bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 14001: Evaluation and Treatment of Patients With Low Ejection Fraction and Positive Troponin
Authors: Hamza Mohammad , Castellano Andrew , Al-Ahmad Majd , Stone John , Waqar Hafiza Hareem , Mullins Jeannette , Torosoff Mikhail , Yager Neil
Published: June 2023

Introduction:
Patients with decreased LV ejection fraction (LVEF) presenting with elevated troponin incur high in-patient and follow-up mortality. Despite guidelines, testing for CAD and guideline-directed therapy in such patients has not been consistently utilized. To better understand this issue, we investigated hospital practice patterns in this vulnerable population.

Methods:
We conducted a tertiary single-center study of consecutive in-patients with abnormal troponin results on testing performed for clinical indications as requested by the treating physician. The study cohort included 432 patients, 67 +/- 14 years old with HTN in 75%, DM in 38%, smoking in 51%, dyslipidemia in 64%, family history of CAD in 28% and personal history of CAD or equivalent in 46%. Among them, 412 patients underwent echocardiographic LVEF assessment. Patients were then stratified according to the LVEF. The use of both ischemic evaluation and evidence-based medical therapy were compared. Hospital and long-term outcomes were analyzed.

Results:
Hospital mortality was 51/432 (11.8%) and during 28.1+/-13.8 months of follow-up additional 82/432 (18.9%) patients expired. Ischemia evaluation (both cardiac catheterization and non-invasive) was underutilized across all subgroups, including patients with decreased LVEF. Regarding guideline-directed medical therapy, only beta-blocker therapy was consistently utilized. Afterload reduction therapies such as angiotensin convertase enzyme inhibitors, angiotensin II receptor blockers, neprilysin inhibitors, hydralazine and nitrates were significantly underutilized. Statins and mineralocorticoid receptor blockers were also significantly underused (Table).

Conclusions:
Despite increased mortality, there continues to be room for improvement in the utilization of diagnostic evaluation and application of evidence-based therapy and in patients admitted with elevated cardiac biomarkers.
Abstract 14037: Nonspecific Tools Performed Better in Discriminating Major Bleeding From Direct Oral Anticoagulants Than Specific Tools in a Real-World Population With Atrial Fibrillation
Authors: Campos-Staffico Alessandra M , Dorsch Michael P , Barnes Geoffrey , Luzum Jasmine A
Published: June 2023

Background.
Direct oral anticoagulants (DOACs) are the first-line guideline-recommended therapy for preventing stroke in non-valvular atrial fibrillation (AF) patients. DOACs are increasingly being prescribed in the US compared to warfarin because of lower bleeding risk overall, but the proportion of Emergency Department visits involving DOACs-related bleeding increased from 2.3% in 2011 to 37.9% in 2017. Therefore, tools that accurately predict bleeding risk from DOACs are needed.
Aim.
This study compared the performance of six tools for predicting major bleeding risk in non-valvular AF patients on DOACs.
Methods.
A retrospective cohort study was carried out with 2,364 Caucasians diagnosed with non-valvular AF and treated with rivaroxaban or apixaban at the University of Michigan Health System. Bleeding risk was calculated using six existing tools: CHA
2
DS
2
-VASc, Anticoagulation-specific Bleeding Score (ABS), HAS-BLED, ATRIA, HEMORR2HAGES, and ORBIT. Major bleeding events were retrieved from medical records and classified according to International Society of Thrombosis and Haemostasis criteria. Discrimination was estimated using the c-statistic, and the areas under the curves (AUC) were compared using the Hanley-McNeil test. RGui was used for all statistical analyses and p-values <0.05 were considered statistically significant.
Results.
A total of 97 (4.1%) patients experienced major bleeding on DOACs over 2.27 ± 2.03 years of follow-up. HAS-BLED and ABS are tools for specifically predicting major bleeding risk, but both had significantly lower performance than ATRIA, HEMORR2HAGES, and ORBIT (
Figure 1
). There was no significant difference in the discriminative performance between HAS-BLED and ABS, as well as between ATRIA, HEMORR2HAGES, and ORBIT.
Conclusion.
ATRIA, HEMORR2HAGES, and ORBIT were the tools that performed better in discriminating major bleeding in AF patients if compared to HAS-BLED and ABS.
Abstract 14060: SGLT2 Inhibitors in Patients With Overweight or Obesity: Systematic Review and Meta-Analyses
Authors: Usman Muhammad Shariq S , Khan Mohammad S , Siddiqui Hasan F , Gangat Shazil A , Siddiqi Tariq , Hall Michael E , Luis Sushil A , Fudim Marat , Krasuski Richard , McGuire Darren K , Butler Javed
Published: June 2023

Background:
RCTs studying the effect of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on cardiovascular (CV) risk factors and outcomes have been underpowered to assess patients with overweight or obesity, thus presenting the need for a meta-analysis.

Methods:
Electronic databases were queried up till February 2022 for RCTs comparing SGLT2i with placebo in patients with overweight (BMI ≥25 kg/m2) or obesity (BMI ≥30 kg/m2) - irrespective of diabetes status - with a follow-up of ≥24 weeks. Meta-analyses were performed using the generic inverse variance technique and a random-effects model. Results are presented as weighted mean differences (WMD) for continuous outcomes, and hazard ratios (HR) for dichotomous outcomes. Outcomes studied were: (i) weight; (ii) systolic BP; (iii) diastolic BP; (iv) heart rate; (v) HDL-C; (vi) LDL-C; (vii) major adverse cardiac events (MACE), i.e., composite of CV death, non-fatal myocardial infarction (MI) and non-fatal stroke; (viii) composite of heart failure hospitalization and CV death (HFH/CV death); (ix) mortality; (x) MI; and (xi) stroke.

