There were 7 reported cerebrovascular accidents (CVAs) (1.22%) within a month after DCC. In these 7 patients, the mean (SD) CHA2DS2-VASc score was 3.57(1.27) ranging between 2 to 5. In the second group, 901 DCC were done in 733 patients who were therapeutic on warfarin (63%) or heparin (37%) at the time of DCC. Mean (SD) CHA2DS2-VASc score was 2.61(1.73). There were 2 reported (0.22%, p= 0.016) CVAs within a month after DCC. These two had CHA2D2-VASc scores of 4 and 6. Of these two patients, one was sub- therapeutic (INR=1.14) when he presented with neurological deficits 18 days after the DCC. The other patient held anticoagulation 10 days after DCC for a surgical procedure which was followed by the TE stroke a week later. The non-treated group therefore had a 5.6 times greater odds of having a thromboembolic stroke within a month of DCC (95% CI: 1.16 to 27.14) .

Conclusions
In patients with acute onset atrial fibrillation, odds of thromboembolic complications are over 5 times higher in patients who did not receive therapeutic anti-coagulation at the time of DCC, despite having a lower baseline stroke risk as defined by their CHA2DS2-VASc scores. In addition, the two patients in our study who did have a stroke in the therapeutically anti-coagulated group had ceased their anticoagulant prior to the stroke.
Abstract 282: Assessing Levels of Active Participation through a VA Provider Network to Improve Quality of Care for Veterans with Heart Failure
Authors: Sahay Anju , Heidenreich Paul
Published: July 2021

Objective:
The goal of the Dept. of Veterans Affairs (VA) Chronic Heart Failure (CHF) QUERI program is to improve the quality of care for heart failure (HF) patients and implement evidence-based practices throughout the VA system. One strategy to achieve this goal was to create a VA heart failure provider Network which occurred in 2006. We sought to characterize provider participation in this mature network.

Method:
We tracked all members of the HF Network including their title, location at one of 144 VA facilities; date joined and if applicable, date left the HF Network. We considered the following activities to be evidence of “active” participation: attended a web-based meeting or the annual in-person meeting, requested meeting materials, or completed a periodic survey of providers. Participation of all other members is considered “passive”.

For this project we assessed each facility’s level of participation in the HF

Network from July 2006 till June 2013 (7 years). Facility participation level was characterized as “None” (no member at that facility with active participation), “Low” (at least one member at that facility attended 1-2 activities) and “High” (at least one member at that facility participated in ≥3 activities).

Data were linked to existing facility-level data that included presence of an HF clinic, cardiac cath lab, use of pharmacist, bed size, membership in Council on Teaching Hospitals (COTH), and presence of an Accredited Graduate Medical Education (ACGME) program.

Results:
Altogether, 1205 providers have participated in the HF Network. As of June 2013, 987 providers from 144 VA facilities participate in this network. They include VACO leadership (1%), VISN leadership (4%), facility leadership (9%), Chiefs of Cardiology (7%), staff physicians (32%), nurses (28%), pharmacists (5%) and others (14%).

Participation at the facility-level has increased from 2008 (None=37, Low=43 and High=64) to 2013 (None=8, Low=16 and High=120, (p <0.001). High participating facilities were more likely to be classified as tertiary (p <.016), COTH members (p <0.001), having ACGME programs (p <0.001), and located in the West or Southeast United States (p =.03). High participating facilities are also more likely to have a HF clinic (p <0.001), a cardiac catheterization lab (<0.001), and use a pharmacist in routine HF care (p <.03).

