bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 12622: Pro-inflammatory Urinary CXCL10 and VCAM Are Elevated After Infant Cardiac Surgery-associated Acute Kidney Injury (AKI)
Authors: Levy- Erez Daniella , Shah Lokesh , Howarth Kathryn D , Meloni Sherin , Laskin Benjamin , Sullivan Kathleen E , BLINDER Joshua J
Published: May 2021

Introduction:
Acute kidney injury (AKI) occurs frequently after infant cardiac surgery and is associated with mortality. AKI mechanisms are unknown, limiting therapeutic targets. Emerging data implicates unregulated immune activation and AKI development.

Hypothesis:
Urinary immune biomarkers will be elevated in the urine of infants developing AKI.

Methods:
One hundred and twenty six infants were enrolled (median age 87 days, 74% male). Urine samples were collected pre-bypass and 6, 24, 48, and 72 hours after surgery. Urine samples underwent multiplex Luminex assays to detect six immune biomarkers: VCAM, CXCL10, MCP, IL-18, TWEAK, and C5-C9. Greater than 150% increase in serum creatinine defined AKI. The Kruskal-Wallis rank test determined the relationship between AKI and biomarker levels.

Results:
Thirty-five infants (27%) developed AKI. AKI subjects were younger (median 6 days (4-98) vs no AKI 107 days (7-164), p<0.01). The AKI group had more complex surgery (STAT 4-5) (60% AKI vs 19% no AKI, p<0.01). Bypass time was longer among the AKI group ((81 min vs 69 min (p<0.01)).AKI infants had higher urinary CXCL10 levels at 24 hours (14.3 pg/ml vs 5.3 pg/ml p=0.04), 48 hours (3.4 pg/ml vs 0.75 pg/ml p=0.01), and 72 hours (1.15 pg/ml vs 0.22 pg/ml p=0.05) (Figure 1). Six-hour VCAM levels were higher among AKI infants (Median 491 pg/ml vs 0 pg/ml p=0.04). Other biomarkers showed no significant differences between groups. (Table1).

Conclusions:
Urinary CXCL10 and VCAM are promising pro-inflammatory biomarkers for early AKI detection and may indicate eventual AKI therapeutic targets.
Abstract 12624: Pathological Analysis Reveals Causes of Poor Patency After Endovascular Therapy for Below-the-knee Lesions
Authors: Inoue Katsumi , Tomoi Yusuke , Soga Yoshimitsu , Ando Kenji , Kimura Takeshi
Published: May 2021

Introduction:
Endovascular therapy for below-the-knee (BTK) lesions often ends in unsatisfactory outcomes not only by balloon angioplasty (BA) alone but also by adding drug-eluting stent (DES) implantation to BA. We assessed the hypothesis that a histopathological analysis of the amputated tissues would reveal the causes of poor patency after BTK endovascular therapy.

Methods:
We examined tissue specimens from BTK lesions obtained by surgical resection after BA alone (n = 15) and after BA and DES implantation (n = 9). All of them were 100 mm or more in length and had rapid worsening of distal leg ischemia within three months after successful revascularization. More than 60% of them had chronic total occlusion. DESs for coronary arteries of similar sizes were repurposed and used for BTK arteries (drug type: everolimus; size: 2.5-3.0 mm х 28-38 mm).

Results:
Histologically, severe atherosclerosis and intimal-medial calcification were observed in all specimens. Many cases treated by BA alone suffered large semilunar dissection caused by guide-wire failure via the true lumen. There were cases where initial luminal expansion was impaired by vessel shrinkage, in which significant intimal-medial disruption, medial dissection, and massive thrombus formation were observed. Also, there were cases where remarkable lumen loss was caused by neointima formation with a considerable amount of smooth muscle cells and proteoglycan. All cases treated by BA and DES implantation suffered total lumen occlusion due to thrombi which were organized by moderate smooth muscle cell proliferation. Their proximal edge segments had moderate to severe intimal hyperplasia caused by balloon dilatation. Three DESs implanted in the middle portion of the BTK lesions were markedly deformed under compression by the surrounding muscles.

Conclusions:
After BTK endovascular therapy, cases treated by BA alone had poor patency due to insufficient luminal expansion, whereas those treated by BA and DES implantation had organized thrombus formation caused by slow and limited flow inside the DES due to intimal hyperplasia in the proximal segment. Smooth muscle cell proliferation inside the DES may be inhibited by the effect of the drug coated on the DES.
Abstract 12625: Promoting Health Equity in Female San Joaquin South Asian Population
Authors: Siddiqui Maha
Published: May 2021

Introduction:
South Asians (SA) have a higher death rate than any other population for cardiovascular disease (CVD) and high blood pressure (HBP). 1 out of 4 women die of heart disease in America. San Joaquin (SJ) has a growing rate of SA immigrant women who may be at risk for CVD.

Objectives:
Trainees conducted hypertension and CVD screenings at SA religious organizations to reduce the risk of CVD and spread awareness about the factors that lead to CVD and its implications in the SA female population due to environmental racism in the most underserved county for healthcare, SJ.

Methods:
I trained low-income minority medically ambitious female high school students to conduct weekly blood pressure screenings and serve as a health technology coach by each student monitoring 1 female hypertensive patient of 24 hypertensive or at risk hypertensive and low-income female SJ residents and constantly stressed, and at risk for CVD. CVD screenings were conducted at all SJ gurdwaras and mosques to spread awareness about female heart health and track hypertension in the SA community.