Results:
Seventeen RCTs (47,649 patients) were included. Compared with placebo, SGLT2i significantly reduced weight (WMD: -2.32 kg [-2.77, -1.88]), HbA1c (WMD: -0.79 % [-0.98, - 0.61]) and systolic BP (WMD: -2.15 mm Hg [-3.08, - 1.22]). SGLT2i did not have a significant effect on diastolic BP (WMD: -0.55 mmHg [-1.51, 0.41]), heart rate (WMD: 0.08 bpm. [-0.21, 0.37]), HDL-C (WMD: 1.62 mmol l
-1
[-0.21, 3.45]) or LDL-C (WMD: 0.53 mmol l
-1
[-0.88, 1.94]). Amongst CV outcomes, SGLT2i reduced the risk of MACE (HR: 0.90 [0.81, 0.99]), HFH/CV death (HR: 0.82 [0.75, 0.90]), and mortality (HR: 0.85 [0.77, 0.94]). No effect was noted on stroke (HR: 0.99 [0.85, 1.26]) or MI (HR: 0.89 [0.77, 1.02]).

Conclusions:
In patients with overweight or obesity, SGLT2i produce a modest but significant reduction in weight, systolic BP and HbA1c. SGLT2i may also reduce the risk of MACE, HFH/CV death, and mortality.
Abstract 14086: Do Outcomes Differ Between STEMI and NSTEMI Cardiogenic Shock?
Authors: Pahuja Mohit , Sinha Shashank S , Kataria Rachna , Blumer Vanessa , Hernandez-Montfort Jaime , Kanwar Manreet , Garan Arthur R , Zhang Yijing , Harwani Neil , LI BORUI , Baca Paulina , Dieng Fatou , Marbach Jeffrey , Khalif Adnan , Vallabhajosyula Saraschandra , Nathan Sandeep , Burkhoff Daniel , Kapur Navin K ,   on behalf of CSWG investigators
Published: June 2023

Background:
Acute myocardial infarction relatedcardiogenic shock (AMI-CS) is a multifactorial syndrome with high morbidity andmortality. Contemporary, real-world data comparing outcomes among patients withST-elevation myocardial infarction related CS (STEMI-CS) versus non-STEMI(NSTEMI-CS) is lacking.

Methods:
Using data from 17 sites from the CardiogenicShock Working Group (CSWG) registry, we compared the clinical characteristics,hemodynamic, and metabolic profiles between STEMI-CS and NSTEMI-CS patients. Between 2016 to 2020, data from 1110 adultpatient hospital admissions with the diagnosis of AMI-CS were collected. Patientswith available data within 24 hours of admission were stratified according to baselineand maximum SCAI Stage. We performed comparison between STEMI vs NSTEMI groupusing one-way Anova analysis.

Results:
Among 1,110 patients with AMI-CS, 731(65.8%) had STEMI-CS and 379 (34.2%) had NSTEMI-CS. Most patients were male andwhite. Compared with NSTEMI-CS patients, STEMI-CS patients were younger (63.8±12.3 vs 69.2 ± 12.3, p<0.001). Overall unadjusted in-hospital mortality was41%. Mortality was similar among STEMI-CS and NSTEMI-CS patients (43% vs 39%,p=0.23). Patients with out-of-hospital (OHCA) or in-hospital cardiac arrest (IHCA)had higher in-hospital mortality (55% vs 39%, p =0.002; 62%% vs 33%, p<0.001, respectively) (Fig 1A).Shock severity defined by SCAI Stage within 24 hours of admission (baseline)and throughout hospitalization (maximum) directly correlated with in-hospitalmortality in both STEMI- and NSTEMI-CS (Fig 1B).

Conclusion:
We report one of the largest contemporary analysesspecifically comparing outcomes with STEMI-CS and NSTEMI-CS. Cardiac arrest is an important determinant ofmortality and SCAI Stages are directly associated with poor outcomes in bothcohorts.
Abstract 14091: Severe Hypothyroidism Revealing Hidden Tracts
Authors: sharma arushi , shah shanil , Shireen Kanamgode Shihla , Kumar Nilesh , Home Madhurima
Published: June 2023

Discussion:

Atrioventricular reciprocating tachycardia (AVRT) is a type of Supraventricular tachycardia (SVT) caused by an accessory pathway can result in symptomatic and also life-threatening arrhythmias. Supraventricular tachycardias are less commonly seen in hypothyroidism than hyperthyroidism. We present a case of a 41 year old gentleman who presented with chest pain and SVT was found to have severe hypothyroidism with pre-excitation pattern on his EKG.

Case:

41-year-old Caucasian gentleman with history of untreated Hashimoto’s thyroiditis presented with palpitations and acute onset left-sided chest pain. His symptoms were aggravated with movement and improved with rest. When EMS found him, his vitals were significant for tachycardia with a heart rate (HR) of 200 beats per minute (bpm). EKG showed supraventricular tachycardia. Vagal maneuvers were attempted followed by adenosine. This resulted in conversion to sinus rhythm and improvement in HR to 88 bpm. His chest pain completely resolved. He was then brought to the emergency room where he had normal vitals. Examination revealed thyroid gland was palpable and noted to be diffusely enlarged. Laboratory data was significant for an elevated thyroid-stimulating hormone (TSH) of 373 mIU/ml and undetectable free thyroxine (fT4) levels. His creatinine kinase (CK) was high at 16260, and troponin was elevated at 0.220 ng/ml (reference:<0.04 ng/ml). TPO antibodies were >600 IU/ml. EKG demonstrated sinus rhythm with pre-excitation and incomplete left bundle-branch block.

He had normal chest x-ray. An echocardiogram showed an ejection fraction of 55% with mild LV diastolic dysfunction. He later underwent a stress myocardial perfusion scan which showed no definite evidence of inducible ischemia.

