bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 220: Technical Performance Scores Predict Outcomes Following Congenital Heart Surgery: Multicenter Validation
Authors: Nathan Meena , Liu Hua , Colan Steven D , Kochilas Lazaros , Raghuveer Geetha , Overman David , Bacha Emile , O Brien James , St Louis James , Kalfa David , Vezmar Marko , Gauvreau Kimberlee , Jenkins Kathy , del Nido Pedro J
Published: July 2021

BACKGROUND:
In previous work from a single center, Technical Performance Score (TPS), a tool that assesses technical adequacy of repair, has been shown to be strongly associated with outcomes in congenital cardiac surgery. We sought to validate the efficacy of TPS in a multicenter environment.

METHODS:
All patients (1 day to 62 years) who were discharged from January 1 to December 31, 2011; and who underwent 9 congenital cardiac procedures (Arterial switch operation [84], Bidirectional Glenn [75], Atrioventricular canal repair [135], Fontan [97], Arch repair on pump [58], Stage I Procedure [85], Pulmonary valve replacement [116], Tetralogy of Fallot repair [112], and Ventricular septal defect repair [163]); from 5 centers were included. Based on echocardiograms (echo) prior to discharge or death, and unplanned reinterventions at surgical site; TPS was assigned using previously established criteria. Case complexity was determined by RACHS-1 category. Outcomes included (a) major postoperative adverse events (AE) excluding unplanned reinterventions, (b) length of ventilation, and (c) postoperative hospital stay. Adjusted analysis used logistic/linear regression to determine odds ratio (OR) and regression coefficient (b) for each outcome.

RESULTS:
There were 925 hospital discharges: 418 (45%) were RACHS-1 category 2, 295 (32%) category 3, 85 (9%) category 4, 86 (9%) category 6 and the cohort included 41 (4%) adults. TPS were as follows: 491 (53%) class 1-optimal, 263 (28%) class 2-adequate, 131 (14%) class 3-inadequate and 40 (4%) had no TPS assigned because of a lack of or incomplete echos (NA). There were 26 (2.8%) deaths (81% of deaths were in class 3) and 105 (11%) adverse events. Occurrence of major adverse events, ventilation time and hospital length of stay were all significantly higher in class 3 (Figure). On multivariable analysis adjusting for age, RACHS-1, prematurity, and presence of non-cardiac anomalies; Class 3 TPS was associated with a higher odds of AE (OR 7.4, CI 4.1-13.2, p<0.001), longer ventilation (b 1.9, CI 1.6-2.2, p<0.001), and hospital stay (b 1.6, CI 1.4 to 1.8, p<0.001).

CONCLUSION:
TPS predicts outcomes after congenital heart surgery in a multicenter cohort, and can serve as quality assessment tool. Outcomes may be favorably influenced by focusing on technical excellence.
Abstract 239: Appropriateness and Impact of Transthoracic Echocardiography in a Veterans Affairs Health Care System.
Authors: Abdullah Kazeen N , Hastings Jeff , Abdullah Shuaib , Matulevicius Susan
Published: July 2021

Background:
Appropriate Use Criteria (AUC) for transthoracic echocardiograms (TTEs) was developed in 2007 and later revised in 2011 to meet the need for guidance on appropriate use of diagnostic imaging. Few studies have evaluated the correlation between AUC and downstream clinical impact. We describe the association of AUC and clinical impact for TTEs from a VA center.

Methods:
All TTEs from April 2011 at a VA center were retrospectively reviewed. TTEs were excluded for LVAD/ transplant patients or for inadequate clinical data to assign AUC or clinical impact. Based on 2011 AUC , TTEs were classified as: appropriate, inappropriate, or uncertain. After blinding to AUC, TTEs were assessed for clinical impact as: change in care, continuation of current care, or no change in care.

Results:
Among 441 TTEs (43% inpatient), 82.7% were appropriate, 9% inappropriate and 8% uncertain. Overall, change of care was seen in 39% of TTEs, continuation of current care in 32% and no change in care in 30%. Appropriate TTEs more frequently resulted in a change in care than inappropriate TTEs (41% vs. 23%, p<0.03, Figure 1).

Conclusions:
Although only 8 in 10 TTEs were appropriate by 2011 AUC, almost 4 in 10 TTEs lead to an active change in care. Appropriate TTEs were more likely to change patient care than inappropriate TTEs. Additional research is needed to evaluate the association of clinical impact and differences in TTE practice at VA vs. non VA medical centers.
Abstract 250: Death Is Expensive: Evaluation of Inpatient Mortality for Acute Coronary Syndromes Admissions
Authors: Page Robert L , Ghushchyan Vahram , Hoetzer Greta , Bhandary Durgesh , Den Bos Jill Van , Gray Travis , Norris Doug T , Nair Kavita V
Published: July 2021

Introduction:
Most economic analyses that have addressed the costs associated with acute coronary syndromes (ACS) have only focused on patients who have survived an inpatient admission. No studies have specifically addressed the cost of dying during an ACS inpatient admission in a commercially insured population.

Methods:
Medical and pharmacy claims from the Truven MarketScan databases (2009-2011) were used to identify inpatient admissions with a primary discharge diagnosis of ACS, among patients with 6 months of continuous enrollment prior to admission. Admissions with a discharge status of “death” (deceased sample) were matched (1:3 ratio) to remaining admissions (survived sample) on age, gender, year, and Charlson Comorbidity Index (CCI), creating a matched sample. Mean length of stay, total admission cost, and mean costs per day for the deceased sample were compared to thesurvived sample. All costs are reported in 2012 USD.