Findings:
-74.2% of the San Joaquin South Asian female population (SJSAFP) are at risk for CVD-52.9% of the SJSAFP are Stage 1 hypertensive-60.9% of the SJSAFP are Stage 2 hypertensive-22.4% of the SJSAFP have normal blood pressure but consume red meat more than 4 times a month-16.3% of the SJSAFP female population of SJ are hypotensive

Direct Outcomes of Events:
-Development of self advocacy in the SJSAFP community and females became activists for their own heart health-SJ female high school students trained for community outreach events and determined to practice medicine in SJ to address female health disparities-Youth learned the value of empathy, multiculturalism, gender health equity and service to disadvantaged communities through the program and volunteering-Increased participation of youth and women, in an otherwise adult and male dominant environment (i.e. the mosques and gurdwaras)-Increased awareness on the determinants of CVD and hypertension in SJSAFP-Increased interaction between community members of different religions, creed and genders -Awareness and education among the SJSAFP community for better heart health-Improved patient provider trust
Abstract 12901: Novel Oral Anticoagulants Are Associated With Decreased Recurrence of Venous Thromboembolism in Patients With Cancer: An Updated Meta-Analysis
Authors: Upadhaya Sunil , Madala Seetharamprasad , Badami Sunil
Published: May 2021

Introduction:
Patients with cancer are at high risk for recurrent thromboembolic phenomenon. Use of novel oral anticoagulants (NOAC) for treatment of venous thromboembolism (VTE) in such patients is controversial. We conducted this updated meta-analysis to evaluate the pooled efficacy and safety of NOAC in patients with cancer.

Methods:
We did systematic search of PubMed and Cochrane library databases for randomized controlled trials comparing NOAC with low molecular weight heparin (LMWH) for VTE treatment in cancer patients till April 2020. The efficacy outcomes were recurrent VTE and all-cause mortality rates, and the primary safety outcome was incidence of major bleeding rate.

Results:
Four randomized controlled studies comparing NOAC with LMWH (1446 patients in NOAC group and 1448 patients in LMWH group) were included in our study. Use of NOAC lead to significant reduction in recurrent VTE rate (odds ratio (OR): 0.55 [0.36-0.84], I
2
= 45 %, p value = 0.006) (Figure 1). However, we did not find any significant difference in rate of major bleeding (OR: 1.30 [0.76-2.23], I
2
= 35%, p value = 0.34) (Figure 2) and all-cause mortality (OR: 1 [0.80 - 1.26], I
2
= 33%, p value = 0.98).

Conclusions:
This updated meta-analysis showed comparatively lower pooled recurrent VTE rate in patient being treated with NOAC, whereas similar rates of major bleeding and all-cause death. NOAC are more efficacious and has similar safety profile compared with LMWH.
Abstract 12910: Use of Optimal Medical Therapy in Patients With Cardiovascular Disease Undergoing Cardiac Rehabilitation
Authors: Jafri S Hammad , Huschsa Pavel , Bousquet Gisele , Lindsay Sonis , Christine Lutfy , Dorbala Pranav , Blankstein Ron , Cannon Christopher P , Plutzky Jorge , Polk Donna , Skali Hicham
Published: May 2021

Introduction:
Optimal Medical Therapy (OMT) in patients with Coronary Artery Disease (CAD) or Heart Failure (HF) is underused despite known benefits. The rate of OMT use among patients enrolled in Cardiac Rehabilitation (CR) is not well known.

Purpose:
To describe prevalence and characteristics of OMT use in patients with CAD or HF undergoing CR.

Methods:
CAD patients were defined as those with prior MI, PCI, CABG, or angina. OMT for CAD patients required all currently guideline-recommended medications (aspirin or antiplatelet, statins, beta-blockers (BB); and ACEi/ARB for concurrent HF or DM). The HF group included patients referred to CR for HFrEF or for another indication and had documented left ventricular systolic dysfunction (LVEF<40%, echocardiography). OMT for HF required BB, spironolactone and either ACEi/ARB or Angiotensin Receptor Neprilysin Inhibitor (ARNI) use. Predictors of OMT were identified using with multivariable logistic regression.

Results:
From January 2015 to December 2019, 612 patients (mean age: 65, 23% female) with CAD were enrolled in CR, with 483 (79%) patients meeting all OMT criteria. CAD patients on OMT were more likely to have hypertension (85%), hyperlipidemia (94%) but less angina (8%). Prior MI, hypertension, hyperlipidemia, and 6-minute walk distance were significantly associated with OMT use.Of 131 HF patients (mean age: 64, 21% female) enrolled in CR, 23 (18%) met all 3 OMT criteria—99 (76%) and 128 (98%) patients met only 2 or 1 of OMT criteria, respectively. Use of spironolactone (least prescribed), ARNI, and ACEi/ARBs all increased over the study period. Study limitations include lack of control for contraindications to medications.

Conclusion:
Although it has improved over time, OMT use remains low (HF 18%, CAD 79%) among patients enrolled in CR. CR may represent a unique opportunity to enhance OMT use.
Abstract 12917: Prognostic Value of the Combination of Model for End-stage Liver Disease Excluding Inr Score and Non-alcoholic Fatty Liver Disease Fibrosis Score in Patients Admitted for Acute Heart Failure
Authors: Kawahira Masatsugu , Yamada Takahisa , Watanabe Tetsuya , Morita Takashi , Furukawa Yoshio , Tamaki Shunsuke , Kawasaki Masato , Kikuchi Atsushi , Kawai Tsutomu , Seo Masahiro , Nakamura Jun , Kayama Kiyomi , Fukunami Masatake
Published: May 2021

Background:
Cardiohepatic interactions have been a focus of attention in heart failure(HF), and the model for end-stage liver disease excluding INR (MELD-XI) has been shown to be useful for prediction of poor outcome in patients (pts) with acute decompensated heart failure (ADHF). Furthermore, it has been reported that liver stiffness predicts adverse prognosis in pts with HF. Liver fibrosis is assessed by non-invasive fibrosis markers such as Fibrosis-4 (FIB4) index, non-alcoholic fatty liver disease fibrosis score (NFS) and aminotransferase to platelet ratio index (APRI). Recently, a new group of HF pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is little information available on the comparison of prognostic significance of MELD-XI and liver fibrosis scores in ADHF pts, relating to LVEF.