Follow up:

He was started on thyroxine replacement therapy. He is due for an EP study to evaluate for an accessory pathway causing pre-excitation with repolarization pattern on his ECG.

Conclusion:
This case suggests that severe hypothyroidism can also cause supraventricular tachycardias (SVT) by metabolic and conduction derangements revealing concealed bypass tracts in patients with accessory pathways. In most cases these arrhythmias are reversible once the underlying thyroid disorder is treated.
Abstract 14104: Trends and Associated Outcomes in Neonates With Ductal-Dependent Cyanotic Congenital Heart Disease Undergoing Surgical Systemic-Pulmonary Artery Shunts versus Catheter-Based Ductal Stents From the Pediatric Health Information System Database
Authors: Valencia Eleonore , Staffa Steven , Maschietto Nicola , Kuntz Michael , Zaleski Katherine , Kaza Aditya K , Nasr Viviane
Published: June 2023

Introduction:
Neonates with ductal-dependent cyanotic congenital heart disease (CCHD) require palliation to establish stable pulmonary blood flow (PBF). Surgical systemic-to-pulmonary artery shunts have been the standard approach. More recently, catheter-based ductal stents have been performed as an alternative less invasive intervention. We aimed to characterize recent trends in the utilization of surgical shunts versus ductal stents and compare associated outcomes.

Methods:
Using data from the Pediatric Health Information System, we retrospectively analyzed neonates with CCHD who underwent surgical shunt or ductal stent placement to establish stable PBF between January 2016 and December 2021. Neonates with CCHD with ductal-dependent PBF were identified by ICD-10 diagnosis codes and stratified by surgical shunt or ductal stent using ICD-10 procedure codes. The primary outcome was post-intervention length of stay (LOS). Secondary outcomes were rate of reintervention on the ductal stent, surgical shunt, atrial septum, right ventricular outflow tract, or branch pulmonary arteries and adjusted hospital charges per admission.

Results:
Of the 931 patients included, 65.4% underwent a surgical shunt over the 5-year period. The proportion who underwent a ductal stent increased from 18.9% to 53.5% from 2016 to 2021. There was no significant difference in mortality (surgical shunt 6.1% vs ductal stent 4.4%, P=0.27). The median adjusted difference in LOS was 11 days greater for the surgical shunt cohort (95% CI: 8.5-13.5, P<0.001). The likelihood of reintervention was significantly greater in the ductal stent group (30 days: adjusted OR=2.19, 95% CI: 1.02-4.71, P=0.044; 3 months: adjusted OR=4.85, 95% CI: 3.13-7.52, P<0.011). Median adjusted total hospital charges were $572,400 (367,600-967,900) versus $302,500 (214,000-523,000) for the surgical shunt and ductal stent groups, respectively (P<0.001).

Conclusions:
Ductal stenting has become an increasingly utilized palliative approach to secure PBF in neonates with CCHD across various centers in the United States. Ductal stenting is associated with decreased LOS and reduced overall charges for the index hospitalization but also with a greater reintervention rate than surgical shunting.
Abstract 14166: Predictors of Mortality in Patients With In-Hospital STEMI After Implementation of a Comprehensive STEMI Protocol
Authors: Kanaan Christopher , Kassis Nicholas , Nair Raunak , Kumar Anirudh , Reed Grant W , Krishnaswamy Amar , Menon Venu , Lincoff A M , Kapadia Samir R , Khot Umesh N
Published: June 2023

Introduction
Patients who experience in-hospital ST-elevation myocardial infarction (iSTEMI) comprise a uniquely high-risk cohort owing to multiple factors including delays in diagnosis and treatment. Improvements in quality care metrics are needed to more fully understand the reasons for the poor outcomes, including high mortality, in this population.

Methods
Consecutive patients with iSTEMI who were treated with percutaneous coronary intervention (PCI) between 01/01/2011-07/15/2019 at a single, tertiary referral center were included. A comprehensive iSTEMI protocol (CSP) was implemented on 7/15/2014, incorporating: (1) nursing chest pain protocol, (2) improved electronic access to electrocardiographic studies, (3) checklist for initial triage and management, (4) 24/7/365 catheterization lab readiness, and (5) radial-first PCI approach. Process metrics and clinical outcomes were compared pre- and post-CSP implementation, and multivariable logistic regression analysis was performed to assess for predictors of in-hospital mortality.

Results
Among 125 iSTEMI patients, the post-CSP group (n=81) were younger with more active smoking and heart failure relative to the pre-CSP group (n=44). CSP implementation resulted in an increased use of trans-radial PCI (14.6 vs. 70.4%, p<0.001), greater rate of ECG-to-first device activation < 90 minutes (36.4% vs. 76.5%, p<0.001), and decreased median ECG-to-first device activation time (114 vs. 64 minutes, p<0.001). In-hospital mortality was numerically lower in the post-CSP group (18.2% vs. 9.9%, p=0.295). On multivariable analysis, the presence of shock was the only independent predictor of in-hospital mortality (OR: 26.05, 95% CI [5.5-211.6], p<0.001).