Results:
A total of 1,160 ACS admissions with deceased discharge status were identified and matched to 3,480 ACS admissions with non-deceased (survived) status. The majority of patients were male (68%) with a mean age of 56.7±6.4 years and mean CCI ranging from 1.94-1.97. The Table summarizes a description of the ACS admissions. The average length of stay for ACS admissions with deceased status (days) were 34% higher compared to those with survived status (6.9±9.2 versus 5.2±4.8 days, respectively, p<0.0001). Similarly, the mean total cost per admission and mean cost per hospital day was 2-fold higher (p<0.0001) and 1.5-fold higher respectively (p<0.0001) for ACS admissions with deceased status compared to those with survived status. The first day of admission was the most expensive for both admissions; although 1.8-fold higher for the deceased sample (p<0.0001) compared to the survived sample. Similar trend continued for subsequent days of admission between both admissions.

Conclusion:
ACS admissions with deceased status are both expensive and longer in duration compared to those with survived status
.
These data can provide financial insights to hospitals regarding their case mix for resource allocation in managing their ACS population.
Abstract 256: Readmission Avoidability in Acute Coronary Syndrome Patients
Authors: Souphis Maria , Sylvester Rachel , Wiles Alison , Subramanian Meghana , Froehlich William , Gordon Lauren , Alexandris-Souphis Tina , Kline-Rogers Eva , Vaishnava Prashant , Rubenfire Melvyn , Bumpus Sherry
Published: July 2021

Background:
Readmissions for ACS are common, costly, and potentially preventable. According to Medicare 13.4% of AMI admissions were followed by a rehospitalization within 15 days. A 2007 MedPAC report declared 76% of 30-day readmissions preventable. These rates are used as quality indicators despite lack of consensus on the definition of avoidable and unavoidable readmissions. We sought to define these terms and to analyze the effect of these definitions on 30-day outcomes.

Methods:
BRIDGE (Bridging the Discharge Gap Effectively) is an NP-led transitional care program for cardiac patients within 14 days of discharge. Retrospective data were abstracted on ACS patients readmitted before their appointments between 2008-2010. All readmissions were characterized as avoidable or unavoidable. Definitions were developed from the literature and in concert with senior cardiologists. Avoidable readmission was defined as being the result of a patient or provider issue that if managed may have prevented the admission. Unavoidable readmissions were defined as a patient in need of acute care. Avoidability status was further divided as related or unrelated to the index diagnosis.

Results:
Of 1188 BRIDGE referrals 304 (25.6%) experienced ACS events. In comparison to the total ACS population, patients readmitted before their BRIDGE clinic appointment (BC) (n=21, 6.9%) tended to be older, female, and were less likely to have a history of a cath or AMI (Table 1). In this study, 81% (n=17) of early readmissions were deemed unavoidable and most (n=14, 66.7%) were attributed to non-ACS issues or disease progression. These unavoidable readmissions included patients with cancer complications, chest pain, or other non-related diagnoses. Only 19% (n=4) of the readmissions were declared avoidable as a result of patient lack of adherence or provider issues such as adverse drug effects.

Conclusion:
The majority of early (before BC) readmissions following an index hospitalization for ACS patients referred to BRIDGE were unavoidable and unrelated to ACS. A clear discrepancy is seen between the 76% preventable readmissions in the MedPAC report and the 19% preventable readmissions in this study. Distinctions between unavoidable and avoidable readmissions should inform the utility of 30-day readmission rates as quality metrics.
Abstract 274: Prevalence of undiagnosed non-valvular atrial fibrillation in the United States
Authors: Turakhia Mintu P , Shafrin Jason , Bognar Katalin , Brown Jeffrey B , Trocio Jeffrey , Wiederkehr Daniel , Goldman Dana P
Published: July 2021

Background:
Because atrial fibrillation (AF) is often asymptomatic, clinically silent and therefore undiagnosed, the prevalence of AF is difficult to estimate. In fact, ischemic stroke is often the first clinical sign of AF among previously undiagnosed patients. In this study, we estimated the prevalence of undiagnosed AF using a back-calculation approach that relies on the fact that AF causes stroke but causality generally does not run from stroke to AF.

Methods:
We first estimated the prevalence of diagnosed non-valvular AF in the elderly (65+) and working age (18-64) U.S. population from a 5% Medicare sample and an OptumInsight commercial claims database from 2004-2010 using validated ICD9 algorithms. To estimate the prevalence of undiagnosed non-valvular AF, our back-calculation methodology used two measured inputs: (i) the number of patients who are diagnosed with new non-valvular AF in the current or subsequent quarter after a stroke; (ii) the probability that patients with non-valvular AF have a stroke, based on CHADS2 risk scores. We confirmed calibration by comparing our prevalence estimates of diagnosed AF with prior Medicare and commercial claims analyses.

Results:
Between 2005 and 2009, the estimated prevalence of AF gradually increased, reaching 9.9% of the elderly U.S. population and 0.88% of the working aged population by 2009. Among the Medicare AF cases in 2009, 11% of these cases (1.1% out of 9.9%) were undiagnosed; among working aged patients with AF, 8% of cases (0.07% out of 0.88%) were undiagnosed. In addition, a large share of the undiagnosed cases was at high risk of stroke. Among the undiagnosed AF cases for elderly and working age adults, 26% and 37%, respectively have a CHADS2 score of 1, and 68% and 26% have a CHADS2 score of 2+.