Methods:
We prospectively studied 466 consecutive ADHF pts (HFrEF (LVEF≦40%): n=164, HFmrEF (40<LVEF<50): n=104 and HFpEF (LVEF≧50%): n=198). At the discharge, we calculated MELD-XI, FIB4 index , NFS, and APRI. The endpoint was all cause death (ACD).

Results:
During a follow-up period of 2.8±1.5 years, 143 pts had ACD. At multivariate Cox analysis, MELD-XI and FIB4 index was independently associated with ACD irrespective of LVEF. The pts with both greater MELD-XI ([HFrEF]≥25.8, [HFmrEF]≥33.2, [HFpEF]≥30.1) and greater FIB4 index ([HFrEF]≥2.58, [HFmrEF]≥2.58, [HFpEF]≥2.22) had a significantly increased risk of ACD than those with either and none of them in all three groups.

Conclusions:
The combination of MELD-XI and FIB4 index might be useful for stratifying pts at risk for ACD in ADHF pts with irrespective of LVEF.
Abstract 12938: An Unusual Case of Malignant Hypertension and Stress Cardiomyopathy Originating From the Urinary Bladder
Authors: Rao Anjali , Vongpatanasin Wanpen
Published: May 2021

A 39-year-old man with hypertension presented for an elective knee surgery. Within 15 minutes of induction of anesthesia, he developed malignant hypertension and acute hypoxia. Surgery wasaborted and he was subsequently transferred to our facility. High-sensitivity troponin was elevated. Chest X-ray demonstrated bilateral hilar opacities, consistent with pulmonary edema.Transthoracic echocardiography demonstrated mildly depressed left ventricular function with hypokinesis of the septum and inferolateral wall. Cardiac catheterization showed normal filling pressures and no coronary artery disease. Initial work up for secondary hypertension, including Duplex Doppler ultrasonography of renal artery and serum aldosterone level were unrevealing. Because of high index of suspicion, additional workup was pursued for adrenal hypertension. Hewas found to have severely elevated plasma normetanephrine level (36 nmol/L) and 24-hrurinary normetanephrine of 8,990 mcg while plasma metanephrine and epinephrine levels were within normal limits. Computed tomography of abdomen showed no adrenal mass but revealed contrast-enhancing mass in the bladder wall with surrounding lymphadenopathy, suggestive of metastatic paraganglioma. He underwent genetic evaluation which identified a heterozy gouspathogenic variant in the succinate dehydrogenase subunit B (SDHB) gene. He was treated withalpha- and beta-blockade and underwent partial cystectomy with lymph node dissection. Follow-up Gallium-68 DOTATATE scan was positive for uptake in several lymph nodes withsubsequent successful lymph node dissection. He is now asymptomatic.

Discussion:
This case illustrates the importance of a complete history in the evaluation of hypertension inyoung people. The presence of labile hypertension and acute cardiomyopathy which isprecipitated by stress or noncardiac surgery should prompt an evaluation of pheochromocytoma.The isolated elevation in plasma and urinary normetanephrine with normal plasma/urinarymetanephrine level is consistent with extra-adrenal production of catecholamines, which iscommon in the presence of SDHB mutation.
Abstract 12941: Long-term Prognostic Value of Cardiac Metaiodobenzylguanidine Imaging and Non-sustained Ventricular Tachycardia in Patients With Implantable Cardioverter Defibrillator
Authors: Kawasaki Masato , Yamada Takahisa , Watanabe Tetsuya , Morita Takashi , Furukawa Yoshio , Tamaki Shunsuke , Kikuchi Atsushi , Kawai Tsutomu , Seo Masahiro , Nakamura Jun , Kawahira Masatsugu , Kayama Kiyomi , Ueda Kunpei , Kimura Takanari , Sakamoto Daisuke
Published: May 2021

Background:
Cardiac MIBG imaging provides prognostic information in patients with chronic heart failure (CHF). Recent studies showed that the highest occurrence of severe arrhythmic events (SAE) was seen in CHF patients with an intermediate decrease in MIBG uptake rather than the lowest values. On the other hand, non-sustained ventricular tachycardia (NSVT) has been shown to be associated with SAE in CHF patients. However, there is little information available on long-term prognostic value of intermediate decrease in MIBG up take and NSVT for the prediction of severe ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) patients.

Methods and Results:
We prospectively enrolled 201 consecutive outpatients with ICD (age: 64±14 years, male: 81%, NYHA class:1.7±0.7, LVEF: 49±17%). At entry, all patients underwent cardiac MIBG imaging and 24-hour Holter electrocardiogram monitoring. An intermediate decrease in heart-to-mediastinum ratio on delayed planar image (H/M) was defined as 1.40-1.89. NSVT was defined as consecutive 3 or more beats and more than 100 bpm. During a follow-up period of 4.0±2.5 years, 59 patients had appropriate ICD discharge for severe ventricular tachyarrhythmias. At multivariate Cox regression analysis, intermediate decrease in H/M and NSVT were significantly and independently associated with appropriate ICD discharge after adjustment with age, sex and low left ventricular ejection fraction (≤35%). Appropriate ICD discharge was significantly more frequently observed in patients with both intermediate decrease in H/M and NSVT and with either intermediate decrease in H/M or NSVT than with none of them (47% vs 36% vs 14%, p<0.0001).