Conclusions
The adoption of a CSP conferred marked improvements in key care metrics in patients with iSTEMI. Its use holds promise in reducing mortality among a vulnerable population at high risk of death owing to underlying shock.
Abstract 14176: Assessment of Atrial Septal Defect Dynamic Changes Within the Cardiac Cycle With Cardiovascular Computed Tomography
Authors: Eghtedari Bibinaz , Alalawi Luay Hussein , Kinninger April , Manubolu Venkat S , Verghese Dhiran , Aldana-Bitar Jairo , Ghanem Ahmed K , Ahmad Khadije , Sanchez Karla , Roy Sion , Budoff Matthew , Pillutla Priya
Published: June 2023

Objectives:
Successful and safe percutaneous closure of atrial septal defects (ASD) is contingent upon the accurate measurement of defect size and adjacent rim tissue, as well as the spatial relationship to other cardiac structures. Previous studies utilizing three-dimensional echocardiography have found significant changes in ASD defect size throughout the cardiac cycle. Cardiac computed tomography (CT) provides excellent spatial and temporal resolution of cardiac structures. Our study examines the efficacy of cardiac CT as a modality for evaluating dynamic changes in ASD defect size throughout the cardiac cycle.

Methods:
Thirty patients with an ostium secundum ASD underwent cardiovascular CT imaging prior to percutaneous or surgical repair. Cardiovascular CT was performed with a multidetector scanner and images were analyzed using a GE Advantage Workstation capable of advanced image processing and manipulation. ASD defect size was measured in the axial, coronal, and sagittal views at (end-systolic phase) 35% and (end-diastolic phase) 95% of the cardiac cycle.

Results:
In 30 participants the mean defect size was not significantly different across the three planes, axial mean was 22.4±15.3, coronal 23.7±16.2, and sagittal at 22.3±16.9, p=0.923. However, the change in defect size during the cardiac cycle was significantly different in all three views, P<0.0001 for all. On the axial view, the mean change from 35% to 95% was 6.5±4.9, while the coronal view change was 7.4±5.7, and the sagittal view change was 4.3±3.9. Additionally, the change in size increases with the defect size (figure 1).

Conclusions:
Cardiac CT imaging accurately depicts dynamic changes in ASD defect size throughout the cardiac cycle, and as such, may be considered a valuable and non-invasive imaging modality for patients undergoing pre-procedural evaluation.
Abstract 14189: Household Income and Trends in 30-day Readmission for Patients With Heart Failure
Authors: Aliyev Nijat , Almani Muhammad Usman , Qudrat Ullah Muhammad , Fonarow Gregg C , Khan Mohammad S , Greene Stephen J
Published: June 2023

Introduction:
The relationship between household income and trends in 30-day readmission among patients with heart failure (HF) is unknown. Further, whether the hospital readmission reduction program (HRRP) had differential associations with HF readmissions among patients with lower versus higher household income is unclear.

Methods:
The National Readmission Database (NRD) was examined to identify all admissions among adults with a primary diagnosis of HF who had at least one unplanned readmission within 30 days between 2010-2019. Median household income by patient zip code was assessed as quartiles: low income, middle income, upper-middle income, and high income. Yearly trends in adjusted all-cause 30-day readmission rates were assessed by household income quartile. Adjusted readmission rates were compared for the pre-HRRP period (2010-2012) vs. post-HRRP period (2013-2019).

Results:
Among 9,020,742 index hospitalizations between 2010-2019, adjusted all-cause 30-day readmission rates increased for patients in low-income (18.8% to 19.0%,
P
trend <0.001) and middle-income quartiles (17.6% to 17.9%,
P
trend <0.001), remained similar in the upper-middle income quartile (17.7% to 17.3%,
P
trend 0.24), and decreased in the high-income quartile (16.8% to 16.4%,
P
trend 0.039)
(Figure, Panel A).
Associations between HRRP and average adjusted all-cause readmission varied by income quartile, such that greater increases in readmissions were seen among patients in lower quartiles (p for interaction <0.001). (
Figure, Panel B)
.

Conclusions:
Among patients hospitalized for HF in the US from 2010-2019, adjusted all-cause 30-day readmission rates significantly differed by neighborhood household income, and increased over time for patients in the lowest two quartiles of household income. Since adoption of the HRRP, greatest absolute increases in all-cause readmission have been observed among patients in the lowest quartile of neighborhood household income.
Abstract 14199: Defining Phenotypic Representativeness of the TOPCAT Trial to a Real-World Electronic Health Record Using Multidimensional Phenomaps
Authors: Thangaraj Phyllis , Oikonomou Evangelos , Jayaram Rahul , Aghajani Nargesi Arash , Suchard Marc , Khera Rohan
Published: June 2023

Background:
The TOPCAT trial did not find an overall benefit of spironolactone in the management of HFpEF. However, subsequent investigations have found heterogeneous treatment effects across patients, questioning the extent TOPCAT is representative of the real world. Previous analyses addressing this question have been limited by focusing on single phenotypic axes that do not capture the entirety of the patient phenotypes.

Methods:
We constructed a multidimensional phenomap of TOPCAT on 76 pre-randomization characteristics spanning demographics, diagnoses, procedures, medications, labs, vitals, conditions, and imaging-derived measures. We then compared this map to patients with HFpEF in the EHR of the Yale-New Haven Hospital. The EHR cohort was based on echocardiography and selected if they had a HF hospitalization during 2015-2019. All corresponding 76 features were extracted for the Yale EHR population by a team of clinicians and data scientists. To accomplish this, we computed a pairwise Gower dissimilarity metric across the 76 pre-randomization characteristics.

Results:
Compared with TOPCAT participants (n=3445), Yale EHR (n=2394) patients were older (69 vs 78 years), more frequently women (52% vs 57%), and Black (9% vs 17%). In univariate analyses, there was similar use of anti-hypertensive therapy. Mutlivariately, however, there was minimal overlap of the clinical population in TOPCAT compared with the Yale EHR, with a median patient-level dissimilarity distance of 41% (IQR 35% - 43%) (
Fig A
), with qualitative separation in the clinical populations in the trial and EHR (
Fig B
).