Conclusions:
Among elderly and working adult U.S. populations, a substantial proportion of individuals with undiagnosed AF have moderate to high risk of stroke. Screening for AF could favorably impact the disease burden.
Abstract 304: Nonfatal Outcomes Following Incident Atrial Fibrillation: A Community Study
Authors: Chamberlain Alanna M , Gersh Bernard J , Alonso Alvaro , Brown Robert D , Weston Susan A , Roger Veronique L
Published: July 2021

Background:
Atrial fibrillation (AF) is the most common cardiac arrhythmia in current clinical practice. Yet, contemporary community data on adverse outcomes, such as ischemic stroke (IS) and heart failure (HF), are scarce.

Methods:
We assembled a community-based cohort of incident AF among Olmsted County, MN residents ≥18 years of age from 2000-2010. IS, transient ischemic attack (TIA), and incident HF occurring through 12/31/2012 were identified using diagnosis codes and were manually validated. Cox proportional hazards regression was used to determine age- and sex-adjusted predictors of IS/TIA and HF, as well as the association of year of AF diagnosis with these outcomes after adjustment for demographics and comorbidities.

Results:
Among 3315 incident AF (mean age 72.6 years, 52% male), 346 (10%) developed a subsequent IS (n=230) or TIA (n=116) over a mean follow-up of 4.2 years. In the 2807 AF patients without prior HF, 782 (28%) developed HF over a mean of 3.9 years. Differences in the predictors of subsequent IS/TIA and HF were observed (Figure). Increasing age, female sex, and prior IS/TIA were associated with an increased risk of IS/TIA, whereas increasing age, obesity, smoking, prior myocardial infarction, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, prior IS/TIA, and renal disease predicted the development of HF after AF. The risk of subsequent IS/TIA or HF did not differ by year of AF diagnosis. Compared to those diagnosed with AF in 2000-2003, the adjusted hazard ratios (HR) (95% CI) for ischemic IS/TIA were 0.84 (0.65-1.08) and 1.02 (0.76-1.36) for those diagnosed with AF in 2004-2007 and 2008-2010, respectively (P
time trend
=0.58); similar results were observed for IS alone. The corresponding HRs for HF were 0.99 (0.83-1.16) and 0.93 (0.76-1.13) for those diagnosed with AF in 2004-2007 and 2008-2010 compared to 2000-2003 (P
time trend
=0.43).

Conclusions:
In the community, adverse outcomes are frequent after AF, and HF occurs more frequently than IS/TIA. Risk factors differed for IS/TIA and HF, suggesting that pathways to the occurrence of these outcomes, as well as prevention strategies, may differ. Finally, the occurrence of these outcomes did not decline over the last decade, highlighting the importance of continued rigorous surveillance of adverse outcomes in AF.
Abstract 309: Is Right Bundle Branch Block Associated with Poor Outcomes in the Setting of an Acute Coronary Syndrome? A Systematic Review and Meta-analysis
Authors: Hazem Ahmad , Sharma Sunita , Sharma Amit , Leitch Cameron , Sharadanant Roopalakshmi , Uriell Matthew , Neutzling Kari , Wang Zhen , Brrionuevo Moreno Patricia , LeBlanc Annie , Sorita Atsushi , Vilesnki Leonid , Prokop Larry , Makkuni Premraj , Ting Henry H , Murad Mohammad H
Published: July 2021

Importance:
Up to 10% of patients with acute myocardial infarction (AMI) have right bundle branch block (RBBB), and RBBB has been associated with a higher risk of mortality. We performed a systematic review and meta-analysis to determine the prognostic significance of RBBB for patients with AMI. Acute coronary syndrome (ACS)

Data Sources:
We have systematically searched Ovid, Scopus and Web of Science through January 2014.

Study Selection:
Reviewers working independently and in duplicate screened all eligible abstracts, selecting studies that described all-cause mortality or cardiovascular death in patients with RBBB and suspected ACS. We excluded studies that reported unadjusted outcomes.

Knowledge synthesis:
We pooled risk ratio with hazard ratio in studies reporting those outcomes. When reported, odds ratio was converted into risk ratio using reported event rate in each study’s unexposed -read: non RBBB- group.

Main Outcomes:
All-cause mortality and cardiovascular mortality (death).

Results:
Eighteen studies were found that reported eligible data. All were observational studies, involving over 89,000 patients. In short-term follow up (up to 30 days), RBBB on presentation was associated with higher all-cause mortality rate, compared to patients without RBBB (RR 2.23, 95% CI 1.76-2.82). There was a trend for higher mortality at long-term follow up (range: 6 months-16 years) that did not reach statistical significance (RR 1.45, 95% CI 0.93-2.25). Figure-1 demonstrates the forest plot. Risk of bias was assessed with the Newcastle-Ottawa scale and majority of included studied were deemed moderate to high quality.