Conclusions:
Involvement and active participation in the VA HF Network has grown and is more likely at academic facilities and those providing more intensive services.
Abstract 301: Evaluation Of Net Clinical Benefits Of New Oral Anticoagulants Used For Acute Venous Thromboembolism Treatment vs. Standard Therapy
Authors: Amin Alpesh , Jing Yonghua , Trocio Jeffrey , Lin Jay , Lingohr-Smith Melissa , Graham John
Published: July 2021

Background:
Venous thromboembolism (VTE) is a significant healthcare burden, but is a preventable and treatable condition. The new oral anticoagulants (NOACs), apixaban, rivaroxaban, dabigatran, and edoxaban have all been shown in phase III trials to be noninferior in efficacy to standard therapies for acute VTE treatment, although there may be some differences in the bleeding rates among the NOACs. This study evaluated the net clinical benefits (NCB) of NOACs vs. standard therapies based on the AMPLIFY, EINSTEIN-Pooled analysis, RECOVER-1, RE-COVER II, and Hokusai-VTE trial results.

Methods:
Event rates of the primary efficacy and safety outcomes, as defined in each original trial, among VTE patients during trial periods were obtained from the published clinical trial data. Data from RECOVER-I and -II trials were combined to represent the findings for dabigatran since the two trials were of similar design. EINSTEIN-pooled (DVT and PE combined) data were used to represent findings for rivaroxaban. The combinations of rates for the primary efficacy endpoint, representing recurrent VTE or death and major bleedings (MB) were evaluated and defined as the NCB of each NOAC. Additionally, the number of VTE patients needed to treat (NNT) to avoid one event (e.g. VTE or MB) with each NOAC was also determined.

Results:
For patients treated in the VTE clinical trials, the differences in event rates of recurrent VTE or death for apixaban, rivaroxaban, dabigatran, and edoxaban vs. standard therapy were -0.43%, -0.23%, 0.20%, and -0.34%, respectively. The differences in event rates of MB for apixaban, rivaroxaban, dabigatran, and edoxaban vs. standard therapy were -1.26%, -0.78%, -0.43%, and -0.24%, respectively. The NCB improved for all NOAC treated patients, with those treated with apixaban (-1.69%) vs. standard therapy having the greatest NCB, followed by those treated with rivaroxaban (-1.01%), edoxaban (-0.58%), and dabigatran ( -0.23%) (Table 1).

Conclusions:
All NOACs were shown to be non-inferior to standard VTE treatments in clinical trials; however, apixaban may provide the optimal NCB with the lowest NNT. How these results translate into real-world outcomes or medical cost reductions will require further evaluation.
Abstract 307: Poor Right Ventricular Systolic Function (lower TAPSE) and Higher Pulmonary Artery Systolic Pressure (PASP) Predicts Early Readmissions and all Cause Mortality in Elderly Patients with Heart Failure
Authors: Choudhary Gunjan , Lakshmanadoss Umashankar , Prasad Hari , Babayan Zaruhi , Stapleton Dwight
Published: July 2021

Background:
Heart failure(HF) related early readmission (<30days) and mortality is higher in elderly patients. Right ventricular (RV) dysfunction is associated with worse prognosis in patients with HF with reduced ejection fraction (HFrEF). We evaluated effect of RV function (as measured by TAPSE - Tricuspid annular plane systolic excursion) and Pulmonary artery systolic pressure (PASP) on early HF readmission and mortality in elderly HF patients.

Methods:
This is single center observational study of elderly (≥65 years )patients with HFrEF. Patients with principal discharge diagnosis of HFrEF are included (n = 278, age 77 ± 9 years, 38% female, LVEF 29% ± 9%). Demographic and echocardiographic data are collected. TAPSE (as a marker of RV systolic dysfunction) and PASP are measured as per ASE guidelines. Prediction models are performed.

Results:
Among 278 patients, 62 patients ( 22.3%) had HF related early readmission and 123 patients (44%) died at the end of 5 year. On univariate analysis, older age, Hypertension, Diabetes, higher PASP , RV systolic dysfunction (TAPSE <16mm) and BMI< 25 are predictors of early readmission and mortality (P value <0.05). On multivariate logistic regression analysis, early HF readmission was predicted by TAPSE <16 mm (OR=23.6; p < 0.001; CI 10.23-54.60) and PASP >50 mmHg ( OR = 34; p < 0.001; 95 CI 14.08-82.81); five year all cause mortality was predicted by TAPSE < 16mm (OR = 1.85; p 0.023; 95 CI 1.08-3.16) and PASP >50 mmHg (OR = 2.11; p 0.009; 95 CI 1.19-3.72).