Conclusions:
In assessments across 76 phenotypic features, there was minimal similarity in patients in TOPCAT and real-world patients drawn from EHR, suggesting challenges with generalizability of the findings. Phenomapping-based strategies can enhance quantitative and qualitative assessment of trial representativeness to real-world populations.
Abstract 14218: Social Isolation Decreases Survival and Worsens Cardiac Function in a Novel Murine Model of Coronary Atherosclerosis
Authors: Mullis Danielle M , Wang Hanjay , Zhu Yuanjia , Bonham Spencer , Padilla Lopez Amanda S , Kocher Olivier N , Krieger Monty , Woo Y. Joseph J
Published: June 2023

Introduction:
With more people working from home after the COVID pandemic, it is of utmost importance to further understand the impact of social isolation on outcomes of patients with coronary atherosclerosis. Our preliminary studies have shown that the novel diet-inducible, fatal mouse model of coronary atherosclerosis,
SR-BIΔCT/LDLR KO
, tend to die on average around 4-6 weeks after starting a high-fat Paigan diet (HFD). This mouse model can be used to further understand the effect of social isolation on cardiovascular disease. We hypothesize that social isolation will decrease survival and worsen cardiac function.

Methods:
Male and female
SR-BIΔCT/LDLR KO
mice were put into social isolation (n=11), in a group of 2-3 (n=13), or in a group of 4-5 (n=22). At six-weeks-old, mice were started on a HFD to induce pathology. Echocardiography was performed to assess cardiac function. Analysis was performed using one-way Analysis of Variance tests and hoc-Tukey’s Honest Significant Difference tests. A log-rank test was used to calculate the difference in survival distributions.

Results:
Mice living in groups of 1, 2-3, and 4-5 lived for an average of 34.9, 35.6, and 41.5 days, respectively, after starting the HFD (
Fig. 1A
). The survival distribution is significantly different between the mice in isolation versus the mice in groups of 4-5 (p<0.01). Mice in social isolation have significantly lower ejection fractions than mice living in groups of 4-5 after two weeks of being on the HFD (
Fig. 1B
, p=0.028).

Conclusions:
Mice in social isolation exhibited decreased survival and reduced ejection fractions compared to mice in groups of 4-5. More mice would be needed to determine whether single isolation is different from mice in groups of 2-3. Further studies should be performed to understand the mechanism underlying the effect of social isolation on heart function. Such studies may influence future prevention strategies to positively affect outcomes of patients with atherosclerosis.
Abstract 14234: A Long-Standing Instance of Undiagnosed Misplaced Pacemaker Lead
Authors: Shah Aangi J , Zaman Muhammad O , McHale Joseph F , APTE NACHIKET MADHAV
Published: June 2023

Introduction:
Misplacement of pacemaker (PCM) lead into the left ventricle (LV) is a rare complication with an incidence of 0.34%. Limited cases of long-standing misplaced leads have been reported in the past. We present a case of misplaced PCM lead in the LV that went undiagnosed for 10 years, complicated by thrombotic strokes.

Case information:62-year-old male with history of sick sinus syndrome and a dual chamber PCM implantation, and thrombotic strokes with residual neurological deficits while on warfarin, presented to our hospital with gastrointestinal bleeding, subdural hematoma, and pulmonary embolism, in the setting of a mechanical fall. The patient had undergone a PCM implantation 10 years ago, and had a recent generator change 6 months prior to his presentation.

Diagnosis: Chest X-ray on admission was suggestive of misplaced PCM lead in the LV which was later confirmed by transesophageal echocardiography, that showed PCM lead attached to the postero-lateral wall of the LV.

Management: Given the patient’s complex presentation, a multi-disciplinary team approach was pursued. The patient was cautiously challenged with heparin drip with simultaneous serial hemoglobin and repeat CT head monitoring. The misplaced lead was determined as the likely culprit for the recurrent strokes. Since percutaneous lead extraction posed a high risk of complications, surgical correction was performed. The patient subsequently underwent a successful percutaneous dual chamber PCM implantation with His bundle pacing.

Conclusion:
Our case highlights a long-standing instance of misplaced PCM lead and consequent recurrent thrombotic strokes. We chose surgical correction over of percutaneous extraction given high risk of LV rupture and systemic thromboembolism with lead traction.
Abstract 14247: Speckle Tracking Echocardiography for Assessment of Left Ventricular Remodeling in Soccer Athletes
Authors: Silva Cássia Aparecida , ALEIXO HAROLDO C , Nascimento Bruno R , Alves André Gualberto J , TACURI CHAVEZ LUZ MARINA , Oliveira Kaciane , Mendes Silva Taylla , Pereira Luana D , Galdino Bruno , Fraga Lucas , Aleixo Thales , Santos Luiza P , Diamante Lucas C , Amaral Arthur M , Rocha João Pedro B , Ruback Lucas , Ribeiro Leonardo , Durães Leandro L , Ribeiro Antonio L , Sable Craig A , Beaton Andrea Z , Nunes Maria D , Barbosa Marcia
Published: June 2023

Introduction:
Speckle-tracking echocardiography (STE)-derived strain is a sensitive tool to detect early signs of exercise-induced cardiac remodeling in athletes, which may contribute to differentiate between physiological and pathological adaptation to sports.

Objective:
We aimed to assess the effect of regular athletic training on myocardial function assessed by STE in soccer players.

Methods:
We prospectively enrolled teenager soccer players who participate in regular training in a professional soccer team from Minas Gerais, Brazil. All asymptomatic athletes without known cardiovascular disease and with a structurally normal heart on transthoracic echocardiogram were included. Global longitudinal strain (GLS) by STE was performed in each athlete and measured offline using EchoPAC (GE) software. GLS was categorized according to absolute value |x| and GLS <16% was considered decreased, 16% to 18% borderline and >18% normal. Clinical, demographic and echocardiographic variables associated with reduced and borderline GLS were assessed by logistic regression.