Conclusion and Relevance:
RBBB is associated with a more than 2-fold higher risk of all-cause mortality in patients with AMI at 30 days follow up. Patients with AMI and RBBB represent a high risk group for adverse outcomes. A sentence on the differential findings for new vs. old RBBB and association with outcomes could follow here.
Abstract 310: 30-day Readmission Following PCI Predicts Worse Long-term Patient Outcomes: Insights from the VA CART Program
Authors: Hegeman Timothy W , Glorioso Thomas J , Baron Anna E , Schneider Preston M , Burke Robert E , Ho P. Michael , Rumsfeld John S , Maddox Thomas M , Heidenreich Paul A , Mavromatis Kreton , Bavry Anthony A , Bradley Steven M
Published: July 2021

Background:
30-day readmission after percutaneous coronary intervention (PCI) is a common, expensive and potentially preventable problem. The relationship between 30-day readmission and long-term patient outcomes has not been studied within integrated care delivery settings. We sought to determine the association between 30-day readmission after PCI and long-term patient outcomes in the VA.

Methods:
We evaluated all VA patients who underwent PCI from October 2007 through September 2011 using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program. Patient outcomes were followed through September 2012. Our primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), revascularization, and the composite of all three outcomes. We compared patient demographics, clinical characteristics, and procedural factors by 30-day readmission status. The association between 30-day readmission status and outcomes was assessed using Cox proportional hazards models.

Results:
Among 32,551 patients undergoing PCI, 4,829 (14.8%) were readmitted within 30 days. Median follow-up after discharge was 30.3 months (IQR: 19.5, 43.6). Over this period of follow-up, a total of 4,548 (14%) died, 2,021 (6.2%) suffered an MI, and 7,040 (21.6%) underwent revascularization. Patients with subsequent readmission were more likely to have chronic kidney disease (26% vs 18%, P<.01) or chronic obstructive pulmonary disease (32% vs 23%, P<.01) and more likely to be presenting with an acute coronary syndrome (60% vs 48%, P<0.01) during the index hospitalization. Thirty-day readmission was associated with worse risk-adjusted outcomes (Table 1).

Conclusions:
In the VA, approximately 15% of patients were readmitted within 30 days of PCI - a rate that is comparable to prior studies from community settings. Patients readmitted within 30-days had significantly higher long-term mortality risks. Future research should aim to understand modifiable causes of readmission and the extent to which 30-day readmission is a quality metric rather than a risk marker.
Abstract 317: Outcomes after Primary Prevention Implantable Cardioverter Defibrillator Placement: Results of the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators
Authors: Masoudi Frederick A , Go Alan S , Magid David J , Reifler Liza M , Glenn Karen A , Cassidy-Bushrow Andrea E , Gurwitz Jerry H , Reynolds Kristi , Smith David H , Fiocchi Frances , Goldberg Robert J , Gupta Nigel , Peterson Pamela N , Schuger Claudio , Vidaillet Humberto , Greenlee Robert T
Published: July 2021

Background:
Implantable cardioverter defibrillators (ICDs) are commonly used for the primary prevention of sudden cardiac death. Controversies persist, however, about outcomes in representative cohorts and in clinically important patient subgroups. Observational studies of outcomes following primary prevention ICD implantation are typically limited to relatively restricted cohorts (e.g. Medicare) or with short follow up.

Methods:
In the Cardiovascular Research Network (CVRN), we conducted a study in 7 integrated health care delivery systems to identify patients undergoing primary prevention ICD implantation for left ventricular systolic dysfunction between 2006-2010. Baseline procedural and clinical data were obtained from the NCDR ICD Registry; longitudinal data to ascertain outcomes after implantation were obtained through clinical health system data from the CVRN Virtual Data Warehouse. We assessed the occurrence of complications at 90 days and mortality, all-cause hospitalization, and heart failure hospitalization up to 5 years after implantation in clinical strata designated a priori. Multivariable models accounting for clustering of patients within site were used to assess the relationship between clinical variables and each outcome. Clinical variables of interest (Table) were included in all models; additional variables were assessed with forward selection to account for possible confounders.

Results:
Among 2953 eligible patients, median age was 69 years and 26% were women Coexisting conditions, including hypertension (74%), atrial fibrillation (32%), COPD (20%), and diabetes (42%), were common. Overall event rates (per 1000 patient years) were 110 for death, 438 for any hospitalization, and 58 for heart failure hospitalization. The association between clinically important variables and outcomes are shown in the Table.

Conclusions:
In a diverse population of patients undergoing ICD implantation in contemporary practice we identified specific clinical variables associated with adverse outcomes. These data can inform prognosis in clinical care and guide the design of future trials of this therapy.
Abstract 365: Continuing to Improve the D2B Process
Authors: Lawson William E , Wilbert Lisa , Sokoloff Lisa , Srinivas Guruprasad , Viccellio Peter , Dowdy Eileen , Kostic Pam , Niegelberg Eric , Scheriff Kathryn , Jeremias Allen
Published: July 2021

Objective:
Early reperfusion of patients with STEMI, with a target door to balloon (D2B) time < 90 min, is a core measure of acute myocardial infarction treatment. “Time is muscle” and efforts are continually made to decrease the time from first medical contact to reperfusion, thereby decreasing cardiac morbidity and mortality. SBUH is a primary PCI referral center challenged by an extended hospital network and a predominately community voluntary EMS, meeting community standards. Process review identified two promising interventions to improve D2B times; increasing community and EMS awareness of the importance of an initial referral to a PCI capable center and obtaining and transmitting ECGs from the field.

Procedure:
Community education and incorporation of the EMS teams as stakeholders in monthly D2B performance review meetings were implemented. The effects of efforts to increase community awareness and provide directed, timely feedback to EMS on process and outcome were assessed.