Conclusion:
TAPSE <16 mm and PASP >50 mmHg are strong predictors of early readmission and five year all cause mortality in elderly HF patients. The assessment of RV function through TAPSE and PASP, helps to risk-stratify elderly patients with HFrEF.
Abstract 321: Impact Of Chronic Kidney Disease On Heart Failure Outcomes In A Minority Cohort
Authors: MUSTAPHA TAOPHEEQ , BHOGIREDDY VARIJA , MADU HARTMAN , BOACHIE ADU , OSENI ABDUL , PEACE WESLEY , WARIBOKO-OKAFOR MINABA , AGBOTO VINCENT , OKAFOR HENRY E
Published: July 2021

BACKGROUND:
Heart failure (HF) and Chronic kidney disease (CKD) are major public health problems that often co-exist with a resultant high mortality and morbidity.

Most of the studies evaluating their reciprocal prognostic impact have focused on mortality in majority populations. There is limited literature on the impact of CKD on HF morbidities in ethnic minorities.

AIMS:
Our study seeks to compare HF outcomes in patients with or without CKD in an African-American predominant cohort.

METHODS:
We obtained data from the NGH at Meharry Heart Failure Cohort; a comprehensive retrospective HF database comprised of patient care data (HF admissions, non-HF admissions, and emergency room visits) were assessed from January 2006 to December 2008. The study group consist of 306 subjects with a mean age of
65±15 years.
81% were African-American (AA), 19% Caucasian and 48.5% are females. Following the NKF KDOQI guidelines, 5 stages of CKD were outlined based on GFR.

RESULTS:
The overall prevalence of CKD in this population is 54.2%. CKD stage 1 was most prevalent with 45.8%, prevalence for stages 2-5 are 21.6%, 18.3%, 9.5% and
4.9%
respectively.

The comparison of the mean of ER visits, non HF hospitalizations and HF hospitalizations between normal and CKD patients was done using independent t-test and showed no significant difference in the mean number of ER visits (p=0.564), or HF hospitalizations(p=0.235). However, there is a statistically significant difference in the mean number of non -HF hospitalizations between normal and CKD patients (p=0.031).

CONCLUSION:
This study shows that the prevalence of CKD in this minority -predominant HF cohort is similar to prior studies in majority populations. However, only the non-HF hospitalizations were significantly increased in the CKD group. Future prospective studies will be needed to define the implications of this in the management of HF patients with CKD.
Abstract 325: Paradoxical Relationship Between Bleeding Risk, Stroke Risk, and Time in Therapeutic Range for Atrial Fibrillation Patients on Warfarin: Data from ORBIT-AF
Authors: Pokorney Sean , Holmes DaJuanicia N , Thomas Laine , Fonarow Gregg C , Kowey Peter R , Chang Paul , Singer Daniel E , Ansell Jack , Blanco Rosalia G , Gersh Bernard , Mahaffey Kenneth W , Hylek Elaine M , Go Alan S , Piccini Jonathan P , Peterson Eric D
Published: July 2021

Objective:
Time in the therapeutic range (TTR) of INR 2.0-3.0 is an important measurement of warfarin anticoagulation quality. There are few reports on TTR in United States (US) clinical practice.

Methods:
Using the US ORBIT AF registry, we analyzed TTR for patients on warfarin with at least 5 recorded INR measurements. The Rosendaal method of linear interpolation was used between each pair of measured INR values. Patients were stratified into quartiles based on TTR.

Results:
We studied 5,451 patients treated at 169 US sites with 48% of patients being followed at an anticoagulation clinic. Patients had a median age of 76 years [interquartile range (IQR) 68-82 years] and median follow-up was 18.9 months [IQR 12.7-23.3 months], and patients were 42% women. The median number of INR draws was 21 [IQR 12-30]. Patients had an overall median TTR of 68% [IQR 52-80%]. The median TTR by quartile was 40%, 60%, 73%, and 87%. Patients were more likely to be subtherapeutic (median time of 17%) than supratherapeutic (median time of 10%). Patients age 61-80 years and those with a college education had the highest TTRs. Patients with their INR followed at an anticoagulation clinic were more likely to be in the highest TTR quartile than in the lowest (27% vs 23%, p=0.0002). Patients with worsening renal function and higher risk for bleeding (ATRIA) or stroke (CHADS2 score) had lower TTR (p<0.0001 for all) (Figure).