Results:
The study population consisted of 352 male trained athletes with a mean age of 14 years (range 9 to 20), body mass index (BMI) of 20.4 ± 2.8 kg/m2, and left ventricular ejection fraction (LVEF) of 70 ± 6%. In the overall study population, the mean GLS value was -19.6 ± 2.2%, decreased in 13 athletes (3.7%) and borderline in 57 athletes (16.3%). In multivariable logistic regression analysis, BMI (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.21 - 1.59; p<0.001), LVEF (OR 0.94; 95% CI 0.91 - 0.98; p=0.004), left atrial volume (OR 0.89; 95% CI 0.83 - 0.95; p=0.001), E/e' ratio (OR 1.52; 95% CI 1.07 - 2.11; p=0.019) and E/A ratio (OR 0.37; 95% CI 0.18 - 0.78; p=0.009) were independently associated with reduced and borderline GLS. The model was well calibrated and with good discrimination, yielding a C-statistic of 0.78 (95% CI 0.72 - 0.85).

Conclusions:
This study provides sport-specific GLS values in the setting of normal LVEF in young athletes. Determinants of abnormal GLS include diastolic and systolic echocardiographic parameters related to exercise adaptation. Decreased myocardial deformation by STE may reflect a forthright relaxed cardiac state rather than underlying pathology.
Abstract 14255: Effectiveness and Safety of Ticagrelor versus Clopidogrel in Acute Coronary Syndrome: A Meta-Analysis of Real - World Data
Authors: Al-Balushi Sara , Rahhal Alaa , Abdelghani Mohamed , Ashour Mohammed Awad , Al-Mohtasib Yazan , Abid Abdul R , ALSUWAIDI JASSIM
Published: June 2023

Background:
Ticagrelor, a potent P2Y12 inhibitor, was superior to clopidogrel in preventing mortality post acute coronary syndrome (ACS) without a major safety concern in the PLATO trial. Nevertheless, the real-world evidence of ticagrelor post ACS is conflicting and inconclusive. Therefore, we conducted a meta-analysis to assess the effectiveness and safety of ticagrelor versus clopidogrel post ACS using real-world data.

Methods:
We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed to identify observational studies exploring the effectiveness and safety of ticagrelor and versus clopidogrel in ACS until 12/01/2022. Two independent reviewers assessed the quality and risk of bias of the included studies. A random-effect model was used to combine data. Effectiveness outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and stent thrombosis. Safety outcomes included major bleeding, gastrointestinal (GI) bleeding, and dyspnea.

Results:
A total of 26 observational studies comparing ticagrelor to clopidogrel post ACS were included. Compared to clopidogrel, ticagrelor significantly reduced all-cause mortality (odds ratio [OR], 0.68 [95% CI, 0.58-0.81], I
2
= 78%)) and cardiovascular mortality (OR, 0.64 [95% CI, 0.48-0.85], I
2
= 78%). Whereas there was no statically significant difference between ticagrelor and clopidogrel in MI and stent thrombosis (OR, 0.92 [95% CI, 0.81-1.05] I
2
=56%) and (OR, 0.61 [95% CI, 0.23-1.66], I
2
= 89%), respectively. Ticagrelor was associated with significantly higher major bleeding incidence (OR, 1.21 [95% CI, 1.06-1.39], I
2
=52%). However, GI bleeding and dyspnea were not significantly increased with ticagrelor use.

Conclusions:
Real-world data of ticagrelor use post ACS demonstrated that ticagrelor reduced all-cause mortality and cardiovascular mortality in comparison to clopidogrel. However, it was associated with increased major bleeding. Real-world evidence with long follow-up confirming the safety of ticagrelor in comparison to clopidogrel post ACS demonstrated in controlled trials is warranted.
Abstract 14295: Asymptomatic Frequent Atrial Ectopy in Healthy Children and Adolescents
Authors: Joyce Thomas , Joyce James J , Gleva Marye J , Ferns Sunita J
Published: June 2023

Introduction:
Premature atrial complexes (PACs) in pediatric patients with a structurally normal heart are usually presumed to be benign and self-resolving. On the contrary, adults with frequent PACs are at increased risk of multiple cardiovascular conditions. This study aims to evaluate a group of asymptomatic pediatric subjects with frequent PACs over time.

Hypothesis:
We hypothesized that, while most pediatric patients with frequent APCs have a benign prognosis there may be a subset that could progress to supraventricular arrhythmias

Methods:
Records for 343 pediatric patients (1-21 yrs) with asymptomatic frequent premature atrial complexes (>50/24 hours) were selected from 6902 pediatric patients that underwent Holters over a 10 year period. Demographics, pertinent clinical characteristics and results of cardiac investigations were tabulated. Comparisons were made between Holter results at presentation and follow-up. Patients were classified into two groups on follow-up, those with a significant (>20%) reduction in burden of atrial ectopy versus those with an insignificant (<20%) reduction or increase in burden of atrial ectopy.

Results:
The median age at initial Holter was 8.26 (1.3-20.9) years with a comparable male to female ratio. An irregular heart rate was the most common reason for a Holter. The most common preexisting medical condition was attention deficit disorder, followed by asthma. Follow-up Holters were performed on 188(54.8%) patients at a median of 2.2 (0.5-8) yrs after the first Holter. Overall there was a significant decrease in atrial ectopy burden on repeat Holter examinations; median 3.6% (0.03-18.7) to 0.5% (0-19) with 166 (88.3%) patients demonstrating a decrease in atrial ectopy by over 20% of baseline. Ten (5.3%) patients had an increase in the ectopy burden over time and 12(6.3%) had an insignificant change. Non sustained supraventricular tachycardia was noted in three patients on the initial Holter but none on subsequent evaluations. Multivariate analysis identified a higher initial burden of PACs as a strong independent predictor for reduction in burden of ectopy with time (p<0.005).