Results:
Overall STEMI calls increased from 368 in 2011, to 453 in 2012, and 467 in 2013. The number and percentage of patients directly presenting to SBUH (a PCI capable hospital) versus a local referral center increased progressively from 142 [48.6%] in 2011, to 201 [53.0%] in 2012, and 227 [56.5%] in 2013. In contrast to initial presentation at a local community transfer hospital, direct presentation to the PCI capable hospital reduced first contact to reperfusion time by 60 minutes. EMS demonstrated a progressive increase in the number of ECG’s obtained in the field [2009-25, 2010-39, 2011-46, 2012-65, 2013-98]; 62% of STEMI’s brought in by our EMS were called in the field in 2013. First ECG in the field compared to first ECG in the ED reduced D2B time by an average of 18.7/ median of 15.0 minutes. D2B times showed a progressive improvement in median time from 57 in 2011 to 54 minutes in 2013 and in the percentage of patients receiving reperfusion within 90 minutes. Accompanying the reduction in D2B times, PCI mortality fell from a baseline of 1.9% with O/E of 1.01 in 2011 to 1.4% with O/E of 0.75 in 2013; AMI mortality fell from a high of 5.2% with an O/E of 0.99 in 2011 to 3.4% with an O/E of 0.69 in 2013 with an accompanying decrease in the median STEMI LOS from 3.1 to 2.8 days .

Conclusions:
Efforts to improve community awareness of the value of early presentation to a PCI capable hospital center and EMS obtaining and transmitting ECGs in the field are effective interventions to improve rapid reperfusion efforts in STEMI. Community awareness of the warning signs of a heart attack is an additional significant contributor to early effective reperfusion efforts and decreasing cardiac mortality.
Abstract 1: Incidence and Predictors of Cognitive Decline in Patients with Left Ventricular Assist Devices
Authors: Fendler Timothy J , Spertus John A , Gosch Kensey , Jones Philip G , Bruce Jared M , Nassif Michael E , Flint Kelsey M , Dunlay Shannon M , Allen Larry A , Arnold Suzanne V
Published: July 2021

Background:
After left ventricular assist device (LVAD) for end-stage heart failure, cognitive function should improve due to increased cerebral perfusion. However, stroke (a well-known LVAD complication) and even subclinical cerebral ischemia may also occur and manifest as transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool.

Methods:
As part of the INTERMACS registry, cognitive function was assessed before LVAD and at each follow-up with the Trailmaking B Test (TBT), where a subject is timed connecting 25 dots labeled with alternating, consecutive numbers and letters (1, A, 2, B, etc.). The TBT can detect several forms of cognitive impairment, including subclinical stroke. Longer times are worse, and cognitive decline was defined as a clinically important increase from baseline to highest follow-up score using Cohen’s D Effect Size (0.2*baseline SD = 13 s). Patients who completed baseline and at least 1 follow-up TBT were included. Multivariable logistic regression was used to examine the association between patient characteristics and cognitive decline after LVAD.

Results:
Among 1151 LVAD patients, median age was 60-69, 19% were female, and 40% were INTERMACS profile 1-2 (cardiogenic shock or declining despite inotropes) at implant. Among patients with 12-mo follow-up, mean TBT score improved from 126 at baseline to 123 at 1 yr. In the total cohort, 333 (29%) patients had significant cognitive decline within 12 mo of LVAD placement. Increasing age, chronic renal disease, better baseline TBT score (shorter time), and higher INTERMACS profiles (≥ 3; less severe heart failure) were significantly associated with greater odds of cognitive decline (Figure).

Conclusion:
In a large LVAD registry, cognitive decline occurred in over a quarter of patients in the year after LVAD and was associated with older age, renal disease, higher baseline cognitive function, and more stable heart failure at implant. These results define the frequency of an important adverse event and provide new insights regarding outcomes after LVAD. Future studies are needed to explore the association of transient and permanent cognitive decline with subsequent stroke, health status, and mortality in patients after LVAD placement.
Abstract 10: Regional Variation in Out-Of-Hospital Cardiac Arrest Survival in the United States
Authors: Girotra Saket , van Diepen Sean , Nallamothu Brahmajee K , Carrel Margaret , Anderson Monique L , McNally Bryan , Abella Benjamin , Sasson Comilla , Chan Paul S
Published: July 2021

Background:
Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across U.S. regions, factors underlying this variation in survival remain unknown.

Methods & Results:
Using 2005-2013 data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 88,305 adult patients (age >18 years) in 107 U.S. counties with out-of-hospital cardiac arrest at home or in a public location, and geo-coded them to a U.S. county using the address where cardiac arrest occurred We constructed a two-level hierarchical regression model (patient & county) and used median odds ratios (MOR) to quantify regional variation in out-of-hospital cardiac arrest survival. Moreover, we examined the proportion of variation in survival that was explained by 1) patient demographics 2) cardiac arrest characteristics 3) county-level rates of bystander cardiopulmonary resuscitation (CPR) and hypothermia treatment and 4) county-level socio-demographic factors. The mean rate of survival to discharge was 10.0%, and varied markedly across counties (range: 1.4%-18.4%, MOR: 1.33; 95% CI: 1.24-1.38, Figure 1). Compared to counties in the lowest quartile of survival, patients in the highest quartile counties were younger (62.5 vs 61.6 years), more likely to be men (60.8% vs 64.4%), have a shockable rhythm (21.1% vs 26.9%), witnessed arrest (50.3% vs 53.0%), receive bystander CPR (23.4% vs 32.6%), and hypothermia (44.4% vs 62.3%, P for trend < 0.01 for all). County-level rates of survival were positively correlated with rates of bystander CPR (ρ = 0.45, P < 0.0001) and hypothermia treatment (ρ = 0.24, P < 0.0001). Sequential adjustment of demographic and cardiac arrest characteristics explained only 4.3% and 12.4% of the county-level variation in survival, respectively. Inclusion of county-level rates of bystander CPR and hypothermia explained a total of 28.5% of the survival variation, and this proportion increased to 36% after adjustment of other county-level factors.