Conclusions:
Combination of cardiac MIBG imaging and NSVT would be more strongly associated with an increased risk for severe ventricular tachyarrhythmias in ICD patients.
Abstract 12964: Complete Revascularization of Stable Patients Presenting With STEMI is Associated With Decreased Cardiovascular Death and Reinfarction If Performed During Index Percutaneous Coronary Intervention, but Not If Complete Revascularization is Staged
Authors: Cerrud-Rodriguez Roberto C , Rashid Syed Muhammad Ibrahim , Katsa Ioanna , Garcia Mario J , Latib Azeem
Published: May 2021

Introduction:
Recent evidence suggests that complete revascularization (CR) of stable patients presenting with STEMI improves outcomes, but the appropriate timing of said CR has not been clearly established (CR during index PCI [iCR] versus staged CR [sCR]). sCR is defined as CR within a mean of 31.5±24.6 days after the STEMI.

Objective:
To determine the appropriate timing of CR for it to be beneficial (iCR versus sCR).

Methods:
A systematic review of Medline, Cochrane, and Embase was performed for randomized control trials (RCTs) that reported outcomes of stable patients presenting with STEMI and whose culprit lesion received PCI, who were subsequently randomized into culprit-lesion only and CR cohorts. Only RCTs with at least a 12-month follow-up were included. The timing of CR, for the subdivision of CR cohort into iCR and sCR, had to be stated. Seven RCTs comprising 6647 patients (mean age: 62.9±1.4 years, male sex: 79.4%) met this criteria and were included.

Results:
After a mean follow-up of 25.1±9.4 months, iCR, when compared to a culprit-lesion only strategy, was associated with a significant cardiovascular mortality benefit (Risk Ratio [RR] 0.48 95% Confidence Interval [CI] 0.26-0.90 p=0.02, Relative Risk Reduction [RRR] 52%) and a significant decrease in reinfarctions (RR 0.42 95% CI 0.25-0.70 p=0.001 RRR: 58%). sCR showed no significant benefit for any of the studied outcomes when compared to a culprit-lesion only strategy. There was no significant difference in all-cause mortality or in the composite safety outcome of contrast-induced nephropathy nor stroke in either the iCR or the sCR groups when compared to the culprit-lesion only group.

Conclusion:
Complete revascularization during index PCI of stable patients presenting with STEMI, but not staged CR, is associated with a statistically significant decrease in cardiovascular death and non-fatal reinfarctions. There is no difference between groups in all-cause mortality or in the composite safety outcome.
Abstract 12975: A New Systemic Inflammation-nutrition Index Provides the Additional Long-term Prognostic Information to Ahead Score in Patients With Admitted for Acute Decompensated Heart Failure
Authors: Yamada Takahisa , Watanabe Testuya , Morita Takashi , Furukawa Yoshio , Tamaki Shunsuke , Kawasaki Masato , Kikuchi Atsushi , Kawai Tsutomu , Seo Masahiro , Nakamura Jun , Kayama Kiyomi , Kawahira Masatsugu , Ueda Kumpei , Kumura Takanari , Fukunami Masatake
Published: May 2021

Background:
Comorbidities are associated with poor clinical outcome in heart failure patients. AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes in patients with acute decompensated heart failure (ADHF). On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index х serum albumin / neutrophil to lymphocyte ratio, is an independent prognostic marker in several types of cancer. We sought to investigate the prognostic value of the combination of AHEAD score and ALI in ADHF patients.

Methods and Results:
We studied 263 patients admitted for ADHF and discharged with survival. At the discharge, we obtained ALI and AHEAD score (range 0-5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus). During a follow-up period of 5.0±4.2 yrs, 67 patients had cardiovascular death (CVD). At multivariate Cox analysis, AHEAD score and ALI were significantly independently associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and serum sodium level. The patients with both greater AHEAD score (≥median value=3) and lower ALI (≤median value=42.3) had a significantly increased risk of CVD than those with either and none of them (45% vs 24% vs 13%, p<0.0001, respectively).

Conclusion:
ALI would provide the additional long-term prognostic information to AHEAD score in patients with ADHF.
Abstract 12976: Higher Triglyceride Level is Associated With Higher Frequency of Macrophage Accumulation in Coronary Plaques
Authors: Asakura Kiyoshi , Minami Yoshiyasu , Katamine Masahiro , Kato Ayami , Katsura Aritomo , Sato Toshimitsu , Muramatsu Yusuke , Hashimoto Takuya , KAMEDA RYO , Meguro Kentaro , Shimohama Takao , Ako Junya
Published: May 2021

Introduction:
The impact of high triglyceride (TG) level on the characteristics of coronary plaque remains to be elucidated.

Hypothesis:
Higher TG level is associated with higher prevalence of vulnerable coronary plaque in patients with coronary artery disease (CAD).

Methods:
A total of 865 consecutive patients who underwent optical coherence tomography (OCT) imaging of the culprit lesion were included. Patients were classified into either the higher TG group (non-fasting TG ≥ 200 mg/dL, n=150) or the lower TG group (non-fasting TG < 200 mg/dL, n=715). The morphologies of culprit plaque assessed by OCT were compared between the two groups.

Results:
The median (interquartile range) of TG in the 2 groups was 265.5 (221.5 – 314.8) mg/dL and 115.0 (84.0 – 152.0) mg/dL, respectively. The frequency of macrophage accumulation was significantly higher in the higher TG group than the lower TG group (41 vs. 33%, p=0.043) (Panel A), whereas the prevalence of other plaque components including thin-cap fibroatheroma (22 vs. 19%, p=0.386), microchannel (24 vs. 25%, p=0.907) and cholesterol crystal (23 vs. 23%, p=0.862) was comparable between the two groups. The incremental frequency of macrophage accumulation according to TG levels was observed (p=0.015, Panel B). Although the frequency of macrophage accumulation was comparable between the 2 groups among patients with a higher HDL cholesterol (HDL-C) level (>35 mg/dL), macrophage accumulation was significantly more frequent in the higher TG group than in the lower TG group (71 vs. 41%, p=0.032) among patients with a lower HDL-C level (≤35 mg/dL).