Conclusions:
In US clinical practices, warfarin patients have therapeutic INR levels about 2/3 of the time. Those at highest risk for stroke and bleeding paradoxically were the least likely to be in the therapeutic range.
Abstract 334: Potential Risk Factors for Recurrent Coronary Revascularization and Hospitalization for Unstable Angina Following Acute Myocardial Infarction
Authors: Smolderen Kim , Li Yan , Cohen David , Arnold Suzanne V , Jones Phil G , Wang Tracy Y , Zhao Zhenxiang , Spertus John A
Published: July 2021

Background:
Subsequent hospitalizations after acute myocardial infarction (AMI) for unstable angina (UA) and coronary revascularization represent common and important clinical events. While numerous studies sought to predict survival, AMI, and all-cause rehospitalization after AMI, there are limited data about how to best risk-stratify patients for UA and subsequent revascularization. Understanding these factors can support the development of more efficient AMI care.

Methods:
In the multi-center TRIUMPH registry, we used 3,283 patients with detailed baseline and 1-year follow-up information, including adjudicated hospitalizations, following initial AMI admission. An initial prediction model was derived after examining > 60 demographic, socio-economic, comorbidity, AMI severity, treatment, psychosocial and health status characteristics using hierarchical Cox Proportional Hazards for UA or revascularization. Staged PCIs and elective CABGs performed ≤1 month were excluded.

Results:
A total of 140 (4.3%) patients were readmitted ≤1 year for UA and 158 (4.8%) for revascularization. Independent predictors of UA were female sex (HR=1.88; 95%CI: 1.33, 2.65), prior PCI (HR=1.64; 95%CI: 1.12, 2.39), prior CABG (HR=2.06; 95%CI: 1.28, 3.32), and GRACE risk score (HR per 1 point increase=0.99; 95%CI: 0.98, 0.99). Independent predictors of revascularization were diseased vessels >1 (HR=2.50; 95%CI: 1.74, 3.60), and GRACE risk score (HR=0.99; 95%CI: 0.99, 1.00). While high-risk patients (those with diabetes, peripheral artery and cerebrovascular disease) were at increased risk of being readmitted for UA (HR=1.48; 95%CI 1.04, 2.10) or revascularization (HR=1.35; 95%CI: 0.97, 1.88), there was no interaction between these associations and risk status, suggesting equal prognostic significance in those with and without high-risk characteristics.

Conclusion:
Unique characteristics are associated with admissions for UA and revascularization. Creating multivariable models, risk scores and prospective risk stratification can support tailoring treatment to those at highest risk, although prospective studies are needed to establish the best management for high-risk patients.
Abstract 336: Real-World Experiences with Novel Anticoagulants for AF: Initial Insights from ORBIT-AF Phase II
Authors: Steinberg Benjamin A , Milford-Beland Sarah , Ollis Donna , Blanco Rosalia , Ansell Jack , Fonarow Gregg C , Gersh Bernard , Go Alan , Hylek Elaine , Kowey Peter R , Mahaffey Kenneth W , Thomas Laine , Chang Paul , Peterson Eric D , Piccini Jonathan P
Published: July 2021

Background:
Novel therapies for stroke prevention in atrial fibrillation (AF) are emerging. However, data on use and outcomes of these agents in the community are limited, particularly in patients newly diagnosed with AF or recently transitioned to a novel anticoagulant.

Methods:
Phase II of the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF II) is a multicenter, national, AF registry. We are enrolling 15,000 patients with new-onset AF, or those with known AF recently-transitioned to a novel anticoagulant. The primary objective is to evaluate the safety of novel anticoagulants, with specific focus on use, transitions, and management around invasive procedures and bleeding events. An adaptive design is used to ensure diversity of enrollment across geographic, provider, and treatment groups. The primary outcomes are major bleeding and thromboembolic events.