Conclusion:
There is substantial variation in out-of-hospital cardiac arrest survival across U.S. counties. Although a large proportion of survival variation was unexplained, most of the variation that could be accounted for was due to county-level differences in rates of bystander CPR and hypothermia treatment.
Abstract 118: Discharge Medications, Hospice Use and 30 Day Outcomes for Hospitalized Heart Failure Patients
Authors: Stearns Sally C , Rodgers Jo E , Chang Patricia P , Sueta Carla A
Published: July 2021

Purpose:
Identifying factors associated with poor 30 day outcomes following hospital discharge for heart failure patients is important for improving quality of care. Discharge on appropriate medications is a critical factor to improve outcomes. Analyses generally have not differentiated discharge medication recommendations based on prognosis such as referral to hospice after discharge.

Methods:
Hospitalized Medicare patients with an adjudicated acute HF diagnosis during 2006-2011 were identified from the Atherosclerosis Risk in Communities (ARIC) study of a biracial cohort of 15,792 participants from 4 US communities since 1987. Logistic regression was used to explore two questions: 1) whether using hospice within 30 days of discharge was associated with being discharged on at least one of three medications [ACE inhibitors/angiotensin receptor blockers (ACEI/ARB), beta-blockers (BB), or diuretics]; and 2) how inclusion of patients likely close to death affected associations of discharge medications (separately or in combination) with hospital readmission or death within 30 days. Hospitalizations for participants who used hospice and died within 30 days following discharge were excluded for the analysis of readmission or death. All regressions controlled for patient demographic and clinical characteristics.

Results:
The study sample included 780 participants (mean age 76, 45% male, 35% black) with 1457 hospital discharges; within 30 days, 24% of discharges were readmitted and 5% died. Hospice was used within 30 days for 105 discharges (7.4%). Using hospice was strongly associated with not being discharged on at least one medication (OR 0.22; 95% CI 0.11,0.46). Forty discharges used hospice and died within 30 days but only 26 had complete data. Excluding these cases, regression with complete data for 1240 hospitalizations (684 patients) showed that thirty day readmission or death was lower (p<0.05) for patients discharged on ACEI/ARB (OR 0.71, 95% CI 0.53,0.95) or diuretics (OR 0.66, 95% CI 0.48,0.91) but not for BB. A regression assessing the joint effect of discharge on all three drugs had the strongest reduction (OR 0.56, 95% CI 0.41,0.76); including hospice users who died within 30 days without readmission showed only a slightly stronger effect (OR 0.53, 95% CI 0.39,0.72), possibly due to the addition of only 26 stays. Other predictors positively associated with readmission or death included race/site, atrial fibrillation, stroke, and longer hospital stay; hospice was weakly associated with a lower likelihood.

Conclusions:
As heart failure progresses, transfer to palliative or hospice services is often appropriate. Including patients when death is imminent in outcome analyses could overestimate medication effects. Mechanisms for identifying such patients other than hospice use are limited but constitute an important goal for future research.
Abstract 130: In Patients Referred for a Stress Echo-cardiogram, Baseline Left Bundle Branch Block is Associated with Increased Mortality Independent of Stress Test Results or History of Heart Failure
Authors: Yager Neil , Ramineni Tina , Badr Salem , Parker Adam , Zhang Lulu
Published: July 2021

Background:
The role of asymptomatic LBBB in long-term survival for patients without heart disease remains unclear. Therefore, we perform a retrospective review to compare the roles of heart failure and conduction dysfunction in long-term outcomes.

Methods:
Records of 398 consecutive patients referred for chest pain or dyspnea evaluation with stress echocardiogram at a single tertiary care center were reviewed. Reasons for stress test, demographic data, including age and gender, co-morbidities including cardiovascular disease (CAD), peripheral vascular disease (PVD), hypertension (HTN), and diabetes mellitus (DM), and use of ace-inhibitors and beta-blockers were collected. Stress test results including maximal heart rate, duration of test, duration of recovery, double product and ischemia shown by echo were recorded. ANOVA, chi-square, and logistic regression analyses were performed. The mean follow-up length was 76+/-18 months. The study was approved by IRB.

Results:
Left bundle branch block (LBBB) was observed in 11 of 398 patients (2.7%). LBBB was not associated with history of CAD and CAD risk factors or equivalents: HTN, DM, PVD, or smoking. There was a trend towards a 3x higher mortality rate for patients with LBBB than for patients without LBBB and for patients with CHF (p=0.2) Results from the stress test were analyzed. There was no significant difference in age or gender. Patients with LBBB had a lower test duration, lower rates of ischemia by ECHO, and a lower double product than patients without LBB and with CHF (p<0.05). Furthermore, patients with LBBB had trend towards a lower time to recovery and a greater percentage of patients with LBBB reached target heart rate than patients with CHF (p<0.05). The highest mortality was observed in patients with LBBB and no evidence of stress-induced ischemia (2 out of 7 patients, p=0.021). Discussion: Traditionally, CHF has thought to be one of the single most important factors determining long-term outcomes in patients referred for stress-testing. However, our study found the highest mortality to be observed in patients with LBBB and no evidence of stress-induced ischemia. Additionally, significantly more patients with LBBB reached target heart rate and had shorter duration of recovery. Overall, the stress test results suggest LBBB to contribute to higher mortality by mechanisms independent of its impact on ventricular function.
Abstract 136: Impact of Abnormal Ventricular Conduction on TAVR Outcomes
Authors: Marthy Andrew , Delago Augustin , Elkharbotly Ali , Bulibek Batyrjan , El-Hajjar Mohammad , Torosoff Mikhail
Published: July 2021