Conclusions:
Higher TG level was associated with higher frequency of macrophage accumulation in culprit plaques in patients with CAD. The present results may partly explain the role of TG on the development of culprit plaque in coronary artery.
Abstract 13006: Digital Diabetes Prevention Program Reduces Medical Costs in the First 2 Years of Implementation in a Workplace Setting
Authors: Birse Charles E , Iakoubova Olga A , Arellano Andre R , Fragala Maren S , Bare Lance A , Castro Sweet Cynthia M , Lagier Robert J
Published: May 2021

Introduction:
The Diabetes Prevention Program (DPP) was shown to reduce body weight and lower incidence of diabetes in a cost-effective manner. Digital versions of the DPP (dDPP) have recently been implemented and shown to reduce body weight and other risk factors for chronic disease. We asked whether implementation of a dDPP in a workplace setting would reduce medical costs.

Methods:
Employees and spouses of a nation-wide medical diagnostic provider were eligible to participate in dDPP (Omada Health) if they had prediabetes (fasting glucose 100 to 125 mg/dL or HbA
1C
5.7% to 6.4%) and BMI ≥25 kg/m
2
at baseline (September to December 2017), and were continuously enrolled in a health plan from September 2016 to December 2019. Of those eligible (n=3,098), 432 participated and completed ≥1 lesson (dDPP group). A control group (n=856) was matched to the dDPP group by baseline age, sex, race, geography, comorbidities, health plan type, and medical and prescription costs. Generalized estimating equations adjusted for age, race and BMI were used to obtain all estimates. Allowed costs from administrative claims data were evaluated per member per month (PMPM); dDPP costs were not included.

Results:
In the control group, costs were higher in the post-dDPP period (2017-2019) compared to the pre-dDPP period (2016-2017) for inpatient ($124 vs $64,
P=
0.01), prescription ($183 vs $155,
P
=0.02), and total ($696 vs $558,
P
<0.001; Figure). In the dDPP group, no changes were observed. Changes in total costs (post-dDPP minus pre-dDPP) were lower in the dDPP group than the control group, with a saving of $141 PMPM (
P
=0.02; Figure).

Conclusion:
In the first two years of dDPP implementation, medical costs were unchanged in dDPP participants but higher in matched controls.
Abstract 13035: Beta3-Adrenergic-Receptor-Deficient Mice Protected From Diabetic Cardiomyopathy in Type 2 Diabetic Murine Model: Beneficial Effects on Cardiomyocyte Contractile Function, [Ca
2+
]
i
Regulation and Beta-Adrenergic Modulation
Authors: Sun Xiaoqiang , Cao Jing , Cheng Heng-Jie , Liu Yixi , Chen Zhe , McClain Donald A , Kitzman Dalane , Zhao David , Cheng Che
Published: May 2021

Background:
Diabetic cardiomyopathy (DCM) is the main cause of increased mortality in Diabetes mellitus (DM). There are no effective therapeutic strategies. Recently, we found that DM is associated with the upregulation of β
3
adrenergic receptor (AR) mediated cardiac inhibitory pathway. This suggests cardiac β
3
-AR activation may contribute to DCM progression and be a therapeutic target. We hypothesize that upregulation of β
3
-AR is maladaptive, and DM-caused progressive decline in cardiac function and β-adrenergic reserve will be prevented in β
3
-AR knockout (β
3
KO) mice.

Methods:
Studies were conducted in female mice of 2
Vehicle controls
groups (n=8/group) of wild-type (CWT) and Cβ
3
KO, and 2
Type 2 DM (T2)
of T2WT (n=8) and T2β
3
KO (n=6).T2 was induced by fed high-fat diet (HFD) for 14 weeks (W), but after HFD for 4 W receiving streptozotocin (STZ, 40 mg/kg/day, i.p. for 5 days). We compared LV myocyte contractile and [Ca
2+
]
iT
responses to β-AR subtype stimulation by random exposure of myocytes to the superfusion of isoproterenol (ISO,10
-8
M) or a selective β
1
-, or β
3
-agonist, Norepinephrine (NE, 10
-7
M), and BRL-37,344 (BRL, 10
-8
M), respectively.

Results:
Mice received HFD plus STZ developed T2DM with elevated mean blood glucose from 128 mg/dl of control to 388 mg/dl and 382 mg/dl in T2WT and T2β
3
KO, respectively. However only T2WT mice developed DCM followed by significant decreases in myocyte contraction (dL/dt
max
, T2WT: 74.8 vs CWT:140.1 μm/s), relaxation (dR/dt
max
, 58.0 vs 117.9 μm/s) and [Ca
2+
]
iT
(0.16 vs 0.22). ISO-stimulated increases in dL/dt
max
(37% vs 58%), dR/dt
max
(30% vs 53%), and [Ca
2+
]
iT
(19% vs 30%) were attenuated accompanied by a diminished NE-caused increase in dL/dt
max
(28% vs 41%), but enhanced BRL-induced decrease in dL/dt
max
(29% vs 15%). By contrary, T2β
3
KO showed normal basal dL/dt
max
(137.6 μm/s), dR/dt
max
(111.4 μm/s) and [Ca
2+
]
iT
(0.22). Importantly, T2β
3
KO myocytes showed preserved ISO-stimulated increases in dL/dt
max
(60%), dR/dt
max
(51%) and [Ca
2+
]
iT
(32%) and restored normal dL/dt
max
responses to NE (41%).