Conclusions:
Asymptomatic childhood PACs in the setting of a structurally normal heart are rare and tend to resolve with time.
Abstract 14304: Does QRS Fragmentation Have a Role in Risk Stratification for Sudden Death in Hypertrophic Cardiomyopathy?
Authors: Studley Rachael , Madias Christopher , Bokhari Nadia , Quintana Erick , Bao Chen , Maron Barry , Maron Martin , Rowin Ethan J
Published: June 2023

Background:
Fragmentation of the QRS complex on 12-lead electrocardiogram (ECG) represents alterations of myocardial activation due to myocardial scarring and has been associated with increased risk for sudden death and adverse prognosis. However the clinical significance of this finding in hypertrophic cardiomyopathy (HCM) remains unresolved.

Methods:
Consecutive HCM patients evaluated from 2004 to 2020 were included and followed for 5.1 ± 4.1 years for outcomes including sudden death events (appropriate ICD interventions for VT/VF, cardiac arrest, or sudden death) and development of endstage heart failure requiring transplant. QRS fragmentation was defined as presence of an additional R wave or notching in the R or S wave in two contiguous ECG leads in the absence of bundle branch block.

Results:
Among 1929 HCM patients, 539 (28%) were identified with QRS fragmentation. As compared to patients without QRS fragmentation, patients with QRS fragmentation had similar baseline demographics including age (52±16 vs. 53±16, p=0.35), gender (60% vs. 61% male, p=0.51), ejection fraction (64 ± 6 vs. 64 ± 5, p=0.77) and presence of LV outflow obstruction (≥30mmHg at rest or provocation; 65% vs. 65%, p=0.9). While patients with QRS fragmentation had more substantial LV hypertrophy (19 ± 4 vs. 18 ± 4, p=0.001) as well as presence and extent of late gadolinium enhancement by cardiac MRI (64% vs. 56%, 6.3 ± 6 vs. 5 ± 5, p<0.01), there was no difference in other risk markers including syncope (9% vs 9%, p=0.89), family history of SD (8% vs. 6%, p=0.31), NSVT (10.5% vs. 8%, p=0.10). Over follow-up, patients with QRS fragmentation were at increased risk for sudden death events (5.6% vs. 2.2%, p<0.001) and development of end-stage heart failure requiring transplant (2.4% vs. 0.8%, p=0.007). However, sensitivity and positive predictive value of QRS fragmentation for predicting sudden death events (50% and 5.6%, respectively) as well as endstage heart failure (52% and 2.4%) is limited.

Conclusion:
In a large consecutive HCM cohort, QRS fragmentation on 12-lead ECG is associated with extreme HCM phenotype and a number of adverse consequences including sudden death events and endstage development, and represents a potential prognostic marker.
Abstract 14349: The Association Between Atherosclerotic Cardiovascular Disease Outcomes and Diseases of Despair: A Retrospective Analysis From 2017-2021
Authors: Nudy Matthew S , Galper Kathleen , George Daniel R , Kraschnewski Jennifer L , Sinoway Lawrence I , Brignone Emily
Published: June 2023

Introduction:
Diseases of despair (DoD) are a major cause of premature mortality in the United States (U.S.) and include substance use and sequela, and suicidality. How despair-related illnesses are associated with atherosclerotic cardiovascular disease (ASCVD) and impact healthcare utilization in those with ASCVD is not established.

Methods:
International Classification of Diseases-10 codes were used to identify adults in the Highmark Health insurance claims database with ASCVD (composite of myocardial infarction, ischemic stroke, ischemic cardiomyopathy and peripheral vascular disease) from 2017-2021. In patients with ASCVD, baseline characteristics were compared between those with and without DoD. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated to assess the risk of ASCVD between those with and without DoD over 5-years of follow-up.

Results:
Among patients analyzed (n=983,513), 67,340 were diagnosed with ASCVD. Among those with ASCVD, 3.1% (2,059) had DoD. Those with DoD that developed ASCVD were younger (<45 years), more likely to smoke, more likely to use psychotherapy services, had more inpatient and outpatient utilization, and had increased total healthcare costs relative to those without DoD that developed ASCVD (Table 1). In addition, those with DoD had an increased risk of ASCVD compared to those without DoD (HR 1.43; 95% CI 1.37-1.50). Covariates adjusted for include frailty, obesity, smoking, gender, age, rurality, and area-level poverty, educational attainment, and social vulnerability.

Conclusions:
Among adults with ASCVD, those with DoD are younger and have higher healthcare utilization. In addition, DoD is associated with an increased risk of ASCVD. Further research to understand cardiovascular disease prevention in those with DoD could reduce healthcare costs and save lives. Also, there is a need to examine overlapping structural factors that may be contributing to concurrent rises in both ASCVD and DoD in the U.S.
Abstract 14352: Variations in Spontaneous Coronary Artery Dissection Diagnosis Based Upon Hospital Status
Authors: Mughal Mohsin S , Tayyeb Muhammad , Mirza Hasan , Akbar Hafsa , Anwar David M , Usman Mohammed Haris , Waqar Fahad , Ghani Ali , wasty najam
Published: June 2023

Background:
Spontaneous coronary artery dissection (SCAD) contributes to a significant number of acute coronary syndrome (ACS) in middle-aged female. SCAD data are accumulating to understand its epidemiology, etiology, presentation, and diagnosis. Despite the rising incidence, there is limited data regarding the number of diagnosed cases based on hospital location. We hypothesized that more cases of SCAD are diagnosed at teaching urban hospitals than urban non-teaching or rural hospitals.