Background and hypothesis:
The association of abnormal ventricular conduction with co-morbidities and effect of conduction abnormalities on TAVR outcomes have not been well investigated.

Methods:
A retrospective chart review was conducted in 200 consecutive TAVR patients. ECG data was collected and stratified into normal conduction (WNL, n=138), LBBB (n=25), RBBB (n=20), and intra-ventricular conduction delay (IVCD, n=17). Outcomes were adjudicated according to the PARTNER trial definitions (NEJM 2010; 363: 1597-1607). Analyses of variation, correlation, chi-square, and logistic regression were used. The study was approved by the institutional IRB.

Results:
There was no association between any conduction delay and history of CVA, PVD, chronic renal disease, smoking, hyperlipidemia, hypertension, or COPD.

Conduction delays were associated with decreased ejection fraction (LBBB 45.4+/-2.2, RBBB 50.3+/-1.5, IVCD 48.0+/-3.2 vs. 50.7+/-10.9 in WNL conduction, p= 0.03) and lower aortic valve gradient (LBBB 35.0+/- 3.2 mm Hg, RBBB 42.2+/- 2.9, IVCD 40.5 +/- 5.0 vs. 46.2+/-1.5 in WNL conduction, p= 0.022). Standard error was used as the measure of dispersion.

Despite the decreased ejection fraction and lower aortic valve gradient, conduction delays were not associated with an increased incidence of post-TAVR death, re-hospitalizations, stroke, or acute renal failure.

Conclusion:
Despite association with decreased ejection fraction and lower aortic valve gradient, electrocardiographic conduction delays do not lead to inferior TAVR outcomes.
Abstract 14: Clinical Characteristics and Treatment Patterns of Medicaid Patients with Atrial Fibrillation: Insights From the ORBIT-AF I Registry
Authors: O’Brien Emily C , Kim Sunghee , Thomas Laine , Fonarow Gregg C , Mahaffey Kenneth W , Kowey Peter R , Gersh Bernard J , Burton Paul S , Piccini Jonathan P , Peterson Eric D
Published: July 2021

Background:
Little is known about whether insurance status affects the presentation and treatment of patients with atrial fibrillation (AF).

Methods:
We used data from the ORBIT-AF Registry (2010 - 2011), a national, large outpatient registry, to evaluate clinical characteristics and oral anticoagulation (OAC) use. We examined differences in comorbidities and receipt of OAC among patients enrolled in the Medicaid program at baseline compared with those not enrolled in Medicaid. After restricting to patients who were taking OAC, we compared receipt of novel oral anticoagulants (dabigatran or rivaroxaban) versus warfarin by Medicaid status during 2 years of followup. We used logistic regression models adjusting for demographic and clinical covariates to evaluate baseline OAC receipt by Medicaid status.

Results:
Of 10,133 patients, N=470 (4.6%) were classified as having Medicaid insurance. Compared with those with other insurance, Medicaid patients were younger (70.0 years; IQR=61.0 - 79.0 vs. 75.0 years; IQR=67.0 - 82.0), more likely to be female (53.0% vs. 41.8%), and less likely to be white (58.7% vs. 90.7%; all p<0.001). Medicaid patients had higher rates of smoking, prior stroke/TIA, diabetes, hypertension, and HF. Medicaid patients were less likely to be taking OAC at baseline, a difference that was particularly pronounced for high stroke risk patients (CHADS2>=2, p<0.001; Table). Among those on anticoagulation, Medicaid patients were less likely to receive NOAC over 2 years of followup. In adjusted analyses, Medicaid patients were less likely to receive OAC at baseline, but this difference was not statistically significant (HR = 0.82; 95% CI = 0.61, 1.09). Among untreated patients with CHADS2>=2, Medicaid patients were more likely than patients with other insurance to have “unable to adhere/monitor” listed as a contraindication to OAC (p<0.001).

Conclusions:
In a contemporary, community-based AF cohort, Medicaid patients had a greater comorbidity burden and higher stroke risk, yet were less likely to receive OAC compared with those with other forms of insurance.
Abstract 15: Assessing Clinical Quality Indicators for Diabetes Care by Patient Home Zip Code
Authors: Roth Gregory , Gabert Rose , Thomson Blake , Gakidou Emmanuela
Published: July 2021

Objective:
Quality of care for diabetes varies widely in the United States but is usually compared at the level of health facilities. As part of the HealthRise project, we analyzed ambulatory clinic data at the level of each patient’s residential zip code to determine whether achievement of risk factor targets is also a function of home neighborhood.