Conclusions:
β
3
KO prevents T2DM-caused contrast changes in β
1
- and β
3
-AR-stimulated cardiac inotropic actions and leading to the preservation of normal myocyte function, [Ca
2+
]
iT
, and β-AR responsiveness in DCM.
Abstract 13060: Calcified Left Atrium: A Therapeutic Challenge for Atrial Fibrillation
Authors: Khatiwala Roshni V , applegate patricia , Srivatsa Uma N , Fan Dali , Pezeshkian Nayereh , Oesterle Adam
Published: May 2021

Background:
Myocardial calcium deposits are common in patients with end stage renal disease (ESRD) but present a challenge in patients with atrial fibrillation (AF) and may limit ablation success with currently available energy sources, while increasing stroke risk during ablation.
Obective:
We describe a challenging case of symptomatic AF management in a patient with a calcified (coconut) left atrium (LA).

Methods:
N/A

Results:
A fifty year old woman with ESRD, seen for longstanding symptomatic paroxysmal AF and AF induced hypotension during hemodialysis (HD). She had cardioverted with calcium channel blockers and amiodarone previously and was maintained on metoprolol and amiodarone. She was admitted for symptomatic atrial flutter and underwent an attempted ablation. Trans-esophogeal echocardiogram (TEE) before ablation demonstrated a dilated and severely calcified/coconut LA (figure). Despite extensive radiofrequency ablation, bi-directional block could not be achieved across the cavo-tricuspid isthmus even with disappearance of the local electrograms and non-induciblity at the end of the case. She continues to have symptomatic AF on amiodarone and hypotension at HD and AF ablation is considered unlikely to be successful with an increased complication rate.

Conclusion:
Porcelain LA has been reported in literature in patients with AF and ESRD. There is no contemporary data on AF management or ablation in these challenging patients and further clinical investigation is needed to determine the feasibility and safety of ablation. Performing pre-operative TEEs in all patients with ESRD is reasonable to assess for LA calcification prior to trans-septal puncture and LA ablation.
Abstract 13065: Blood Pressure Response to Treadmill Cardiopulmonary Exercise Testing in Children With Normal Hearts
Authors: Sasaki Takeshi , Kawasaki Yuki , Takajo Daiji , Ross Robert D , Kobayashi Daisuke
Published: May 2021

Background:
Blood pressure (BP) response to the treadmill cardiopulmonary exercise test (CPET) has yet been studied with no standard criteria for abnormal BP responses in children. Our hypothesis was that the reference values of BP responses to the treadmill CPET should be defined by gender and age in children.

Objectives:
The objective of our study was to describe the BP responses to the treadmill CPET and propose the criteria for abnormal BP responses in children.

Methods:
The treadmill CPET data were retrospectively analyzed to evaluate the BP responses to exercise during the period of 8 years (2011-2018). Children aged <18 years with normal hearts were included for the analysis.

Results:
Our cohort consisted of 1,085 children (males 59%) aged 7-17 years. The analysis of variance for Systolic BP at peak exercise (peak SBP) and change (Δ) of SBP showed significant age and gender effects and age-gender interaction effect (
p
<0.01). In the multiple linear regression model (
p
<0.001), peak SBP (mmHg) was predicted as 100.39 + 4.68 x age (years) for males; 132.27 + 1.37 x age (years) for females. The following criteria for abnormal BP responses in children were proposed. Hypertensive BP response were defined by peak SBP >90% confidence interval upper limit of reference values based on age and gender. Blunted BP response was defined by 1) ΔSBP <10 mmHg for age 7-11 years and <20 mmHg for age 12-17 years in males; and ΔSBP <10 mmHg in females.

Conclusion:
Blood Pressure response to the treadmill CPET was dependent on age and gender in children with normal hearts. The proposed criteria for abnormal BP responses in children should prove useful in interpreting BP responses in children during the CPET.
Abstract 13084: Epsilon Waves on Electrocardiograms in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy: Relationship to Left Ventricular Invasion or Heart Compression Due to an Enlarged Right Ventricle
Authors: FUNABASHI Nobusada , Kobayashi Yoshio
Published: May 2021

Introduction:
Epsilon waves on V1-3 leads are known as one of the specific lead ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) that suggests the presence of RV conduction delay. Four dimensional (4D) cardiac CT visualizes ARVC characteristics, such as fat and fibrotic invasion in RV (RVM) and left ventricular (LV) myocardium (LVM), an enlarged RV, reduced RV motion, and bulging.

Hypothesis:
If epsilon waves are observed in V4-6 leads, this finding suggests the occurrence of LV invasion in ARVC. Another hypothesis exists in which extreme RV enlargement may compress the LV and cause clockwise rotation; an enlarged RV itself may cause epsilon waves in V4-6 leads.

Methods:
This is a retrospective analysis of 17 patients (11 males, 57 ± 17 years) with suspected ARVC who underwent cardiac CT. On 4D CT, nine met 2010 ARVC task force criteria.

Results:
All nine patients had epsilon waves on ECG. Five had fat and fibrotic invasion in the LVM but four did not. We divided nine into the following five groups by CT findings. On CT, a markedly enlarged RV compressed the LV to the left side and a fibro fatty change were observed exclusively in RVM (gp 1, N=1) or were observed in both RVM and LVM (gp 2, N=2). A moderately enlarged RV without compression of the LV to the left side and a fibro fatty change were observed exclusively in RVM (gp 3, N=3), or observed in both RVM and LVM (gp 4, N=2). The complications of severe mitral valve regurgitation, a markedly enlarged LV, and a fibro fatty change were observed in both RVM and LVM (gp 5, N=1). A patient in gp 1 showed epsilon waves in V1-6 leads. Patients in gp 2 showed epsilon waves in V1-6 (N=1), and V3-5 (N=1) leads, respectively. Patients in gp 3 showed epsilon waves in V1-4 (N=2), and V1-3 (N=1) leads, respectively. Patients in gp 4 showed epsilon waves in V1-3 (N=1), and V1, 2 (N=1) leads, respectively. A patient in gp 5 showed epsilon waves in V4-6 leads.