Results:
Of 1,011 patients in ORBIT-AF II, the median age was 73, 44% were female, 23% had a history of heart failure, 34% had a prior MI, and 11% had a prior stroke/TIA. The mean CHADS2 score was 2. Overall, 76% had AF new-onset, and a range of anticoagulant strategies was used in these patients (Figure). Among the 24% with known AF transitioned to a novel agent, 66% received rivaroxaban, versus 8.1% dabigatran, and 26% apixaban. Compared with patients having new-onset AF, those with known AF recently-transitioned to a novel anticoagulant were slightly older (median age 74 vs. 72), had higher CHADS2 scores (>2 in 70% vs. 62%), but less severe kidney disease (0 vs. 1.7%).

Conclusions:
Patients with new-onset AF are frequently treated with novel anticoagulants and these patients have lower risk scores than those with known AF transitioned to a novel drug. These data will provide insights into clinical management and patient centered outcomes among those treated with novel anticoagulants in real world practice settings.
Abstract 340: Thirty-day Repeat Hospitalizations for Patients Treated with Prasugrel Compared to Ticagrelor following Acute Coronary Syndrome: Findings from a Large Hospital Charge Master Database
Authors: Vetrovec George W , Larmore Cynthia , Molife Cliff , DeKoven Mitch , Karkare Swapna , Zhu Yajun E , Frech-Tamas Feride , Lu Jingsong , Lee Won C , Mc Collam Patrick , Marrett Elizabeth , Effron Mark B
Published: July 2021

Background:
This retrospective, real-world claims data base study in patients (pts) with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) demonstrated that prasugrel (pras) was non-inferior to ticagrelor (ticag) for 30 day safety and effectiveness outcomes. This report provides further evaluation between pras vs ticag of 30 day readmission rates for myocardial infarction (MI), revascularization (revasc), and bleeding.

Methods:
IMS Patient-Centric Data Warehouse claims data was used to identify ACS-PCI pts ≥18 years old with at least one in-hospital claim for pras or ticag between 8/1/11-4/30/13. The groups were propensity matched (PM) based upon demographic and clinical characteristics using index and prior hospitalization records dating back to 1/1/2008. Relative risk (RR) and 95% confidence interval (CI) were estimated to assess binary endpoints. Non-inferiority was computed by comparing the mean from a normal distribution of log (RR) with log (1.2), a predefined non-inferiority margin. Three cohorts were predefined: ACS-PCI (primary), ACS-PCI without prior TIA or stroke (label), ACS-PCI pts without prior TIA or stroke and if age ≥75 years with evidence of diabetes or prior MI (core).

Results:
Prior to PM, the primary cohort included 16,098 pts; 13,134 (82%) on pras, 2,964 (18 %) on ticag. Compared to pras, ticag pts were older, more often female, had increased cardiovascular risk factors, and more often treated at a teaching hospital. Unstable angina was seen more often in pras pts with no difference in STEMI or NSTEMI between the 2 groups. Using PM pts (table), pras was non-inferior to ticag in the primary cohort for rehosp for MI, revasc, and bleeding at 30 days post discharge. Rehosp for MI and bleeding was significantly lower with pras vs ticag while rehosp for revasc was lower, but not significantly. Results for the label and core cohorts had the same directionality as the primary cohort.