Methods:
Minnesota Community Measurement (MNCM) collects comprehensive patient-level clinical data from all non-federal ambulatory clinics in their state. Using MNCM data from the year 2013, we assessed risk factor targets for diabetes, defined as the percentage of adult diabetics seen at least twice in 12 months who achieved all of four risk factor targets (HbA1c < 8%, LDL<100 mg/dL, systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg, and documented to be free of tobacco use). We aggregated the data to the zip code in which the patient resided for Hennepin, Ramsey, and Rice Counties, representing Minneapolis-St. Paul and a nearby rural county.

Results:
Success in meeting the HbA1c target was similar between counties, with 74.1% of patients in Hennepin, 74.4% in Ramsey, and 76.2% in Rice meeting the target. However, this varied widely at the zip code level. Across zip codes, the HbA1c target was achieved by 58.8% to 90.0% of patients and the LDL target by 46.7% to 83.6% of patients. Blood pressure and tobacco use targets were met by more patients (74.4% to 95.3% for blood pressure and 70.2% to 94.6% for tobacco). The lowest-performing zip codes were consistent across all four targets. Populations with the lowest achievement levels were found in the neighborhoods of North Minneapolis and Camden in Hennepin County, Downtown St. Paul, Southwest Downtown St. Paul, and South East Downton St. Paul in Ramsay County, and outlying rural areas in Rice County.

Conclusion:
Small-area geographies based on residential zip code appear to stratify the achievement of risk factor targets for diabetic patients in Hennepin, Ramsey and Rice Counties. Patients living in socioeconomically disadvantaged areas are less likely to achieve these clinical targets. Policies to improve cardiovascular risk factor control within clinics should also consider expanding their data collection to include the role of patients’ neighborhood environment.
Abstract 175: Longer Term Follow Up of the Population Health Impact of Cardiac E-Consults
Authors: Wasfy Jason H , Rao Sandhya K , Kalwani Neil , Chittle Melissa D , Richardson Calvin A , Gallen Kathleen M , Isselbacher Eric M , Ferris Timothy G
Published: July 2021

Background:
Cardiac e-consults may be an effective way to deliver value-oriented outpatient cardiology care in an accountable care organization (ACO). Initial results of cardiac e-consults have demonstrated high satisfaction among both patients and referring providers, no known adverse events, and low rates of diagnostic testing. Nevertheless, the effects of e-consults over time for population health are unknown.

Methods:
We established a cardiac e-consult program on January 13, 2014. To determine impact of cardiac e-consults over time, we conducted detailed chart reviews of all patients with greater than 6 months elapsed after the e-consult. We also identified referrals from primary care providers to cardiologists through an electronic referral system. We compared patient age and gender between e-consults and traditional consults with t-tests and chi-squared tests respectively.

Results:
From January through July 2014, 100 e-consults were requested. Of those, 14 e-consults were immediately refused and converted to a traditional cardiology visit. Of the 86 e-consults actually performed, 11/86 (12.8%) recommended an in-person cardiology visit. In 10/86 (11.6%) cases, the patient eventually had a traditional cardiology visit without a visit recommended. In 65/86 (75.6%) cases, the patient did not have any type of traditional cardiology visit within at least 6 months of follow up.

From January to December 2014, 1642 traditional referrals and 165 e-consults were requested. The proportion of e-consults of all evaluations requested was 9.1%. Gender balance was similar among traditional consults and e-consults (44.8% male for e-consults vs. 45.0% for traditional consults, p = 0.981). E-consult patients were younger than traditional consult patients (55.0 vs. 60.4 years, p < 0.001). Distribution of e-consults and traditional consults by age is shown in Figure 1.

Conclusions:
E-consults may be an effective mechanism to enhance value in outpatient cardiology care, with low rates of bounceback to traditional consults. E-consults can account for one-tenth of total outpatient consultation volume over one year within an accountable care organization.
Abstract 202: The NIH Stroke Scale Can Miss Improvement After IV tPA For Acute Ischemic Stroke
Authors: Marsh Elisabeth B , Lawrence Erin , Llinas Rafael H
Published: July 2021

Background and Objective:
The National Institute of Health Stroke Scale (NIHSS) is the most commonly used metric to evaluate stroke severity and improvement following intervention. Despite its advantages as a rapid, reproducible screening tool, it may be too insensitive to adequately capture functional improvement following treatment. We evaluated the difference in rate of improvement by previously accepted criteria (change of ≥4 NIHSS points) versus physician documentation in patients receiving IV tissue plasminogen activator (tPA) for acute ischemic stroke.

Methods:
Prospectively collected data on all patients receiving IV tPA over a 15 month period were retrospectively reviewed. NIHSS 24 hours post-treatment and on discharge were extrapolated based on examination and compared to NIHSS on presentation. NIHSS scores at post-discharge follow-up were also recorded. Two reviewers evaluated the medical record and determined improvement based on physician documentation. Using tests of proportion, ‘significant improvement’ by NIHSS was compared to physician documentation at each time point.

Results:
Forty-one patients were treated with IV tPA. The mean admission NIHSS was 8.6 and improved to 6.4 24 hours post-tPA. Twenty-nine of 41 patients (79%) were “better” by documentation; however only 11/41 (27%) met NIHSS criteria for improvement (p compared to documentation <0.001). On discharge, 20/41 patients (49%) met NIHSS criteria for improvement; however a significant difference between physician documentation remained (p=0.04). The mean post-discharge follow-up NIHSS score was 2.0. 20/21 patients (95%) were “better” compared to 16/21 (76%) meeting NIHSS criteria (p=0.08).

Conclusion:
The NIHSS may inadequately capture functional improvement post-treatment, especially in the days immediately following intervention.