Conclusions:
The distribution of epsilon waves on ECG in patients with confirmed ARVC by cardiac CT was highly influenced by the degree of LV compression due to a markedly enlarged RV on CT rather than the presence of LV invasion. Also, structural change due to complicated heart diseases, such as valvular diseases, may also influence the distribution of epsilon waves in ARVC.
Abstract 13086: Left Atrial Function in Adult With Normally Functioning Bicuspid Aortic Valves
Authors: XIE Mingxing , Wenhui Deng , Jing Wang
Published: May 2021

Background:
Bicuspid aortic valve is a complicated and heterogeneous disease that has aroused great interest in recent years. Traditionally the greatest attention during a routine echocardiography is paid to the function of the ventricles and aortopathy, much less is known about dysfunction the left atrium. The objective of this study was to characterize left atrial strain (LAS) and functions by two-dimensional speckle tracking echocardiography in adult BAV with normally functioning, and interrogate the risk factors.

Methods:
This is a prospective cohort study of 52 patients (age 40.23±11.29 years) and 33 healthy volunteers (aged 39.12±12.74 years) were recruited. All subjects included in both groups were in sinus rhythm and no clinical history of cardiovascular diseases. We mainly assessed left atrial reservoir, pump, and conduit function using 2D STE, then determined relationships among indices of segmental aortic stiffening, BAV cusp fusion pattern, LV diastolic function indices and LA deformation.

Results:
Without adjustment, the indices of LA functions in patients with BAV were significantly decreased compared with controls (LAS 49.41 ± 11.14 vs 59.48 ± 9.53, p<0.001, LAEF 71.56 ± 6.57 vs 76.36 ± 5.72, p=0.001; LAS-passive 29.43 ± 9.42 vs 36.67 ± 9.60, p=0.001, LAEF-passive 43.72 ± 10.78 vs 49.58 ± 6.80, p=0.003). However, after adjustment on age, gender, systolic blood pressure, diastolic blood pressure, BSA ,only the LAS was lowering (p<0.001). With or without adjustment, the ascending aorta of patients with BAV were still stiffer at each segment compared with controls. As parameters of LV diastolic functions, the E/e’ ratio (p=0.01) and e’ value (p=0.01) were significantly altered. The LA volume were increased in BAV patients (59.33 ± 19.12 vs 46.10 ± 9.73). In patients with BAV, LA functions, LV functions and segmental aortic stiffness were not influenced by the Sivere valve types. In multiple regression analysis, the stiffness at the sinus of Valsalva were independently correlated with LAS (adjust R
2
= 0.82, β = -0.33, p<0.001).

Conclusion:
Left atrial dysfunction is common in adult BAV with normally functioning. LA dysfunction is associated with stiffness index at the sinus of Valsalva, and is independent of LV function.
Abstract 13104: The Concomitant Inflammation Affect the Ratio of N-terminal Pro B-type Natriuretic Peptide to B-type Natriuretic Peptide in Patients With Heart Failure and Preserved Ejection Fraction
Authors: Kawai Tsutomu , Yamada Takahisa , Watanabe Tetsuya , Tamaki Shunsuke , Hikoso Shungo , Nakatani Daisaku D , Yano Masamichi , Takaharu Hayashi , Nakagawa Akito , Nakagawa Yusuke , Yasumura Yoshio , Fukunami Masatake , Sakata Yasushi
Published: May 2021

Backgrounds:
Although B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-proBNP ) are interrelated parameters in assessment heart failure severity and prognosis, the ratio of NT-proBNP to BNP (NT-proBNP/BNP) are affected by various clinical factors, such as renal function. However, little is known about the influence of inflammation on NT-proBNP/BNP in patients with heart failure and preserved ejection fraction (HFpEF).

Methods and Results:
Patients data were extracted from PURSUIT-HFpEF registry, which is a multicenter prospective observational study including patients hospitalized for acute heart failure with left ventricular ejection fraction of >50%. Of 871 patients, data of BNP and NT-proBNP was available in 654 patients. The median baseline concentration of BNP was 474 pg/ml (299-720), NT-proBNP was 3310 pg/ml (1740-6840), and NT-proBNP/BNP was 7.6 (5.0-11.8). In multivariable linear regression analyses, older age [odds ratio (OR); 1.05, 95% confidence interval (CI); 1.02-1.09, p=0.001], higher creatinine [OR; 2.63, 95% CI; 1.66-4.16, p<0.001], and higher C-reactive protein (CRP) [OR; 1.17, 95% CI; 1.06-1.28, p<0.001] were significantly associated with a higher NT-proBNP/BNP (>median value of 7.6). However, other factors expected to affect NT-proBNP/BNP, such as atrial fibrillation and body mass index, were not associated with a higher NT-proBNP/BNP in this study. Patients in the highest CRP quartile had significantly higher NT-proBNP/BNP than those with other quartiles.

Conclusion:
In HFpEF patients, concomitant inflammation was associated with high NT-proBNP/BNP, which indicated that we need a careful interpretation on these two natriuretic peptides of patients with HFpEF and inflammatory status, such as infection.
Abstract 13111: Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults With Atrial Fibrillation: Implications for Patient-Provider Communication
Authors: Mehawej Jordy , Saczynski Jane , Abu Hawa O , Bamgbade Benita , Gagnier Marc , Lessard Darleen , Trymbulak Katherine , Saleeba Connor , KIEFE Catarina I , Goldberg Robert , McManus David D
Published: May 2021

Introduction:
Though engaging patients with atrial fibrillation (AF) in the decision-making process for stroke prevention is encouraged by guidelines, little is known about the extent of, and the factors associated with, patient engagement in this process.