Methods:
In this retrospective study, the discharge data were extracted from the National Inpatient Sample (NIS), and Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 2010 to 2017. We used the 9th and the 10th revisions of International Classification Disease (ICD-9-CM code 414.12, ICD-10-CM Code I25. 42) for SCAD. SCAD cases per year (weighted to represent nation sample) were collected and stratified by hospital location (urban teaching, urban non-teaching, and rural). p
-
value was calculated by Cochran-Armitage test. A
p
-value of <0.05 was considered significant and all p-values were two-sided.

Results:
We found a total of 490 patients with a primary diagnosis of SCAD. The numbers were weighted to present a national total of 2432 discharges. Demographic characteristics are shown in table-1. Year-year SCAD cases quantified by rural, urban teaching, urban non-teaching status are shown in table-1. Of these 2432 discharges, 72.34% were at the urban teaching hospitals, followed by 25.05% at urban non-teaching hospitals, and only 2.6% were at rural hospitals. This difference was statistically significant (p
-value
<0.001).

Conclusions:
A higher number of SCAD cases at urban teaching hospitals may indicate the diagnosis bias due to better availability of expertise and advanced modalities to diagnose this entity at urban teaching hospitals.
Abstract 14404: Variation and Predictors of Referral for Cardiac Rehabilitation Among Patients With Heart Failure Before and After Expansion of Coverage and Association With 1-year Clinical Outcomes
Authors: Keshvani Neil , Subramanian Vinayak , Wrobel Chris , Solomon Nicole , Alhanti Brooke , Guhl Emily , Greene Stephen J , Allen Larry A , Yancy Clyde W , Devore Adam D , Fonarow Gregg C , Pandey Ambarish
Published: June 2023

Introduction:
The Centers for Medicare and Medicaid Services(CMS) expanded coverage for cardiac rehabilitation(CR) in 2014 for patients with clinically stable heart failure(HF) with reduced ejection fraction. Contemporary CR referral and participation rates among eligible patients with HFrEF are not known.

Methods:
Patients hospitalized for HF with ejection fraction ≤35% in the American Heart Association Get With The Guidelines®-HF(GWTG-HF) registry from 2010-2020 were included. Trends in rate of referrals and predictors of referral were determined. Among subset of participants with available Medicare-linked data, rate of CR participation was assessed, and 1-year outcomes were compared among patients referred vs. not referred to CR.

Results:
Of 69,441 HF patients eligible for CR, 17,076(24.6%) were referred to CR. There was substantial variability in referral across GWTG-HF participating centers (range 0-100%, IQR 4%-50%). Of patients with fee-for-service Medicare referred to CR, only 4.2% participated in CR in the year following HF hospitalization (median sessions: 3, range 1-76). Referral rate increased from 2010-2020, with significant increase since 2014 CMS coverage expansion (p
trend
<0.001). Patients not referred were more likely to be older, of minority race, and with greater burden of comorbidities. Patients admitted to rural hospitals and those in the Northeast were less likely to be referred to CR. Among patients free of HF events within 30 days post-discharge, CR referral was independently associated with lower risk of 1-year all-cause mortality vs. those not referred (HR 0.84, 95% CI (0.73 - 0.98, p = 0.0267), without significant difference in 1-year HF-related or all-cause readmission.

Conclusions:
Although CR referrals have increased among eligible HF patients since CMS expanded coverage in 2014, absolute referral and participation rates remain low. Age, race, and burden of comorbidities were independently associated with CR referral.
Abstract 14419: Cerebrovascular Stability Index is Associated With Motor Development Scores in 6-month Infants With Congenital Heart Disease
Authors: Tran Nhu N , Rajagopalan Vidya , Panigrahy Ashok , Brady Ken M , Votava-Smith Jodie K
Published: June 2023

Introduction:
Infants with congenital heart disease (
CHD
) have an increased risk for poorer neurodevelopmental outcomes (
NDO
) compared to healthy infants. Impaired cerebrovascular autoregulation (
CA
) may contribute to neurologic abnormalities in CHD infants. This study’s purpose is to assess cerebrovascular stability index (
CSI
), as a surrogate for CA, and its associations with NDO in infants with CHD compared to healthy control infants at 3 early-age timepoints.

Hypothesis:
We hypothesized that CHD infants who have poorer CSI will have significantly poorer neurodevelopmental outcomes than infants with better CSI.

Methods:
We conducted a prospective, longitudinal study in CHD infants and healthy controls (
HC
). We measured CSI and NDO at 3 ages (neonatal, 3-month, and 6-month). We performed 3 tilts while measuring cerebral oxygenation via near-infrared spectroscopy. CSI was determined by subtracting the average 2-minute sitting cerebral oxygenation from the 2-minute supine value for each tilt, then averaging the 3 tilt values for each age. The Einstein Neonatal Neurobehavioral Assessment Scale (
ENNAS
) measured neonatal NDO, while the Bayley-3 evaluated the 3 and 6-month NDO.

Results:
We assessed a total of 28 CHD and 40 HC infants. CHD infants had significantly lower ENNAS scores as neonates (68 CHD vs 83 HC, p<0.001), and at 6-months had lower cognitive (94 CHD vs 100 HC, p=0.04), and motor (86 CHD vs 98 HC, p<0.001) composite scores compared with the HC. However, the other domains did not significantly differ between groups. Linear regression analyses showed that motor development scores in the CHD group improved as CSI improved when adjusted for sex and ethnicity (β=3.64, SE=1.47, p=0.02). CSI did not significantly associate with the cognitive score or NDO for the other ages.

Conclusion:
We found better CSI significantly associated with higher motor development scores in 6-month old CHD infants, suggesting that impaired CSI may underlie abnormalities of motor development in CHD. Future studies are needed to better understand the mechanism of interaction between CSI and motor development.