Conclusion:
Rehosp for MI, revasc or bleeding was non-inferior for pras compared to ticag at 30 days post discharge. Pts treated with pras had lower 30 day rehosp rates, particularly related to readmission for MI, compared with ticag. Although limited by selection bias, these results support the clinical utility of pras, regardless of cohort, to limit 30 day rehosp for pts undergoing PCI for ACS.
Abstract 366: Procedure Change To Reduce Radial Artery Compression Device Bleeding Following Radial-approach Angiography: A Single Centre’s Preliminary Results.
Authors: Lee Vanessa , Davey Toni , Kenny Ellen , Cowie Kath , Cox Nicholas
Published: July 2021

Background:
Radial access is an increasingly common approach to coronary angiography whereby a radial artery compression device (RACD) is applied to achieve haemostasis following sheath removal. Current procedure recommends the removal of 5mL of air at 5-minutely intervals from the RACD; 45 minutes post angiogram sheath removal and 2 hours post PCI (Percutaneous Coronary Intervention) sheath removal. Haemostasis failure at the puncture site however was frequently reported and required re-insertion of air. Patients reported increased discomfort and, in 44% of elective cases, post-procedure stay was increased and discharge delayed by 30-180 minutes as a result of prolonged recovery time.

Methods:
Hospital procedure was revised to remove 3mL volume (air) at 5-minutely intervals from the RACD instead of 5mL. The RACD was also to remain untouched for 60 minutes post angiogram sheath removal and remained at 2 hours untouched post PCI sheath removal. A retrospective audit was conducted pre- and post-procedure change and included patients undergoing radial-access angiogram or PCI

Results:
A total of 258 cases were reviewed; 158 angiogram and 100 PCI. Initial volume of air used to achieve haemostasis was 10-18mLs and heparin dose administered was 2000-10,000units. Prior to procedure change, 5mL (air) was removed from the RACD and subsequently haemostasis failure occurred in 43.8% (35) of angiogram patients and 55.1% (27) of PCI patients. Following implementation of the 3mL procedure, haemostasis failure was reported in 12.8% (10) of angiogram patients and 19.6% (10) of PCI patients.

Conclusion:
Whilst total time taken to remove the RACD marginally increased, decreasing the volume of air removed from 5mL to 3mL significantly reduced the incidence of haemostasis failure. This effect was achieved without adjustment of anticoagulation dose or initial volume of air inserted into the RACD.
Abstract 372: Electronic Medical Records Can Identify Patients With Persistently Elevated Blood Pressure Without A Prior Diagnosis Of Hypertension.
Authors: Odunukan Olufunso W , Rahman Ahmed S , Roellinger Daniel , Cha Steven , Naessens James M , Nyman Mark A
Published: July 2021

Background:
The diagnosis of hypertension requires systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg on at least 2 different occasions. Therefore, there is the possibility of patients with elevated BP remaining undiagnosed if not seen by the same provider.

Purpose:
To utilize electronic medical records (EMR) to identify patients not previously diagnosed with hypertension that have elevated blood pressure meeting criteria for a diagnosis of hypertension using a threshold of SBP ≥ 140mmHg or DBP ≥ 90 mmHg (high BP) on 2 or more occasions.

Methods:
This was a cross sectional design utilizing retrospective multi-year billing and clinical data from a large multi-specialty center in the Midwest. Using electronic records of all outpatient visits in each year from 2009 - 2011, patients with at least 2 visits with SBP ≥ 140mmHg or DBP ≥ 90 mmHg (2HBP) in the measurement year were identified. These patients were compared with previously identified cohorts of known hypertension patients (Known HTN) compiled using the EMR problem list. A sensitivity analysis was done using patients with high BP at 2 consecutive visits (2CHBP) and also those with high BP at 3 consecutive visits (3CHBP). We compared proportions of patients with high BP without a prior diagnosis of hypertension (UDHTN).

Results:
The proportion of patients with SBP ≥ 140mmHg or DBP ≥ 90 mmHg without a prior diagnosis of hypertension (UDHTN) when compared to the cohort of known patients with a diagnosis of hypertension (Known HTN) was 25% in 2009, 26% in 2010, and 28% in 2011 in the 2CHBP cohort compared to 27% in 2009, 28% in 2010, and 30% in 2011 in the 2HBP cohort and 18% in 2009, 19% in 2010 and 23% in 2011 in the 3CHBP cohort.

Conclusion:
About a quarter of patients meeting current thresholds on multiple and consecutive visits did not have a known diagnosis of hypertension. The use of EMR can identify these patients for commencement of appropriate management.

Table 1