Hypothesis:
Patient engagement in shared decision-making (SDM) would be modest and that older participants will less likely engage in SDM for stroke prevention.

Methods:
Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study which enrolled older adults aged 65 years and older with AF from clinics in Massachusetts and Georgia. Participants on an oral anticoagulant (OAC) reported whether they were engaged in the decision to be on an OAC by answering “Yes” to the question: “Did you participate actively in choosing to take an OAC?”. We used multiple logistic regression analysis to examine the sociodemographic, geriatric, psychosocial, and clinical factors associated with patient engagement in SDM for stroke prevention.

Results:
Participants (N= 807) were on average 75 years old and 48% were female. Approximately, 61% engaged in the decision to be on an OAC. Participants aged 80 years and older (aOR= 0.53; 95 % CI:0.31-0.89) and those cognitively impaired (aOR= 0.69; 95 % CI: 0.48, 0.99) were less likely to engage in SDM than respective comparison groups. Participants who reported being very knowledgeable of their AF associated risk of stroke had higher odds of engaging in SDM than those with less knowledge (aOR= 3.06; 95 % CI:1.59, 5.90).

Conclusions:
Clinicians should identify older patients and those who are cognitively impaired who are less likely to engage in SDM for stroke prevention, promote patient engagement, and provide support to ensure sustained engagement that would enhance long-term treatment outcomes for patients with AF.
Abstract 13117: Incorporation of High-Sensitivity Troponin Along With the AHA/ACC Cholesterol Guidelines for Improved Risk Stratification and Targeted PCSK9 Inhibition in Atherosclerotic Cardiovascular Disease
Authors: Marston Nicholas A , Oyama Kazuma , Tang Minao , Jarolim Petr , Sever Peter S , Keech Anthony C , Lira Pineda Armando , Wang Huei , Giugliano Robert , Sabatine Marc S , Morrow David A
Published: May 2021

Introduction:
The 2018 AHA/ACC cholesterol guidelines only recommend PCSK9 inhibitors in patients with very high risk ASCVD. However, high-sensitivity troponin (hsTn) can reclassify some lower risk patients as very high risk, identifying a subgroup who may benefit from PCSK9 inhibitors.

Methods:
We performed a nested prospective biomarker substudy including 22,224 patients enrolled in the FOURIER trial, which tested the PCSK9 inhibitor evolocumab. Per the guidelines, patients were assigned to ASCVD risk categories of “very high risk” or “not very high risk” (lower risk), followed by classification based on hsTnI (Abbott ARCHITECT) using an a priori risk threshold of 6 ng/L. The primary endpoint was a composite of CV death, MI, stroke, unstable angina, or coronary revascularization. The median follow-up was 2.2 years.

Results:
Clinical ASCVD categories alone identified a gradient of risk from 7.1% to 12.3% (HR 1.83, p<0.0001). Adding hsTnI further risk stratified patients by 1.5- to 2-fold in both the lower and very high risk ASCVD categories (HR 1.73, p=0.017 & HR 1.81, P<0.0001). Among patients with lower risk ASCVD, 25% had an elevated hsTnI and carried a similar risk (10.5%) to patients with very high risk ASCVD and low hsTnI (9.8%). Very high risk ASCVD patients receiving evolocumab had an absolute risk reduction of 1.9% (0.98-2.72). A similar absolute risk reduction was seen in the 25% of patients in the lower risk group with elevated hsTnI (ARR 2.0%, Figure).

Conclusions:
Either hsTn or ASCVD clinical criteria can identify patients who benefit from evolocumab. Specifically, hsTnI identifies a significant cohort of nominally lower risk ASCVD patients who are actually at greater risk than appreciated and may derive absolute risk reductions on par with very high risk ASCVD patients.
Abstract 13118: The Use of Automated Daily Reporting Improves Utilization of the HEART Score in Evaluation of Patients With Chest Pain in the Emergency Department
Authors: Bell Kris , Monk Glen , Townes Jeremy , Griffis Kathy , Sigal Stephen L
Published: May 2021

Introduction:
Despite the proven effectiveness of the HEART Score in discriminating the need for further observation versus discharge of patients presenting to the Emergency Department (ED) for evaluation of chest pain, utilization rates remain low in many institutions. One reason frequently cited for failure to use this tool is concern by the ED providers that discharged patients will not receive appropriate follow-up.

Hypothesis:
We hypothesized that the use of a simple daily report (DR) of treated patients would improve utilization rates of the HEART score, and allow for close follow-up of patients discharged from the ED.

Methods:
We created an electronically-generated report which listed all patients presenting to the ED with a complaint of chest pain in a community hospital, along with their HEART score, and their admission or discharge status. The report was provided on a daily basis to the ED medical director, who could provide counseling to providers who were not utilizing the HEART score regularly, and to case management, who could contact each discharged patient to assess their clinical status and ensure that they had appropriate follow-up plans.

Results:
Baseline utilization of the HEART Score in chest pain patients (n=305) over a 4 month period prior to the use of this DR was 51.8%. After instituting the DR, utilization rose to 66% (n=339 patients) over the next four months (p=0.0003). Furthermore, correlation of the numbers of ER discharges vs. patients kept for observation or admitted continued to correlate well with the calculated HEART score.

Conclusions:
The use of a simple DR significantly increased the utilization of the HEART score in the ED of a community hospital to identify patients who could be discharged safely, versus those who required further observation or admission.